The Substitute Therapist

A resident colleague preparing for maternity leave asked me to provide treatment for one of her patients for 2 months. The patient, a young adult with a diagnosis of complex posttraumatic stress disorder (PTSD) and borderline personality disorder, had struggled with extensive impulsivity, substance misuse, and multiple suicide attempts and hospitalizations. This patient experienced adversity at a young age and as an adult struggled with disruptions in mood, suicidality, and use of harmful substances as a coping strategy. For the past 10 months, she had engaged in weekly individual treatment sessions. Because the patient was considered to be at high risk of suicide and impulsivity, clinic policy required weekly coverage of both therapy and medication management, but with a plan to adjust her sessions to every 2 weeks for the last 2 months of the 12-month treatment period, which happened during my coverage.

Context

Although one therapist covering for another is a common occurrence, little has been written about these temporary substitutions. Previous articles regarding the transfer of therapists have emphasized the importance and challenge of establishing trust in the therapeutic alliance, especially in the posttransfer period, when patients may be experiencing feelings of abandonment and rejection by the departing therapist and hostility that may be directed toward the incoming one (1, 2). Establishing a trusting therapeutic alliance is particularly difficult for patients with complex PTSD and borderline personality disorder (3).

The correlation between high levels of childhood adversity and extensive physical as well as psychiatric morbidities is well established (4). Complex PTSD is a diagnostic conceptualization that has been accepted and used by researchers for over a decade (3). For patients with complex PTSD, adversity usually occurs early in childhood, in a pervasive repetitive manner, and mostly within the context of family. Because of their long legacy of abusive experiences and the lack of safe and stable attachment figures early in childhood, such patients develop an overactive limbic system (5). As a result, they are more prone to scan their environment for potential threats in an attempt to survive their dangerous environment. Later in life, what was once adaptive becomes maladaptive because these patients become primed to expect the worst, perceiving most interactions as threatening. Mistrust is thus a fundamental obstacle in their interpersonal relatedness (3).

The therapeutic alliance becomes a challenge because such patients are easily pulled into old roles and projective identifications. They may reenact traumatic experiences that occurred during their childhood into the current therapy relationship, thus viewing the therapist as an abusive authority figure. This representation of prior experience may induce the patient’s anxiety about and mistrust of the therapist and a fear of judgment and criticism by the therapist, directly impacting the development of the therapeutic alliance (3).

Course of Treatment

For the previous 10 months, the primary therapist had been applying an evidence-based psychodynamic treatment called dynamic deconstructive psychotherapy (DDP) (6), which I continued to apply upon transfer. DDP is a psychotherapy approach developed for treatment of borderline personality disorder. Although further research is needed, randomized controlled trials of DDP conducted to date indicate some strong treatment effects for borderline personality disorder, depression, and psychosocial functioning compared with other available treatments (7).

In the DDP model, individual psychotherapy sessions are conducted weekly for a period of 12 months. The techniques used are aimed at remediating neurocognitive deficits in association (the ability to verbally represent emotion-laden experiences), attribution (the ability to view oneself and others as multifaceted and having complex motivations), and alterity (the ability to objectively reflect on oneself and others), resulting in a more coherent and differentiated sense of self (6).

DDP is more similar to mentalization-based therapy (MBT) than to dialectical behavior therapy in that sessions are unstructured and exploratory instead of being focused on teaching skills and problem solving (8). In MBT, an important focus is placed on the therapeutic relationship and the development of epistemic trust (i.e., trust in the authenticity and personal relevance of interpersonally transmitted information), which enables patients to expand their mentalization capacity and learn about themselves and others by being in a relationship (9). DDP also focuses on using the alliance in the therapeutic relationship as a crucial tool to enhance patients’ ability to deconstruct attributions about themselves and others. Unlike MBT, however, DDP does not encourage patients to focus on gaining insight into the motivations and intentions of themselves and others (10). Rather, DDP attempts to remediate the three neurocognitive deficits defined earlier and work toward self-acceptance through the practice of verbalizing recent emotion-laden experiences, offering new perspectives on those experiences to deconstruct simplistic polarized schema, and providing deconstructive experiences in the patient-therapist relationship to open new possibilities for relatedness (6).

