Magazine article Clinical Psychiatry News

When Time Runs Out

Magazine article Clinical Psychiatry News

When Time Runs Out

Article excerpt

We've all had patients who introduce hot topics late in their sessions. Do you return to those topics in subsequent sessions? What's your interpretation of this situation if it tends to be a recurring problem?

Handle Neutrally Unless Urgent

This is a ubiquitous issue, and I can't imagine any clinician who has never encountered it. A beginning resident might get caught off guard by it, but I think that once you begin to appreciate some of the meanings behind this particular kind of interaction, you can regain your composure and approach it like you would any other communication.

Therapists generally handle the behavior in either one of two ways once they take notice of it. When the "door handle" question arises when a patient is leaving a session, it behooves the psychiatrist to at least acknowledge the importance of the event. Most clinicians would argue that it would be a boundary violation to invite the patient to sit back down and discuss the issue at some length. It would not be a boundary violation, of course, if the patient said, "Oh, by the way, I just bought a gun yesterday, and I'm planning on killing myself." A clinician would be obligated to explore that statement immediately.

In a less urgent situation, however, I would handle this type of encounter in a neutral way by saying, "You know, that sounds to me like an extremely important issue that you just raised. Since we don't have time to address it today, I need for us to have further discussion next time we meet." Some psychiatrists might object to this kind of acknowledgment of the revelation and would argue that it may set an agenda for the next meeting, thereby determining what the patient should discuss. I have not found this to harm the doctor-patient relationship in any way.

I had a patient who said, "Oh, by the way, I'm getting married this weekend." This was a woman with bipolar disorder, alcoholism, and a severe personality disorder. Her life was marked by these impulsive kinds of things, especially with men. I made an appointment to see her the next day.

Ultimately, my task is to understand the meaning behind this type of interaction. Some clinicians become adversarial about these behaviors and, without further appreciation of the patient's experience, interpret it uncritically as manipulative. Such a move invariably is a detriment to the working relationship. We should ask ourselves why is the patient acting like this right now, and what does that behavior say about our relationship at that point in time? If this begins to be repetitive, the clinician is obligated to point out the pattern and invite the patient to explore its meaning.

Other patients repeatedly bring up issues at the very end of a session because they may be experiencing significant discomfort. For example, they may feel anxious, extraordinarily alone, or vulnerable outside of the security of the therapeutic relationship. We are obligated to explore and assist such a patient in understanding the nature of that discomfort by addressing what it's like for the patient both inside and outside the sessions. It behooves the psychiatrist to help those patients appreciate and verbalize their concerns and fears.

Jerald Kay, M.D.

Dayton, Ohio

How Immediate Is the Threat?

I am a psychiatrist and psychoanalyst, and most of my patients receive both medication and psychotherapy. When a patient introduces a hot topic at the end of a session, I consider the immediate threat to life and limb. If a patient suddenly describes unprotected sex with someone who is HIV positive or an interaction with an unknown sexual partner who is a violent sadist, I keep the patient over the session time or arrange to see him or her again later the same day (with appropriate supervision until then if I think reality testing is impaired).

Much more commonly, people ask for advice about a complex problem or wait till the last moments of the session to recount a dream. …

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