How to keep your composure during an interview?

[punkedoutriffs]

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I was in clinic yesterday w/ a patient who was having real trouble articulating himself and was rambling on and on, but he did it in a way that made it real hard for me to not bust out laughing, like "WTF is he talking about? LOL." I know it's bad, but I swear I almost lost it in there and was really thinking about excusing myself from the exam room. But it brings up a legitimate question. I'm sure that somewhere along the line, you guys have had a patient that said or did things that challenged your ability to keep your composure. Do you have any tips?

This is what I'm afraid of, that in the middle of an interview, I'll just go:

 

[F0nzie]

I've had this happen to me several times in the ED and inpatient unit. Happened again yesterday in the outpatient clinic but I was lucky because the patient burst out laughing and so did the rest of his family. Just excuse yourself and let it out 🙂.

 

[Armadillos]

In this situation I've literally bitten on my tongue to the point its painful to keep myself from laughing. For me the toughest times to keep a straight face are when schizoaffective patients get super grandiose.

 

[Psychedelicious]

How about reminding yourself that those patients you are seeing are actually suffering from a biological disease which is making them "funny"?

 

[digitlnoize]

It can be hard occasionally. I was very worried about this during med school, but I found that the more psych I did, particularly by the time residency started, the more sympathy I had and the less I found it funny. I find it helpful to try and "detach" a bit and make it more clinical. Are they circumstantial or tangential? How disorganized are they? Become a tape recorder and memorize or write down some juicy quotes to record in your note.

Nevertheless, sometimes it just happens. I haven't done it in a long time but Tuesday a patient started talking about our judge masturbating onto his chair and I lost it. I hide behind my note paper when this happens.

 

[whopper]

Watch the above first



The last time I almost laughed was a patient who was in his 50s, a rather unattractive man that made Cliff Claven look like a hunk (and ironically the guy was too a postal worker) was manic, parked his car in the middle of a crime ridden neighborhood, opened his doors, kept the car running, and blasted music while dancing sexually. The locals yelled at him to leave (trying to help him) because they knew he was out of place and yelled things such as "White guy get out of here!"

After him being there for 20 minutes, his car blocking the road, some kids went into his car and stole it. The police came by and dropped him in our PES. I asked the guy what he was doing and he told me he had the power to seduce any "Black woman I want" while talking (or more like attemping) to talk ghetto, and I asked him what made him think he had this power. He started dancing sexually, gyrating his hips, while his belly fat going through his t-shirt flopped up and down.

Whenever such things happen I do feel bad afterwards because the guy's car was stolen, I don't think he'd get reimbursed by his car insurance (most have a rule that if you left the keys in the car you don't get reimbursed), and his mania was destructive upon him.

But I also reminded myself I'm human and if a resident almost laughed, I would've congratulated them for not laughing. What ended up happening was I was about to laugh, it got up to a smile and then I intentionally coughed to wipe the expression off my face, walked out of the room for a few minutes to compose myself and walked back in.

The time before that, a guy was in court, and his lawyer, known for court theatrics, was arguing that I was being unfair and unjust in holding the guy against his will. I went to the the stand, told the court the guy was psychotic and lacked capacity and that he refused a PPD test and CXR so I was concerned he had tuberculosis, and that I needed the court to allow me to force the labs.

Within a second, the defending lawyer heard it he immediately looked at his client in horror, and moved his seat from right next to the guy to about 15 feet away. I was on the witness stand so I did my best not to laugh.

 

[Bartelby]

You have to read the patient--- sometimes with, for instance, a manic patient they might be glad to laugh with you and it might build rapport (but if in doubt I would err on the side of not laughing!). Overall though I agree with Psychedelicious, often times those who seem the funniest are the most drastically ill. I run through quickly in my mind the immense suffering their disease has caused to them and those around them and consider how I might feel if I or a loved one developed the same syndrome to the same level of severity. That's often enough to tone down any gut response to one of more serious compassion.

 

[hamstergang]

How about reminding yourself that those patients you are seeing are actually suffering from a biological disease which is making them "funny"?

I don't see how recognizing this is at all inconsistent with laughing when your patient says something funny.