At the beginning of the transfer, I learned that the patient’s therapeutic alliance with the primary therapist had been tenuous over the preceding month. I hypothesized that the patient, in a likely reaction to the therapist’s impending leave, was feeling abandoned by her therapist and jealous of the baby-to-be and its care, as well as having self-doubts about her ability to sustain herself without the support of her primary therapist.

In our first virtual session, the patient appeared tense and uncomfortable. At one point, her cat appeared on the screen. I shared the thought of how pets can sense our anxieties, approaching us to soothe our discomfort. She smiled, and for the duration of the session she appeared more at ease, recounting times when her cat helped her to contain difficult emotions.

A challenge arose during the second session, when she reported abrupt discontinuation of all psychiatric medications. I viewed this in multiple ways: one was that the patient was displacing onto me her anger toward the primary therapist, and another was that the patient was attempting to gain control over her treatment after a loss of control of who would be her therapist. From both views, she may have been testing whether I was trustworthy, depending on my reaction. Would I abandon her or discipline her? Would I allow her space for her own autonomy and respect her decisions?

In every session, I screened for risky behaviors, including substance misuse, overspending, binge eating, and frequency of suicidal thoughts. In contrast to my concerns and expectations, the patient continuously denied all such behaviors and functioned well throughout her time with me.

During the 2 months following transfer, the patient eschewed all psychiatric medications. Although her affect was mostly cheerful during sessions (she was always joking and smiling), intuition and experience enabled me to act in a way that allowed her space to connect with deeper emotions that she defended with humor. Within the DDP framework, we worked toward exploring and connecting to these emotions, and we worked through and integrated conflicting emotions and perspectives. In this work, I also provided her space to safely mourn both the loss of her primary therapist and the future loss of me, her substitute therapist.

By giving the patient space to reflect on her emotions and conflicts and by simultaneously being a therapist whose stance was nondirective, nonjudgmental, and empathically attuned, I noticed improvement in her overall functioning and ability to build authentic relationships with others. At the end of our prescribed sessions, she left with a strong alliance and shared happy tears of farewell.

Reflections on the Therapeutic Experience

Given the patient’s clinical history and elevated risk of impulsive behaviors and suicide before our initial session, I had concerns about my ability to contain her anxiety until her primary therapist returned. However, by our last session, my concerns were replaced with both a strong urge to continue working with the patient and sadness about having to leave. I was pleasantly surprised by her developing capacity to openly reflect on her emotions and by her ability to rapidly build a trusting relationship with me. I later learned that the patient successfully graduated from treatment and transitioned into monthly maintenance sessions, where she has continued to improve and grow both personally and socially.

I hypothesized that the success of therapist substitution in this case was due in part to consistency of the theoretical treatment model and techniques between therapists, thereby providing familiarity and comfort to the patient and fostering trust and confidence in the new therapist. Another key element may have been creating space for the patient to mourn her losses, thereby enabling her to move on and continue her therapeutic progress and growth.

My experience as a substitute therapist with a strong therapeutic alliance equivalent to that of the primary therapist, despite challenges at the start, was gratifying, and I can best describe the termination as hopeful sadness. I believe that sadness at termination indicates the strength of the bond built between us. At our last session, the patient expressed her appreciation for the experiences elicited from our work, noting that the 2 months of therapy with me were helpful and complementary to her previous 10 months of therapy with her primary therapist.

I consider myself fortunate to have had sufficiently nuanced clinical experiences with different psychotherapy modalities throughout my residency training and more fortunate to add to them the unique experience of being a substitute therapist. My psychotherapy training in evidence-based modalities such as DDP, supported by weekly supervision sessions, has equipped me to confidently help many patients with borderline personality disorder and complex PTSD and has allowed me to successfully guide patients through their journeys of recovery, self-discovery, and growth.