What will happen in counseling?

July 5, 2009 4:09 PM

What can my friend/former SO expect from community mental health counseling?

Long background explanation: I have lived with someone for 9 years. He has mental health problems, with an ever-shifting diagnosis. This shrink it's Bipolar I with features of personality disorder, last was Bipolar II, before that...well, assorted nuts. All his previous treatment has been pharmaceutical, barring some short-lived and disastrous attempts at counseling when he was a teenager.

Most of the time I don't mind having him around and may actually like him to be present, but sometimes he gets angry, and turns it on me. For example, his computer desk breaks, and this turns into screaming, getting in my face, and calling me names, with screaming soliloquies about my assorted personality traits as viewed by him. This has happened occasionally as long as I've lived with him. I find it unacceptable, possibly abusive, and after several years of broken promises and apologies, he is to move out very, very soon.

I have suggested he go to counseling for (what I see as) an anger problem, and he says he will ask his shrink next week. He is on SSI, so his options for counseling will likely be limited to a community mental health system we have here. What can he expect from this, assuming he makes it through the waiting list? They say they use CBT - does anyone have any personal experience of whether this is effective with anger problems? Are there any other useful alternatives for someone with questionable motivation and no money?

Note that SSI leaves people desperately poor, and we are leaving open the possibility that he can move back in when his new lease is up if this helps (although he says he's not convinced this is his problem). He has not been an SO for several years now, but he is still my good friend and I do not want him at any risk of surviving in shelters or starving naked in the street.

posted by dilettante to Health & Fitness (10 answers total)

To me it sounds weird that a psychiatrist would see him and give him diagnosis (and presumably medication), without advising him to be in therapy concurrently with that treatment. Community mental health is the place that most therapists start out in their training, but not all community MH workers are new trainees or interns, either. The great thing about community MH services for his particular situation is that anger problems are one of the absolute most common reasons for referral of most of the people who receive services (usually via child abuse or domestic violence charges, counseling mandated by a judge). So it could potentially be a great environment because he might have access to one-on-one therapy and group therapy as well.

CBT is shown in clinical research to be one of the most effective therapies for anger. Can't say whether it is appropriate for his particular situation, as it sounds to me like a lot more than just anger, but it may be a good start. The problem I foresee will be resistance to the process--he can't make any progress if he's not accepting of the idea that 1) something is wrong, and 2) he needs to do something to work on it. So hopefully he can take it seriously and see in an honest and open way what's really going on for him. Best of luck to you both.
posted by so_gracefully at 6:07 PM on July 5, 2009

Response by poster: To me it sounds weird that a psychiatrist would see him and give him diagnosis (and presumably medication), without advising him to be in therapy concurrently with that treatment.

Yeah, me too. But as long as I've known him, through two cities and three psychiatrists or so, they've only given him meds and pushed for him to take anti-psychotics (he won't, I don't blame him a bit), all in 20 minute appointments once every three months or so. The wonders of SSI, Medicaid, and poverty.
posted by dilettante at 6:11 PM on July 5, 2009

Medicaid will pay for him to see a psychiatrist but not necessarily a very good one. A lot of the doctors that work in community mental health settings are not staff doctors but contract doctors that float from site to site charging Medicaid on a fee-for-service basis, so it's to their benefit to see as many patients as possible. After an initial psych eval he'll probably be prescribed meds if he's willing to take them and then referred to outpatient mental health services. He'll probably have an individual counseling most likely with a clinical social worker and probably also a group also lead by a social worker.

These agencies vary TREMENDOUSLY in terms of quality of services, and while many are fantastic and save lives, quite frankly, some can be just awful. I would recommend finding a social worker or other mental health professional in your community who knows the local landscape and can steer your friend towards one of the better agencies.
posted by The Straightener at 7:40 PM on July 5, 2009

My DD is bipolar. For years, we couldn't get her into treatment as she refused meds and they wouldn't have her in a program until she was stabilized with medication. I'm in Canada, so the rules might well be different here. The old treatment for bipolar disorder is lithium. There are newer ones, one of which is an antipsychotic which, in low doses, is used for anxiety. She only agreed to take the meds when her doc gave her this one for anxiety. The minute she found out it was used for bipolar disorder, she ditched it. A few years later, she ended up with a similar 'anxiety' drug which has helped her stabilize. After over 10 years of pure unremitting hell and terror for her safety, she's doing amazingly well. You'd never know that she was any different from any other young woman on the street and she's busy getting her life together as if she'd just skipped over 10 years without noticing.

