Clientele in psych-Do I have to work with sociopaths?

[rubisco88]

This question may be naive and silly, but after residency/fellowship can a psychiatrist choose to see certain groups of patients and not really see others. I'm interested in doing a child psych fellowship and prefer to see only children, geriatric patients, and women (eating disorders etc). I would also be interested in seeing couples as well for psychotherapy regarding relationships and sex.

Are all psychiatrists pretty much required to see criminals, sociopaths, and other types of highly dangerous patients or do you have an option? I imagine it's part of training to see these patients during residency, but do I have to once I start practicing. Will there be jobs available to see just a subset of patients?

I'm a tiny girl and I'd prefer not to work with that population. I also don't want any of those people going after my family.

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[birchswing]

As a patient, I hope this doesn’t sound offensive, but I think the more experience you have, the less you might believe the notions you currently have about people. It also might mean the less you want to do psychiatry at all.

As an aside, there is no DSM diagnosis of psychopathy. And it’s generally best to avoid calling people by a diagnosis anyway (“psychopath”). So, even if psychopathy were an illness, you would preferably say, “my patient with psychopathy.”

If a person had frank psychopathy in the sense that you see on TV, he/she probably wouldn’t be seeing a psychiatrist voluntarily anyhow. I know of no law that you have to see any particular segment of the population. There is a psychiatrist a couple hours away from me who does infomercials for really “soft” psychiatry services. It’s what I call greeting card therapy. Seems to be advertised toward people who don’t really have mental illness but have life issues they want to talk to someone about. She’s in private practice, doesn’t take insurance, and charges a boatload. And her pink web-site makes it pretty clear that she’s the squeamish type that is looking for women who think it’s scandalous just to say they’re dissatisfied with life. She has all these disclaimers about how she protects privacy by not taking insurance, etc., etc. Once you've been to a community services board as I have, you get over that "fear" of going to a professional because of wondering what your life has come to that you need help--which is the population she seems to be appealing to. I would not go to her for medication management or therapy, personally. IMO, psychiatry is about nuts and bolts—a soft touch is nice, but knowledge is key.

I’ve been around the block a few times with mental healthcare, and I think you’ll find that will be the case even with geriatric and child patients. I’m not exactly sure what you’re trying to avoid, but if it’s the baseness of humanity or disturbing issues, avoiding middle-aged men isn’t the answer. As a psychiatrist you need the ability to not be shocked by things and to have positive regard for your patients. I couldn't be treated by someone who I thought was squeamish around me or my issues. I haven't had that experience with psychiatrists, but I did have a PCP who was the squeamish type and it didn't work out.


EDIT: Also, are you from outside the US? People don't generally go after each other's families in the US. Maybe in Northeastern port cities, lol.

 

[wolfvgang22]

Psychiatric patients in general aren't as dangerous as many lay-people think. "Psychopaths", or more accurately, people with severe anti-social personality disorder or even sociopaths are in the vast minority of patients. When psychiatrists do see such people it is most often in a prison or hospital with lots of staff, security, injectable medication, and physical restraints available if needed.
Your size doesn't matter as a psychiatrist anymore than it does anywhere else. You aren't going to be engaging in wrestling matches with patients anymore than you do people in your neighborhood, probably less. Most psychiatrists, myself included, have probably never been touched by a patient.

Do not confuse people with psychotic disorders like schizophrenia with "psychopaths".
People with psychotic disorders such as schizophrenia are actually much less likely to harm others than people who have an active substance abuse disorder, according to available evidence.
I would worry more about people abusing drugs in your community, since there are so many more such people in the community and you are much more likely to be around them on a daily basis whether you know it or not - on the roads, in the shopping mall, etc. Patients, on the other hand, are seen in the controlled medical environment, and we don't tell patient's where we live, all about our family, and so on.

That said, yes, if you train as a psychiatrist you will have to interact with people who have committed crimes, harmed themselves, or harmed others. Such patients may have Bipolar Disorder, Schizophrenia, Borderline Personality Disorder, Major Depressive Disorder, Eating Disorders, Anxiety Disorders, and others. Part of becoming a psychiatrist is learning how to interact with all types of patients. If you don't, your training will be incomplete and you'd be a very poor psychiatrist.

