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14. Fictionalized Case Consultation: Working with Treatment-resistant Depression

“I love that each of you is bringing your experience theoretical and treatment orientations to the table and everyone is finding these little glimmers of different ways this case could be approach which is so wonderful about case consultation because it allows the therapist Steve to hear about other types of therapy or other perspectives that might assist this client that he’s either not exposed to or hasn’t tried.”


Welcome to the colleague down the hall podcast. This episode is sponsored by the collab Oasis clinical consultation groups. Hi, I’m Janine Wolf, and I’m your colleague down the hall. I have a passion for helping fellow therapists get the clinical and collegial support, we all need to do this work. And wow, it just keeps getting harder every day. I’m the founder and facilitator of the collaborative Asus clinical consultation groups. I have been a social worker for almost 30 years, and I own a successful solo online private practice, more of us than ever are practicing in solo or online practices. And we all need colleagues to process cases with commiserate with on those really hard days and also to celebrate our successes with in this podcast, I’ll bring you insights about trends and changes in our field and sit down with amazing therapists who are doing amazing work will discuss fictionalized cases, way to practice sustainably. And of course, there will be plenty of laughing. I love laughing with friends. I’m so glad to have you as one of my colleagues down the hall.


Once again, welcome. We have a great group of therapists here today that we’re going to be able to dig into this case and see what we think about it. So John is a 40 year old male who has been in and out of therapy since he was a teenager. The therapist Steve has been working with him for nine months, John presented with a long history of treatment resistant depression and has never found any significant relief from his symptoms. In spite of trying a variety of pharmaceutical therapies, as well as EC T and TMS and more recently ketamine treatment, Don is tired of the toll all of this has taken on himself and his family who were very supportive of him. He does not have any hope that his depression will ever improve and believe some people are just not meant for this world. He has had suicidal ideation for many years, and also has a plan that he tells the therapist he plans to utilize in the near future. Okay, so does anyone have any clarifying questions about this case scenario so far? Okay.


So let’s jump in. Steven is saying, I just met with this client, and I have some concerns about this. I would love to hear input about how I can manage this client, because my mind goes in lots of different ways, right, Steve? It’s like you can think of lots of different. And so he wants to make sure that he’s getting good consultation, because this is a tricky case that has life or death implications. Does anyone have any thoughts? what are treatment concerns? what are suggestions that you might have you have questions for Steve about this client? Oh, there you go. Yep, that’s it perfect. I


just wondered how the client was diagnosed, you know, some type of bipolar or major depression, recurrent, how they’re diagnosed? goes, C major depression, recurrent, severe.


Okay. Without psychotic features. Without


psychosis, yes.


All right. And he was diagnosed, he’s been struggling with this since his teen years.


And he’s had inpatient treatment before for partial. Yes, he’s done




treatment for yes. Yeah, I was just wanting to know, he said he’s been in treatment for since he was a teenager, I was just wondering, just in terms of a little bit more history with them, just to find out some of the things that he went through as a teenager during his depressive state, it may be perhaps a life graph was introduced, just to get a little bit more clarity of his experience and his core beliefs about self


would be great. Anything in history would be good. Absolutely.


I would just wonder in that only because sometimes when, you know, just a little brief scenario here just to dig in a little bit deeper, because if he’s been doing dealing with this as a teenager, maybe going back to see what’s happened and his core belief, because a lot of that stuff starts then. And trying to figure out what that core belief is about self and seeing how you can move forward through that and, you know, move forward based on that


information. Yeah, and let me just throw in for the purposes of this case, let’s presume that they A therapist over the years I’ve thoroughly explored any trauma background, and there’s no significant trauma in this client’s life.


How about substance abuse? That I think that might be interesting to know. And that has some long term effects in terms of depression, sometimes dopamine and all that. So


the gist that we’re getting and correct me if I’m wrong, Steve, is that this really seems to be more biological. Like he was predisposed to depression. It’s something that’s been there his whole life. He’s seen so many therapists over the years who’ve tried all the different things no one has ever been able to give. John any relief.


That sounds about right. Yeah. So yeah, everything we’re trying nothing seems to be working in the long term. Okay.


That’s mindfulness been try?


Yes. Has working at this from a physical activity level. ever shown him any relief, because somebody studied


a little bit more with physical activity,


physical activity, walking, running something where he’s engaging physically in an activity on a regular basis? Because we know so many studies show it’s as good as medication per many people are better.