What helped us cope was the information sessions run by the local community health outreach that is a part of the psychiatric hospital. They had one for family&friends of people with schizophrenia, bipolar disorder and something else, run by two psychiatric nurses who had seen it all. They were also very helpful in finding resources for DD which I would never have found on my own. Mind you, getting her to attend anything while not stable (the odd one that would allow it) was futile. While she was not stable, it was impossible for her to plan or organize on her own or get to appointments. Sometimes I think the mental health system forgets who their clients are. I wish you luck.
posted by x46 at 9:42 PM on July 5, 2009

I disagree very much with The Straightener's comment. Community MH agencies are NOT solely staffed by social workers, in the vast majority of US states. Most social workers are NOT therapists in the first place, and social work is a whole different field when compared with psychotherapy professions (again, in many states in the US). I suppose that it probably varies a lot, because mental health licensing is different in different states, but Kentucky has psychologists, professional counselors, and marriage and family therapists in addition to social workers, and all of those professions train and work in community mental health sites. So if he uses a community agency in KY, he will likely get a therapist who is trained to be a therapist, and he is not as likely to get a social worker.
posted by so_gracefully at 10:01 PM on July 5, 2009

I didn't say community MH agencies were solely staffed by social workers, nor did I imply that a social worker is PhD. clinical psychologist, or a PsyD. therapist. I honestly wish that extremely poor, mentally ill clients going to community mental health providers on Medicaid with no income other than SSI were so assured access to top notch PhD. or PsyD. level clinicians as you seem to think they are, but my experience is that they are not. I am simply trying to prepare the OP for a reality based intro to the mental health care system as it is often experienced by the poorest of the poor, which her friend who lives only on SSI income qualifies as, based on my experiences in that system, working with that kind of client, and the kinds of services that type of client is likely to be qualified to receive based on the fact that they are on medical assistance.
posted by The Straightener at 10:29 PM on July 5, 2009

I hate to be negative, but I think that if he's not motivated to change, he won't change. With any form of councelling/therapy/etc, if someone goes in without a willingness to change and/or only because someone else is telling them to the chances of success are slim. He needs some sort of internal motivation.

You say he thinks this isn't a problem, to me it seems like he doesn't appriciate how his anger outbusts affect you. Before talking about how he can change this behaviour, I think he needs to think about whether he wants to, why he would or wouldn't, and the (positive and negative) consequences of both.
posted by bjrn at 3:28 AM on July 6, 2009

Response by poster: Maybe I should clarify: I have some tangential contact with community mental health in the course of my work, so I know how that's set up around here (and The Straightener is right, the therapists and staff in most of the offices in this state are LCSWs, with the occasional ARNP). I was wondering about the mechanics of the therapy itself - what is it? Little exercises, just talking? Does anyone know much about actual prospects with it? Does it really help? Also, while my friend has trouble with more than anger, I was focusing only on therapy for the anger/outbursts/tantrum issues.
posted by dilettante at 3:31 AM on July 6, 2009

Best answer: Try reading up a little on the recovery model of mental health service provision, which will give you some idea of the principles (hopefully) guiding the service professional your friend interacts with. As far as specific modes of therapy, again, it varies widely. Maybe he gets a social worker individual counselor who is up on CBT and weaves it into the recovery process, maybe he gets one who has no idea what CBT is, you really don't know what you're getting when you go to a community mental health provider until you get it, at least that's what I've seen.

Basically, since he's on Medicaid he's going to get as much therapeutic interaction as the county says he can. The previous instances where you say he received medication but no out patient care may have been due to funding issues. Also, if he has previously been referred to treatment and either didn't engage or was unsuccessfully discharged, that plays a role in funding decisions, also. The county gatekeeper agencies that make decisions about who to fund or not to fund generally like people who stick with treatment. If you don't complete treatment and later enter the system again needing emergency intervention that unsuccessful treatment is kind of considered a waste of money. Money is seriously tight right now since municipal, state and fed budgets have gotten killed. Services that used to come easy are more difficult to secure for all of my clients.

If you need medication, usually you can get that funded without much difficulty, but everything else isn't considered as vital when dollars are tight. Which is why the idea of landing an ongoing therapy slot with a PhD. psychologist is pretty far fetched, the fact is that a social worker is going to bill a lot less for what managed care companies consider to be an identical service. Considering your friend's housing problems and your concern that he may wind up on the streets, a social worker might be exactly what he needs. Psychologists don't know housing subsidies from a can of paint and wouldn't know how to help him find one. Loss of permanent housing is one of the biggest factors in accelerating the decline of many people struggling with chronic mental illness.

Anger management classes are generally not considered to be the strongest set of services provided in these kinds of settings, in the context that I have worked with them. I have many clients who are stipulated to anger management by the criminal justice system, very few report gaining any level of insight from these classes that helped them radically change their behavior.

I hope I'm being cynical and your friend's treatment is fully funded for the highest level of quality care he can receive. However, be mentally prepared to see him come up somewhere shy of that.
posted by The Straightener at 6:48 AM on July 6, 2009

Response by poster: Well, so much for that. I managed to get him an appointment for today for 12:30, and he went. He arrived and was told the person he was supposed to see was not going to be there until after 2. No, no one tried to call here to reschedule. He agreed to reschedule for Thursday, but came home and canceled the appointment because he says he doesn't need another stressful obligation and they charge $10 for missed appointments (and Medicaid gets hit for $160 for every appointment that's kept). He was also informed while he was there that in August the office will be moving out beyond easy bus range. The current location is 5 blocks from the central bus hub deal downtown.

Yeah, thanks a lot, CompCare.
posted by dilettante at 2:25 PM on July 20, 2009