Personally, I just became very good at biting my lower lip.

 

[Chimed]

I don't see how recognizing this is at all inconsistent with laughing when your patient says something funny.

Personally, I just became very good at biting my lower lip.

I agree. In my mind, there's a big difference between finding the humor in what someone is saying to you versus laughing AT them or their situation. It's only natural to find some of the bizarre stories a patient tells to be humorous. However, I have used trying to change my mind set unto how much the person in front of me must be suffering as a way to avoid an inappropriate facial reaction, if it seems like it would be inappropriate to show my amusement. But I do that mainly for therapeutic purposes rather then because I think I'm some how cold and insensitive if I think something my patient tells me is funny.

 

[Psychedelicious]

I don't see how recognizing this is at all inconsistent with laughing when your patient says something funny.

Personally, I just became very good at biting my lower lip.

Because if you recognize that, it simply ceases to be funny. I am not yet a resident but I have seen quite a few patients with bizarre delusions owing to the way our hospital is set up and I have not once had the urge to laugh during any of my interviews.

 

[Nasrudin]

Because if you recognize that, it simply ceases to be funny. I am not yet a resident but I have seen quite a few patients with bizarre delusions owing to the way our hospital is set up and I have not once had the urge to laugh during any of my interviews.

I understand what you're saying. Intellectually it makes sense. But like the interesting video whopper posted you can be in a situation where something strikes you as funny and the fact that your not supposed to laugh can make it worse. It's possible. And once laughter and it's suppression take over your thoughts it's very hard to recover. I haven't faced this with patients. But I did experience it as a teenager facing the cops. I couldn't help myself from laughing even against my own interests let alone somebody else's.

Come to think of it, it happened again on my surgery rotation last year. We were getting our butts chewed and my friend made me laugh, and the more the surgery resident glared at us in increasing levels of rage the more I couldn't contain my laughter. Maybe this isn't the same for all minds. But offense or insensitivity are not the motivation in these cases, at least as I'm relating to them.

 

[Ceke2002]

I totally agree with learning to read the patient. Sometimes laughter in session can be a good thing, other times not so much. My Psych and I often get into little banter sessions, and will crack jokes and laugh back and forth with one another. It makes me feel more at ease, and therefore more likely to start opening up about the deeper stuff. And yes he has laughed, well more like chuckled and made a sarcastic quip, when I've been describing some of the psychotic symptoms I might have been having at that time. I've never taken it personally, I've usually countered with a quip of my own and then laughed along with him. I know the things I see, hear, and/or think sometimes aren't exactly normal, being able to laugh about them though makes me feel more like a person and less like a shapeless lump with the word 'mental patient' stamped across it. Having said all that; however, if I come in in a paranoid, depressed, or clearly anxious state, he will then take the cues from me and adjust the session, and his approach accordingly. To give an example I came into session one day having paranoid ideations centred around hidden filming and listening devices and was freaking out at the site of any sort of TV or computer screen. He didn't crack jokes with me, or laugh about that. He let me know when he was switching his computer on, made sure I was okay with that, and turned the computer screen away from me so I would feel more at ease. Same patient, different situations, different approaches.

 

[Ceke2002]

Just adding to the above. I probably shouldn't be saying this, but back in the 90s my then partner and I would hold impromptu dance parties in the grounds of the local Psych Hospital (think old style Asylum set up). We'd park our car in the car park at night, stick on some rave tunes and crank the volume up to 11. Those patients who weren't in lock down would sneak out and come chat and dance with us. Most of them were people we'd previously met and befriended at other places (mainly the University where my partner was studying computer science), others we met on the night and got to know then. We knew to be careful of the paranoid schizophrenics in terms of any sort of banter or shared laughter, but the rest of the patients who came out to party with us - well let's just say some of their dance moves were creative, to say the least. and it was near impossible not to laugh. Because we'd gotten to know them we knew who we could start teasing and having a laugh with, and believe me they'd give back as good as they got, 9 times out of 10 we'd all end up doubled over at the sheer humour of the entire situation. I remember one night in particular I was feeling a little more reflective and suddenly had a guilt attack over laughing at people, friends, who I knew were very, very ill (and doubly guilty, because there but for the grace of insight go I as well). I sat down with one of the female patients, who I'd regularly teased and laughed with over her bizarre dance antics, and apologised if I'd ever hurt her feelings. She laughed and told me not to be so stupid, she knew damn well how crazy she looked when she danced like that, but she didn't care it made her feel free. And if people wanted to laugh and tease her about that, it was fine by her. Like I heard from many other patients, and like I've experienced for myself, laughter made them feel human and connected to others. It was pity they didn't want.