Yes, well, if we’ve done that, it has some short term efficacy, and then drops back to baseline after a little bit.


Okay. And the next question I would have is, what’s the family history? Does he have either parent who also struggled with this? Or does he have siblings who struggle with this,


we just reread this case real quick,


doesn’t say, Steve, so you can decide what the family history is. Good dad say that your family supportive of him. And in His dealing with this depression over the years,


parents have been treated for depression, but not long term. Seems like they had a couple backs several years ago. But it was relatively easily results.


When you say with the physical activity, some short term gains, but not really sustainable as in the activity isn’t sustainable. Like he doesn’t stick with it or feels better for a little while, but then it doesn’t last,


he will stick with it. And whatever benefit he has had the depression will just come back up.


Okay, so any other clarifying Go ahead? Marla, we’re gonna say something.


I don’t know. I just feel like some of this stuff is just kind of the unknown. I guess that’s why we’re exploring asking these questions. Because when you say everything has been tried, has really everything been tried, I guess. It’s just too much. I feel like there’s just a lot of in between, we don’t know, to kind of provide a really good input about the case. I mean, it says pharmaceutical we went through that as far as E. C. T, you said and mindfulness to and we’re kind cognitive behavioral therapies, reality, reality therapy, perhaps maybe, you know, assessing that? Or has that been tried, where we’re actually doing the Watson and analyzing and looking at? How are we going to get to these paintings in the sermon from that time, whether what you’re doing is actually providing you what you want? So have those things been tried? Because everything we say everything has been tried?


In our pocket? Can you tell us a little bit more about reality therapy,


just really, like, you know, reality therapy and acknowledging that we have a choice, we have a choice to a combination with the mindfulness and that, you know, we could choose to change our way of thinking. And for example, for depression, not saying we are depressed, but saying we are depressing, in that case, and acknowledging that we can make a choice to not be depressed, and kind of just focus on what we could do and activities for us to not just feel all of those symptoms in a way.


Okay, cool. I’m not familiar with reality therapy to too much, but would definitely love to look into it, get some techniques, and see if this would be effective for John. does.


Does he have any foundational, religious or spiritual strengths that he leans on in any way?


raised Catholic, but currently secular? So None None currently know.


When he’s had remittances from the symptoms, his experience, he has a history unfortunately, of going up and down, we would say, life is good, and then a lot of life is really hard. Would that be fair to say? So, what uh, when he has remittance from the symptoms, does his life change as far as how he engages in it is there’s big differences. You understand what I’m saying? I may not be wanting to throw up. Well,


I’m just a smidge confused. Let me repeat it back to you. And you can tell me if I’m understanding it correctly. So in regards to when he’s on an upswing, if the next one, are there any actual changes and changes in his life.


Yes, yes. And how he engages in it, his activities and such?


Well, what really seems to happen is we’ll give a technique or a coping skill to have some short term efficacy, and then it’ll lose efficacy over time. So the techniques are what’s really changing. But in regards to basic lifestyle, nothing really seems to change their


theme, the case is that he’s never had any significant relief from his depression. He’s had, like you described some of the short term, you know, relief, but never anything significant enough that he felt like, oh, wow, maybe I’m gonna have quality of life at some point.


I’ve got an interesting question. And that is, has he ever made a suicide attempt a serious suicide attempt?


I’m gonna say no, or at least I don’t know of any. This plan that he has in place that he is threatening will be his, at least as far as my knowledge. This first time, I’d


like to say a little bit about why I asked that question. And I’m reflecting on a client, I’m pulling my hair about out about these days. I’ve been working with this person for a while. And one of my frustrations is that we have tried, I’m not going to say everything, but a lot of things. And the person has been on a lot of different medications, but they never stick with any treatment for very long, they’re not willing to, seemingly, the person may have something invested in being chronically ill, or in having this symptom. And sometimes I wonder if it’s, it gives them a way of controlling their lives life in various different ways. I’ve wondered if there was an obsessive compulsive component to it. Or if mood stabilizers would be a helpful approach to take if the antidepressant medications aren’t working, if that’s been looked at, and whether or not it’s really a personality disorder, which I hesitate to say. And these days, we think more about complex trauma. But I guess I wonder about in my client anyway, I wonder about secondary gains, sometimes. what would a person be giving up to give up being severely depressed all the time? Yeah, that’s


genius. I love it as definitely can see maybe some personality components here. And maybe something like a variant of mu chalices, some some level of yeah, as you said before secondary game, because right now, our boy, John has a lot of attention coming his way. As a so sick.