You can choose to "cherry pick" only the healthier patients that are easier for you to relate to, but in my opinion a psychiatrist should think carefully about the ethical implications of such a practice. We are most needed serving those who suffer from downward drift of socioeconomic status due to their serious mental illness, in addition to those with less severe illness. The truth is most patients have no desire to harm his or her doctor in the first place. In my experience that even includes most incarcerated patients. I don't lose sleep over it.

 

[rubisco88]

No, I'm not from outside the US. But in some TV shows criminals, mafia members, etc will go after the person or the person's loved ones if they put them in jail, persecuted them etc. If a certain criminal/prisoner is really unhappy to see a certain psychiatrist isn't it probable that they may try to harm the psychiatrist or even their family.

Ah yes I meant sociopaths not psychopaths ><. But don't children and the geriatrics population also really need psychiatrists? Even more so. I thought there was a bigger shortage of child psychiatrists anyhow.

 

[birchswing]

No, I'm not from outside the US. But in some TV shows criminals, mafia members, etc will go after the person or the person's loved ones if they put them in jail, persecuted them etc. If a certain criminal/prisoner is really unhappy to see a certain psychiatrist isn't it probable that they may try to harm the psychiatrist or even their family.

Ah yes I meant sociopaths not psychopaths ><. But don't children and the geriatrics population also really need psychiatrists? Even more so. I thought there was a bigger shortage of child psychiatrists anyhow.

There's no sociopath diagnosis either. In common usage, they mean the same thing. Yes, children and geriatrics need psychiatrists. But consider this: pedophilia is a DSM mental illness. It normally first presents in adolescence. Can you help an adolescent with pedophilia with positive regard? I don't say that to be shocking but just to point out that I don't think that whatever you're trying to avoid will really be avoided by seeking out patients by age. A child with OCD can have thoughts where he's terrified he will kill his parents.

I see no why reason why you would be compelled to treat a prisoner. You don't "persecute" patients, either. Or prosecute them for that matter

In terms of mafia, that's why I made the joke about northeastern port cities

Out of curiosity, are you currently in med school or thinking of going to med school?

 

[BobbyB]

No, I'm not from outside the US. But in some TV shows criminals, mafia members, etc will go after the person or the person's loved ones if they put them in jail, persecuted them etc. If a certain criminal/prisoner is really unhappy to see a certain psychiatrist isn't it probable that they may try to harm the psychiatrist or even their family.

Ah yes I meant sociopaths not psychopaths ><. But don't children and the geriatrics population also really need psychiatrists? Even more so. I thought there was a bigger shortage of child psychiatrists anyhow.

since you think that TV shows are an accurate reflection of psychiatry, you should be more worried about your colleagues than your patients. haven't you watched Hannibal?

 

[wolfvgang22]

I want to be more clear, as most non-psychiatrist don't know:
Psychopaths are not sociopaths, though the two have similarities. Both are rare patients that have personality disorders. In practice, we usually just diagnose both psychopaths and sociopaths as "anti-social personality disorder" and they receive the same treatment.
People with psychotic disorders, such as schizophrenia, are not usually either psychopaths or sociopaths. Patient's with psychotic disorders generally have problems with perception (like hearing voices, or seeing things) and delusional thinking and trouble thinking in a coherent, logical manner. Most people suffering from psychosis are not criminals.
Psychopaths and sociopaths (Anti-social Personality Disorder) on the other hand usually have no hallucinations or delusions and are usually very calculated, logical, and organized and the main issue is that they lack empathy. They usually are criminals.
This is of course a very incomplete description.

Also, kudos to the original poster of this thread for asking and risking getting flamed. I didn't know most of this stuff when I started medical school, either. I remember I used to think negative symptoms = being depressed when I was a student.

 

[rubisco88]

I'm barely into my 2nd yr of med school. Haven't completed our neuro/psych module, so sorry for my wording. I don't think I'd be scared of the child thinking those thoughts. I'm scared of someone raping/ murdering me or hurting my family members and although it's possible a child can do that, I think it's less likely and the situation can probably be more easily put under control. Can't those with severe anti-social personality disorder pretend to be good though in order manipulate you? They just seem extra dangerous, especially if they are a middle aged man and I am a young tiny woman.

