This happens a lot with my BPD patients, and it almost always backfires; I may think the help I’m providing isn’t sufficient and that they need a higher level of care, so I try to refer them out, which is exactly what they didn’t want to occur. Remember, a therapist can’t read your mind. If we think you’re just continuing to struggle or that the resources and tools we’re offering aren’t helping, we will look into other options for you. This could mean we think you need a day program, hospitalization, or possibly a different therapist altogether. If this has been ongoing for a while, it will be hard for you to convince us that you are actually doing much better. We may become confused and think that you are now pretending to be better to stay with us.
The fourth thing you shouldn’t tell your therapist is that something is working great when it’s not.
If something isn’t effective for you or the advice we offered isn’t relatable, please let us know. It’s our job to provide options we believe could help, and it’s your job as the patient to give them a try and inform us if they’re helpful or not. If you know you aren’t going to be able to do something—for instance, if what I’m asking you to do or the homework I’m giving you feels overwhelming or isn’t something you’d enjoy—please let me know. It doesn’t help anyone if you pretend you’ll do the homework or try a new communication tool when you already know you won’t follow through. A good therapist won’t be ego-driven about it either; we want to offer various things that will really work for you, so just speak up and be honest about it. That said, if we find ourselves always rejecting anything and everything our therapist offers, we might want to consider if we’re genuinely ready for therapy or if we’re being overly defensive, as there is a balance to this as well. It’s normal to not like or want to try all the things our therapist suggests, and we expect that from you.
With that, let’s conclude with the things you may be nervous to share but definitely should.
Number one: any thoughts of suicide.
I know, I know—everyone is so scared of being hospitalized, and I completely understand. But it’s important to know what your therapist’s protocol is for situations like this. You can ask right away, even in your first session. You might inquire, “Just curious, when do you have to break confidentiality? If I have thoughts of suicide, what do you do?” It’s okay to ask these questions. In fact, it’s crucial that you know, so that if you’re struggling, you understand what the next steps will be and feel safe sharing what’s really going on with you.
To give you an idea of the process most therapists follow, including myself: I first assess your risk, then put together a safety plan with you. Next, I have you sign a safety contract for the time between our sessions, stating that you won’t harm yourself until we meet again. If that’s not enough and you’re still at risk, I’ll ask who I can reach out to for a safety check if I can’t contact you—if I try to text you and don’t receive a reply, who else can I get in touch with? If that still isn’t helpful, I will discuss the option of taking yourself to the hospital, which is the last resort. We know no one wants to be there, and most hospitals aren’t very therapeutic, unfortunately, but it can prevent us from acting impulsively and harming ourselves.
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