The client, I’m thinking about actually, I think has a significant amount of control over her family and the people she works with and things like that they alter their behavior, around a combination of anxiety and depression. And recently, she’s decided she’s going to try another therapist other than me, and I’m like, Oh, really? Yes.


Feel like a relief. Right, Carolyn?


I have to be really careful. I said, you know, I’m neither trying to give you the bum’s rush, nor am I trying to cling to you. And you have to make your own decision. So she’s going to interview some other people and make a decision about it. But yeah, I think at this point, I’m treatment resistant.


I think all of us have probably been there at some point. Yeah.


And also, I was wondering if the client, this client here in this scenario, we talk about, like, you know, how they been introduced to a lot of things and things haven’t stuck with long term. So I’m questioning the willingness for the actual client to accept and want change. Are these interventions being introduced to this client? And maybe is the client kind of, for lack of better term given up and not really going through? And seeing the interventions all the way through, to show to see, and so I’m wondering if that is made possible with the situation with the client as well?


Yeah, absolutely. Okay, so those really good points. And I would say with permission with the release of information, maybe psychosocial history from the family, both Carolyn, see what’s kind of control dynamics are there and Marlowe to explore Well, is there a history of this? Is there like, what did this guy actually accomplish? Or is there is this a repeated pattern of behavior or rephrase that? Is it giving up? Yes. Has that been a repeated? Pattern? Yeah. Does it make was that correct? How you’re trying to say that? Well? Yes. Okay. Cool. Thank you.


I noticed in the treatment that EMDR hasn’t been mentioned, has that ever been used? Because approaching that from a blocking beliefs perspective might be in service to uncovering some of


what’s beneath Are you? Okay? And can you tell me more about how would you go about utilizing EMDR and blocking beliefs,


his belief that some people aren’t meant for this world would be a good starting point and going beneath that? Okay,


cool. Thank you,


I would just like to point out that I love that each of you is bringing your experience theoretical and treatment orientations to the table. And everyone is finding these little glimmers of different ways this case could be approach, which is so wonderful about case consultation, because it allows the therapist Steve to hear about other types of therapy or other perspectives that might assist this client that he’s either not exposed to or hasn’t tried. So I think that’s wonderful the way you all are bringing all these different elements in. Okay, so for the purposes of taking this a step further, let’s presume all the things have been tried. At this point, John is saying to Steve, I’m tired of being everyone’s guinea pig, my family is supportive, I get that you’re trying to help me. I don’t see change on the horizon. And I really feel like the best thing for me to do is to go ahead with my plan. So this is this is where we’re at in the present moment. Thoughts, next steps?


Well, obviously, you have to, I would think you would have to explore whether a higher level of care is appropriate, be that partial hospital or inpatient care, and whether or not you might need to pursue that involuntarily if the clients not willing to pursue it. So they’ve said enough that if something happened, you would be very liable.


Okay. So if somebody wants to contemplate suicide, is that enough to break confidentiality, if they


if they express a plan and intent in the near future? Yeah, I would say


I agree to and, of course, we have to pay attention to our own state laws and regulations at the same time in the state of Georgia. Absolutely.


what I’ve done in situations like that in the past, is to run the case by somebody in emergency services and the local community services board, they will just about always tell you, you need to file a petition under those circumstances, because they don’t want to be liable. The problem I’ve run into in the past year or two, is that often the police won’t pick them up on an EC yoke, because they’re so busy. That’s a fine situation to be in. Absolutely. So I think you have to go through the motions and be able to document everything that you’ve done to deal with it. And also, if you have a release with a family member, being able to talk to them, or having them come into a session with you too, might be a way of evaluating that, or having the person go to partial as opposed to inpatient is a way of having them available, evaluated, day by day. So it’s less threatening than being locked up. And it also gives the opportunity for group therapy, which might never have been trying and for daily evaluations as to whether they’re safe enough to go home.


Does the client’s right to self determination come in play here at all?


