This ended differently than it started.

I'm not used to blogging about my countertransference with patients. I'm not used to walking away from a situation feeling like I fucked up, either. Yesterday my therapy session with my patient, my 16 year old who shows up routinely in my dreams now, ended abruptly when she asked to go back to the unit. That was a first. Within an hour, her mood had gone from generally pleasant to neutral to dysthymic to totally despairing and hostile. And then she returned to her room to throw out all of her books because she was never going to learn to read, and nothing was ever going to change that. The whole premise of our treatment is that her attachment to her therapist is curative because the experience of relating is corrective, and need-meeting, blah blah blah. Not to mention the trauma work, the anxiety management, the reduction of self injury. I can get really bogged down in the laundry list of things to do for and with this patient. I didn't start out that way. Only recently have I noticed a shift in my own outlook, wavering in my unconditional positive regard. I hear myself saying ridiculous things in my head like "if you only knew what I DO for you!"I imagine her other caregivers have said these things to themselves, or worse, to her. She pretty much feels like crap about herself all the time. It seemed like in our Monday session, she descended the well and hit the bottom, where the fundamentals of her world lie: I am worthless and others are not to be trusted/won't take care of me. She said very pointedly to me that I am only here because I am paid to do therapy and don't actually care.

Diana's internal response: "Would I have dragged your ass to the dentist three times to resolve tooth pain if I didn't care? Would I have gone to TWO stores to find the right shoelaces for your sneakers?"

Now I know the hazards of working with chronically traumatized and [gasp] personality disorder directioned adolescents. It can be exhausting, good boundaries are absolutely necessary, as are a clear treatment plan and map of where the hell you're going and what the patient needs. When I get really frustrated, or thrown off course, I usually turn towards the experts in biblio-form and read. This assures me that my experiences are expectable, normal, and I also get reassured that I knew the pitfalls all along. I get reminded of my overall treatment plan and get steered back toward a more moderate and less frustrated viewpoint. It all becomes less personal and I am free to be more present and precise in my interactions with her, rather than feeling like I got hit with an avalanche.

This week it seems like it has been harder to turn myself around. I've shunned my books, and anything work related in my non work time. I spent hours negotiating some office politics, when a directive about my patient was handed down to me from on high that I didn't understand, and didn't agree with. In the end, the outcome was probably the same as if I had just complied in the first place and not thought twice about it. The directive bothered me though. I was told to help my patient accept having a male psychiatrist even though she has explicitly asked not to have one. I bitched and moaned to myself, conversed and clarified with others, and in the end way too many cooks got into the kitchen. I wanted to be oppositional, say "fuck you" to the psychiatrists and not help, because of the lack of awareness of the issues that plague my patient, and why those issues cause her to be stressed in the presence of men. In the end I didn't say that, and instead issued a set of recommendations for my patient's care and changed the goal. I agreed to help the male psychiatrist begin to have a relationship with my patient, which is a totally different expectation. It was utterly exhuasting to sort that out and communicate with all involved.

Next, I heard that admissions to our residential and day treatment units have been closed indefinitely. The word is, we may never get new admissions, and these units may close. Ummmm, what about my training experience? Well, none of the executive administrators will say a word about it except that a decision will be made in a month. Maybe. I don't know if post doctoral fellowships will remain. I'm guessing they will, but the format and details will be changed, doubtless. Who knows if it will fit for me. Who knows if there will be enough information to even make a decision when it comes to application time. I spent an hour today revamping my post doc application list, perhaps with the idea that I wouldn't live here next year. I got thrown back into the anxiety of not knowing, kind of like when I was waiting to hear where I matched for internship. I went back through those emails, reread my match notification email, my offer letter here at VTCC, and just sort of reminisced about that time. I dealt with it then, I'll deal with it now. I suppose forevermore I won't have that 5 year plan locked down, since I'm in my final stretch of graduate school. Time to accept!

I'm still considering Virginia (Charlottesville, and Richmond if the post doc here is acceptable), Atlanta, D.C., Boston, and Chicago. Maybe Ann Arbor. Maybe NYC. Probably not NYC. My parents would kill me. Texas has a lot of options too, but I don't know if I would elect to move back like that for a year.

In the meantime though, I'm now working under the assumption that I won't be getting any new residential patients ever. I need to refocus my goals for what I need to get out of my training experience here, and take on some new outpatients. I can be an outpatient therapist. In fact, it might be a nice change of pace. I have wanted to spend more time on assessment since I half-assed my first two I was assigned here, and its a clinical task I previously loved. I need well-wrtten, recent assessment reports to send off with post doc applications anyway. I'm beginning the research for a journal article, to be written in collaboration with my mentor Helen and my colleague Grace.

This too shall pass. And this weekend, I'm going to NC to see my mama!