 

[Ceke2002]

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[Ceke2002]

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[dl2dp2]

Are all psychiatrists pretty much required to see criminals, sociopaths, and other types of highly dangerous patients or do you have an option? I imagine it's part of training to see these patients during residency, but do I have to once I start practicing. Will there be jobs available to see just a subset of patients?

I'm a tiny girl and I'd prefer not to work with that population. I also don't want any of those people going after my family.

I don't think the above posters have sufficiently answered your questions and some of the posts might've made you even more confused.

The reality is more often than not during residency, especially during public psychiatry and emergency psychiatry months, you would likely learn to manage patients with either a criminal history and/or have a diagnosable antisocial personality disorder. However, as a poster above had said (1) these patients rarely remember who you are if you are in the ER. (2) taking care of them on an inpatient unit is not the same at all as interacting with them in a usual way (i.e. very controlled, no touching, security everywhere).

Your size is really not very relevant in these situations, as you'll see once you start the psychiatry rotation. Avoiding assaults is more about interpersonal skills and deescalation than actual size. Small women are at less risk IMHO because patients don't feel threatened by you. I have never heard of anyone's family being pursued by a patient (for what? court mandating them for treatment? You don't have that kind of power.) Nobody can FORCE someone to TALK to a psychiatrist. People including criminals usually like their psychiatrist. That's a theoretical risk that's more of what you would see in a movie than in reality. Not every criminal is violent. Not everyone who's violent is violent to everyone. Learning how to deal with potential violence makes you less afraid and more informed. Given that more than 50% of psychiatry residents are now women, and many of them are very small, I don't think this is an issue at all.

Should you choose to work with a more affluent population after residency, this is certainly your choice and a possibility. However, in addition to potential supply-demand related issues (who wouldn't want to make a lot $$ treating fancy cooperative patients who smell good in private practice?), there are other issues: (1) without doing the actual work, I wouldn't make the decision so quickly. You might end up enjoying working with a certain population or a certain kind of work (i.e. addiction psychiatry, for example). (2) you don't really know what child psychiatry is like. The kind of daily headache may not be worth it (3) adolescents can be equally scary but for different reasons. I actually think a teenager who has ODD or CD is way scarier than a middle aged man with a criminal past. And believe me if you are a child psychiatrist, ODD would be your bread and butter. (4) wealthy people might not "murder" you, but your chance of getting sued by a wealthy person is higher. (5) geriatrics might be where you wouldn't get assaulted, but you might get tired of seeing delirium and dementia all day.

As you can see, there are various issues in choosing psychiatry as a career, but they aren't really the ones that you are imagining in your head right now. This will become clearer to you as you do your psych rotation.

 

[Ceke2002]

and some of the posts might've made you even more confused.

I think mine may have been some of them. I've gone ahead and redacted the posts in question, my apologies to rubisco88 I was hoping to put her mind more at ease by giving her a more realistic appraisal of actual threat risk when it comes to the way certain things are presented for on TV versus real world experience; however, I can see I may have wandered off topic a bit in my answer.

I will just quote and reiterate this:

People including criminals usually like their psychiatrist. That's a theoretical risk that's more of what you would see in a movie than in reality. Not every criminal is violent. Not everyone who's violent is violent to everyone.

Very well put.

 

[Elisabeth Kate]

I'm barely into my 2nd yr of med school. Haven't completed our neuro/psych module, so sorry for my wording. I don't think I'd be scared of the child thinking those thoughts. I'm scared of someone raping/ murdering me or hurting my family members and although it's possible a child can do that, I think it's less likely and the situation can probably be more easily put under control. Can't those with severe anti-social personality disorder pretend to be good though in order manipulate you? They just seem extra dangerous, especially if they are a middle aged man and I am a young tiny woman.

Your concerns are valid. I'm also a petite woman and I was concerned about the same thing. Yes, there is the risk of a patient attacking you as a psychiatrist (it happens), but that risk also exists in many fields of medicine, especially ER. The risk is there and part of your residency training should include safety skills and safety protocol as you will be seeing some potentially dangerous patients, especially on the forensics service. Once you're out of residency, there is no reason why you can't pick the patient population you'd like to see. You might have to go into practice for yourself, but there's no legal requirement that you have to see all psych patients. One of the great things about psych is that there are so many ways to tailor your practice. If you want strictly geriatric patients, there are jobs for you. If you want strictly child and adolescent, there are jobs for you. I wouldn't let this fear keep me from a field I otherwise enjoy. That said, wait until your third-year clerkship to make a decision. Psych is one of those fields that some love and some hate and you really won't know which camp you're in until you do it.