I actually want to answer this, because I worked in palliative care for a year and a few months and one of our cases, we don’t have euthanasia here. But they do have in Canada, Denmark, other places. And, again, here’s the state laws, and you’re the federal laws, listen, your board all that stuff. But that one’s especially with international travel, that might be an area to discuss.


And I think that would need to be decided by the state agency that would evaluate whether they needed involuntary care or not. In the end, your decision is only whether you’re going to refer the person for involuntary evaluation.


I was recently listening to a podcast between a trauma therapist and suicide ologists. And their perspective was that in most states, a client being suicidal is not enough to break confidentiality, that the laws can be really specific around that. So I agree that you would really need to know your state laws, because you have an adult who is not in any type of psychosis, who is presenting with a long standing history and they’re saying this law I was miserable. I don’t want to live this life anymore. And under that scenario, can you break confidentiality. And again, this is going to involve people’s different perspectives, and probably also your licensure type, the, you know, I think there might be some differences in social workers versus psychologists versus licensed professional counselors, and each of those types of licensure, have guidelines about how you manage a case like this. So clearly, this is a very complicated situation. And I really feel for Steve, because this is really stressful. There’s a lot at stake here. But you also were trying to, you know, support the therapeutic alliance you’ve made with this client and respect his perspective.


I think imminent danger is I know, in the Virginia laws anyway, that phrase is in there. And it’s been interpreted different ways at different times. Right after where was the thing, Charlottesville? I think there was, right after that, they they actually retrained and I, they may have changed the state regs about that to some extent, and they were calling a lot tighter than they were in the past. And they’re, they’ve loosened back up again, because of the economic situation and COVID, frankly, but I think imminence makes a lot of difference if there’s substantial evidence that they’re going to be a danger to themselves or others in an imminent way that and that’s a real key. If they are saying, I’m going to do it soon. I’ve got it planned soon, that makes a lot of difference.


Okay, would this scenario change, if kind of what Steve was referencing that this is a person who has had really compromised physical health for a very long time, in such a way that there is no potential relief for the physical implications of the illness, that they are experiencing that there’s the doctors have basically said, there’s no hope that we can make this better for you. This is sort of like, this is the best it’s gonna get, does that change anyone’s perspective? Or do you still feel the same way?


I feel like that becomes a very, very slippery slope and a very gray area, because how how to you, whoever you make the distinction between the physical part versus the mental health part? what is that? Where’s that line full of when it becomes okay, this is the best it can be versus their mental state at the time. And I think it’s a very gray area.


I agree. And I think also, just just like you say, it really just depends on what’s happening. You know, you’re talking about somebody who’s coming into psychotherapy. But if you’re talking about somebody who is, I don’t know, they have cancer, for instance, suppose he had cancer, and you still have to go by the state and like the state of Georgia, we can’t do that. One thing I can tell you that I’ve been with hospice for over 25 years, I wrote hospice inpatient unit. And we can’t do it, we just can’t it is. It just is what it is. I have patients all the time. I have patients today right now on the inpatient unit, and no hope, but they’re on hospice is just it just just that you are so right, it is such a slippery slope.


Absolutely, yes. So I want to thank you all, for your participation. In this case, this, again, highlights this complexities of our work. One of my major frustrations when I do ethics training is that they give you all the scenarios of ethical conundrums. And there’s no right answer. And so I typically leave there feeling worse. Okay, you told me all the things that can go wrong, and the things I need to consider, but there really is no right answer. And so in a case like this, it’s super important that we consult with colleagues. And that is in your best interest not only in the way you’re managing the case, but for yourself and your license as well. Because if someone were to investigate a case that you were managing, and you went to court, or your licensing board was investigating, and they’re gonna say, How would your peers have managed the same case? And so in a case like this, especially, it’s so important that not only do you meet with colleagues, but that you document document document that consultation, specific names of who you met with the date, what were the considerations that were discussed? what were the legalities, what were the ethics, the client’s right to self determination, all of those things that were discussed. And then the the therapist deciding to either continue the treatment plan as it was already, you know, being implemented, or a new course of treatment was taken based on the cost consultation. So there is no right answer today. I think there’s so many facets of this, that can be really difficult. And so I want to I want to thank you all for, for going through the different scenarios with that.


Thank you. I really appreciate this.


Good. Yes. Go ahead. Marla.


