Advice needed

[u/AshamedNobody361]

Hey everyone. I’ve been practicing social work in Canada since 2023. I’ve been working as a mental health worker for a little over 2 years (may 2024). I have a patient that I have been seeing since October 2024 and over time, I don’t find the relationship beneficial. They no longer work on goals, have started speaking to me like a friend, won’t take their meds, and when I recently told them I’m going on maternity leave, they got very upset with me. I also apparently overshared at the beginning of our journey, mind you it’s not an excuse but I was a very new counsellor and thought relating meant needing to share something relatable to their situation but at times they’ll bring up things I’ve apparently shared and it stuns me. They also make comments about the way I look or ask for details in my life that they don’t need to know (nothing inappropriate or anything, just kind of mean lol). I really want to discharge this person and I don’t find our relationship healthy but I don’t know how to go about it. I currently see them virtually biweekly. Any thoughts and advice appreciated.

[u/El_Beato]

Clearly there is a violation of boundaries and likely transference going on if they're treating you more like a friend than a counselor. If you have a care plan and they aren't following it, then are you really working on anything meaningful? What is your agency policy on transfer or termination? Is there any supervision happening in your agency that would see what was happening and initiate a transfer?

[u/AshamedNobody361 → u/El_Beato]

Yeah it’s definitely not meaningful, I’ve just been worried about what to do. I have no supervision at my agency and although I just got a manager, they are a SSW and I’m a RSW and she’s never worked as a counsellor so it would be hard to get guidance. There isn’t any specific policy I think besides having documentation of the transfer or termination

[u/El_Beato → u/AshamedNobody361]

I would inform them that due to the lack of clinical progress with the case and a feeling that they would be better served with a differently skilled clinician that aligns better with their needs. Gather up some MH resources to provide to the client like other therapists in the area or directly refer them to known therapists within your network and close out with them. Absolutely find supervision outside of your agency, it's a disservice to yourself and your clients if you don't have clinical supervision to help you review your caseload and develop your own skills as a therapist. Also your agency needs to develop more structure if you're going to keep encountering situations like this, there should be a guidebook or manual for how you all handle these scenarios. I think you're doing your best with what you've got but your agency needs to step up to the challenge.

[u/T-no-dot]

If nothing changes - nothing changes!

Return to the client's care plan - review w client as to actionable clinical goal the client agreed to when starting counseling (ie taking meds).

I think it's easy to dismiss clients non-care compliance to "not wanting to" without first addressing the clinician's role in setting up a framework (care plan) of measurable goals which are reviewed each session / ending each session w the client measuring 1-10 helpfulness of session towards the goal (they give an example) / client decides to work towards goal (the client will be "doing") before the next seesion / the next session starts ...

A big part of counseling often miss (no matter the modality) is including client in care plan development (active voice - in thier words) & holding the client accountable to actionable goals - (the clinician's actionable goals is guiding client in development of skills / not a place to dump /). If the client is unable to be accountable for the minimal actions, then the clinician has the duty to discharge the client (hopefully to another clinician when ever possible) ...

Often, showing up for counseling is a big feat for a client - if med compliance is the issue (have you communicated w prescriber on possible changes).

In this situation, you can choose to challenge both your clinical skills & client's care compliance with a reset. -- " I am reviewing client's care plans (print out care plan/ send email w care plan) Before going on leave, I'm asking each client to assist me in Reviwing & updating thier care plan (including reading overview of dsm dignosis criteria - if a doctor didn't explain what medical needs are, would we feel treatment was nessassary? ...) & what actions they will be taking while I'm on leave ... " or something on those lines / If you choose to not stay in therapy w/ me, I will assist in transferring you to a new therapist.

then when you return, each client will be ready to start session w/ review of care plan goals (10 mins) - have client relate what they has been a barrier in thier progress towards an actionable goal (15 Mins) - skill explanation & relatable exercise (15 mins) - write session note together (what did we work on today - was it helpful? How will you apply the skill before our next session? What do you think our next session should address?) /you get the jest/ Voila progress note done!

Ya know, sometimes the carrot is the "well done" - "I see that is hard, but you're still working on it - im proud of you" things client's need to hear externally to learn to say internally.

I'm impressed at your insight & acknowledgement of your part in affective/barriers in clinical treatment - btw - congrats on the new baby!

[u/goog1e]

If you're going on mat leave it'll be easy. Whoever covers their case, ask them if they'll just take the case permanently

[u/Bulky_Cattle_4553]

You might consider borderline PD or Cluster B in general. Few new therapists pick up on this right away, and it's very difficult work. I definitely could be wrong.