 

[slappy]

Can't those with severe anti-social personality disorder pretend to be good though in order manipulate you?

Manipulation is a central feature of ASPD. Anyway, to answer your original question, you would most likely have to work with patients you are not entirely comfortable with during your residency, but, depending upon what the job situation is like for psychiatrists in your country (unless of course you decide to practice here), you should be able to build a practice seeing only those you're entirely comfortable seeing. This versatility that psychiatry affords is perhaps its biggest strength in my opinion.

 

[F0nzie]

Stay away from forensics and court ordered treatment. Occasionally an antisocial personality disorder will sneak in with a misdiagnosis of bipolar disorder and it's like... no you're not Bipolar...you're just a very dangerous individual that likes to stab kittens and blow things up. If you do not feel safe you can always refuse to see them.

 

[Bartelby]

You will see ASPD / psychopaths during your residency, mostly in the context of malingering in order to get onto the inpatient unit for secondary gain (food and shelter, messing with other patients, avoiding a court date, etc). This means most encounters will happen in the ER or in the inpatient unit if they make it there. In fairness people with ASPD will also at times need legitimate treatment for substance dependence or other axis I disorders.

You will not be making determinations of whether someone is not guilty by reason of insanity, testifying in court, etc about psychopaths in residency. That is left to forensics.

The odds that a sociopath will go after you or your family in residency or afterward are pretty much zero. Why would they? Typically the only thing they get angry about is an earlier than desired discharge, and I have never heard of a psychopath following someone home over that.

 

[Elisabeth Kate]

You will not be making determinations of whether someone is not guilty by reason of insanity, testifying in court, etc about psychopaths in residency. That is left to forensics

Most (all?) psych programs include a rotation in forensics though. But beyond that one month, it is possible to avoid it, from what I've been told.

The odds that a sociopath will go after you or your family in residency or afterward are pretty much zero. Why would they? Typically the only thing they get angry about is an earlier than desired discharge, and I have never heard of a psychopath following someone home over that.

I agree that it's very unlikely one of these patients will stalk you outside the hospital. I think the most likely place a patient would attack you (and even that is a rare occurrence) would be at the hospital itself, not in some dark alley afterwards.

 

[psych md jd]

In private practice, if there are patients you do not feel you want to treat, you can refer them elsewhere.

My private practice is limited to the NGI . Some are sociopaths, psychopaths, sex offenders, murderers, arsonists, child molesters etc. Probably a serial killer or two as well. If they are not felons, I refer them elsewhere.

I would keep an open mind. By the time you finish residency, a lot of forensics will be via telepsychiatry.

 

[rubisco88]

I guess I've been watching to much law and order SVU. Yeah I've worked in the ER where I think a patient who didn't get pain meds or the treatment they wanted kept coming on the grounds to try and harm the ER doc that saw him. Thankfully, security was pretty good about keeping it safe. I just hope something like this situation doesn't happen frequently in psych. I'd probably just quit if patients were trying to go after me. I guess I'll just have to see how psych actually is 3rd year.

 

[Salpingo]

Maybe try dance therapy?

 

[Ceke2002]

I guess I've been watching to much law and order SVU. Yeah I've worked in the ER where I think a patient who didn't get pain meds or the treatment they wanted kept coming on the grounds to try and harm the ER doc that saw him. Thankfully, security was pretty good about keeping it safe. I just hope something like this situation doesn't happen frequently in psych. I'd probably just quit if patients were trying to go after me. I guess I'll just have to see how psych actually is 3rd year.

Yeah, TV cop shows not generally a good yardstick to measure the real world. I know the State/Country I live in (Adelaide, South Australia) has a lower population and probably a different demographic to where you are, but in all honesty I've been a consumer of the mental health system for at least 20 years and in all that time I know of only one major incident that has ever occurred. I've never personally witnessed any aggressive or violent behaviour from any fellow patients, whether within the private or community (Government run) systems.