I would just want to say I mean, this is me just being Marlo. My personality was talking to you guys for real now. Okay, straight up. Like this is where I feel, you know, as Georgia Yes. LPCs. We can 1013 our clients and this that any other can I have 100% agree about the documentation. Like if I was in that situation with the client today, I’m going to call everybody I need to call, I’m going to figure out some things. But at the end of the day, I’m going to trust my gut. And if I feel that I need to 1013 somebody and somebody be mad at me because I did it to save their life. Because I do not know whether or not they’re truly going to do it than daggone it, I’m going to do it. It’s almost like saying that you have a best friend guys or your best friend, you guys are out. She’s drunk, right? You I care that she’s gonna be mad at me by take her keys, she could be mad at me all she wants. Yeah, absolutely. I’m not going to take that chance. So I don’t know how you guys will receive what I just said,


yeah. Well, Marlo, I think you raised an important point. And this comes up over and over in our field is that our instincts, which have come from years of training and experience, also intersect with our values, okay, we can’t take our own personal values about humanity and what people deserve or should reasonably expect from a therapeutic relationship. And there are times that our ethics and our values might clash. And we’ve a couple of cases ago, we kind of got into some of that. And so that’s why the consultation documenting, you know, do a review of your laws, do an ethics consult with your professional body or your liability insurance company, do a literature review, like use all of the resources at your disposal, but keeping in mind that we are also humans, and we can’t take our humanity, our values out of the equation, nor should we necessarily.


I have a question with that. And I guess kind of just more from a practical standpoint, you know, consulting with all the colleagues with your licensing board with state laws, all those things, then this bit kind of sounds silly, but just from a practical standpoint, okay, that all of that makes sense. And all of that are things that we need to do and should do. But how do you reconcile that with like this person sitting in your office and saying, like, Yeah, this is this really likely might happen soon? You know, whether that’s today, tomorrow, next week, like how do you? And I guess there’s no right answer, but just I’m curious how each of you would approach that because there is sometimes I feel like that sense of urgency, and you can’t just get a bunch of colleagues on the phone. And don’t, don’t leave my office yet. Until I figure this out.


You can attempt to do that. And you can document that you’ve done that you’ve asked them to wait. And that’s, you know, you can’t restrain them yourselves. But you can have your somebody in the office or you even can call 911. And if they leave, they leave, that’s just like if somebody leaves your office drunk, you have some obligation to do something about that. Well, in


fact, that’s a good point with it. I was a while back, though, it was not a drunk situation. But if I know, for example, that a client has come into my office or whatever, and I know from the beginning, that we were not, first of all, we’re not having a session, that’s just not happening. Number one, we can’t have a session when you’re when you’re drunk or intoxicated. You just can’t, you know, so it gets just like you say Carolina just it really depends. And, and we don’t know, I mean, we taught in school, and we all know that. We never know if they’re really going to do it. We never know.


How do we decide? They may not know and the any, when somebody is that fragile, any small thing could make a difference and stuff. So I do think it may be helpful sometimes to explore what suicide means to a person. You know, they see that as relief from all pain. Are there other ways that they can get relief from pain at least briefly that that might allow them to hang on for a while longer? And to look at what suicide means and I one of the things I say to people sometimes who are actively suicidal, but maybe it felt that way before is sometimes I feel like it’s a safety mechanism. People used to say that they’re suicidal, because it means if it got terrible if it got so I couldn’t stand it any more, there would be a way out. And that makes them feel safe enough to keep on trying. Yes. And if that’s true with a person, then maybe you don’t necessarily have to go the involuntary route, if you can put together plans and contact a relative and things like that, but what suicide means to them, and how imminent it is, I think are the real important things. And I’ve been in a number of these situations over the years, and it’s hell for the therapist.


Yeah, absolutely. Yeah. And I think that that is something that we don’t talk about in society, the relief, somebody who’s really struggling might feel that maybe they don’t even want to kill themselves, but they just wish they would go to sleep and not wake up and normalizing that that’s a coping skill. But that knowing that that sense of relief, relief, that things are really bad, there is an out not that I have a thought about really doing it or a plan. But it’s a relief to know. Maybe I wouldn’t wake up one day, maybe I wouldn’t have to be dealing with this one day. Okay. Well, thank you all again, that was a really great conversation. There’s so many complexities in the case like this. And it’s so hard as the therapist to take that on. And to know that there’s a lot at stake when we’re, we’re doing this work. So I thank you all for sharing your experience and your perspectives today.


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