My Psychiatrist works with a lot of Cluster B (personality disorder) types. He seems to have a fairly set protocol he follows when dealing with these, or any other patients:

- Set clear boundaries right from the start. Let the patient know exactly what is acceptable and what is not (eg 'Yes you may email me at my work address for therapy purposes, no you may not friend me on Facebook).
- Reiterate those boundaries if a patient steps outside of them (eg, 'Patient X, I have given you permission to email me notes for the purpose of conducting therapy with you; however, you have been emailing me several times a day often just to ask how I am or what I'm doing. I need to remind you that this behaviour goes outside the boundaries that were set at the start of your therapy).
- If the patient persists in violating boundaries, and the situation is unable to be resolved, be prepared to refer on.
- Keep your home address and telephone number unlisted. Ensure patients do not have access to your personal/private information, either in or outside the office.
- Use a separate email address for work/therapy purposes.
- Make sure your personal social networking presence is secure.

 

[LupaCupcake]

When I first got hired as a psychiatric technician I was very nervous. Our hospital is an acute care inpatient facility so our PTs come to us in the midst of some crisis and our objective is to stabilize them before they are sent to outpatient therapy or sometimes a long term care facility. I kept hearing horror stories and I was VERY nervous. The technicians are the staff members that put PTs in holds or restraints when absolutely necessary, the ones that have to run towards the aggression so I was not allowed to back off if it happened. I happen to be a military VET so that helped me feel more comfortable than you currently do, but once you are around PTS on a frequent basis that anxiety goes away. Fast forward through time and I am the patient advocate currently and I don't blink an eye when a PT is triggered. Just another day on a lock down unit and I try to calm them.

Yes, I have seen violent situations, but they are not a normal occurrence. I have seen physicians attacked, but honestly the PTS usually attack each other more than they attack staff. That is not to say that staff does not get attacked, it has happened, but we often see more bite than bark when it comes to that. I understand your hesitation with an aggressive PT, but you really do get used to it and learn how to respond appropriately. If you can get some time on an inpatient unit, it might help you to ease those worries.

Even if you have a PT with homicidal ideations and a long history of violence, that does not mean they will try to hurt you. Most of the PTs here know better than to attack the physician because that is the person that decides their DC date, what meds they get, what restrictions they may get. If they are going to attack staff it is usually the techs or nurses.

A few things I have learned while working in this environment.
1. Build a positive rapport with the PT. I cannot stress this enough. Some staff members here get yelled at by PTs on a regular basis because they lack this basic skill. Treat them with respect and show that you genuinely care and it goes a long way.
2. Set clear boundaries that are simple yet precise and stick to them.
3. Don't turn your back on a PT or place yourself physically in a corner or a room where they stand between you and the door.
4. If you are going to be alone with them, inform other staff members first.
5. If you have paperwork that lists triggers, coping skills etc. for the PT then read that over before you sit down with them.
6. Try and relax, they may be a behavioral health PT, but they are still human.
7. DO NOT give them personal information, contact info, if they find you on social media then block them immediately. Keep your personal life separate.

 

[Ceke2002]

also geriatrics isn't full sweet demented old ladies. agitation and aggression are the major reasons for psychiatric consultation in the geriatric population.

My late Grandfather in law used to work as a Psychiatric Nurse in one of the old state run hospitals here. Without hesitation he would always say the geriatric ward was the most unpredictable and dangerous to work on, because it was far too easy for staff to be lulled into a false sense of security and mistakenly let their guard down. I remember him telling me about the time he was taking one of the rookie orderlies through their induction/training and the orderly completely dismissed the warnings that a sweet looking, diminutive little 86 year old lady was in fact one of the wards most violent patients and should be approached with extreme caution. After said sweet little old lady had managed to break the orderly's arm, and throw him against a wall, he soon learnt to take warnings like that a little more seriously.

 

[LupaCupcake]

We have a geriatrics wing.
Wooooooooooo, we get some wild ones sometimes lol.

My mother has worked in geri for as long as I can remember. Nursing homes, not necessarily psych facilities although they often have a psych area. I remember them finding a knife hidden under a wheelchair cushion once....