I'm still amazed that the staff never came out to admonish us for what we were doing, I mean you could hear the car stereo blaring for miles around the block. Apparently they were happy to turn a blind eye though, because the patients always came back in happier and better behaved.

My point in all this rambling is sometimes laughter can be healing and as long as you're laughing with someone in a sense of camaraderie then don't try to suppress it, you never know what sort of connections can be made through shared experiences of humour*.

(* Of course I'm not advocating you turn your practice into a stand up comedy routine and crack up in fits of hysterics at ever patient that walks through the door 😉)

 

[hamstergang]

Because if you recognize that, it simply ceases to be funny.

Well that's just not true. Allowing yourself to relax, be human, and want to laugh when someone says something humorous does not have to impair you in any way in your ability to care for the patient and be empathic. Just because someone is sick doesn't mean everyone around them has to be all serious and somber. What a depressing world that would be.

 

[Psychedelicious]

Well that's just not true. Allowing yourself to relax, be human, and want to laugh when someone says something humorous does not have to impair you in any way in your ability to care for the patient and be empathic. Just because someone is sick doesn't mean everyone around them has to be all serious and somber. What a depressing world that would be.

We are probably talking about two different types of patients here. I was referring to patients who have "trouble articulating" or are "rambling on and on". Both are quotes from the first post on this thread. I would never find those "humorous" - at least I never have. I don't find bizarre delusions humorous either. I'm constantly searching for weird associations and wondering why they are having such associations anyway (not that they are clinically relevant in modern psychiatry).

 

[shan564]

I think that the more experience you get, the better you get at restraining yourself, simply because you quickly get to the point where you've heard most of it before. Common things are common - so a majority of patients will have symptoms that are similar to things you've seen in the past, which makes it less novel from your perspective, which makes it easier to see it objectively.

 

[hamstergang]

We are probably talking about two different types of patients here.

No, we are talking about the same patients.

And finding it humorous doesn't stop you from working on understanding the associations and their causes.

 

[Psychedelicious]

And finding it humorous doesn't stop you from working on understanding the associations and their causes.

Didn't say it would. I simply do not know as I had never found them humorous or worth laughing at to have been in such a situation before.

 

[Ceke2002]

Just thought of an ideal example where humour/laughter in a situation with a patient might well be of benefit. Bearing in mind that I'm talking about a group of lay people, there was an old friend of ours, many years ago, who at times could become floridly psychotic. His biggest trouble was sticking to his medication regime, because he'd feel better on the meds, think he was cured, go off them, relapse, end up back in hospital again, and the cycle would go on non stop repeat again and again. One night he up and declares that he owns a Ferrari that changes colour depending on what speed he's doing. He was really pumped about it and there were 3 of us in the room all laughing at this awesome idea of a car that changed colours and going 'Oh man that sounds great, tell us more'. It got him talking, first in overly excited details about the car and its chameleon like abilities, then as we continued to share a laugh and encourage him to keep chatting with us the conversation slowly meandered into one where we ended up talking about his decision to give up medication, the effect that was likely to have, the fact that he was able to admit he could feel his illness returning but thought he could handle it. We were able to offer encouragement, and gentle reminders that going by his past history it was more than likely things weren't going to get better, not without some form of medical intervention. Because we'd established a rapport through being able to have a laugh and just relax and shoot the breeze with the guy, it allowed him to be more open and allowed us to eventually at least get him to agree to touch base with his Psychiatrist.

You get to know someone well enough over a period of time, and chances are you'll also get to know the best way to respond to them in any given circumstance.

 

[gabafan]

I have found it important to laugh about bizarre pt. stories with coworkers in a setting (away from pts, o course). The work that we do is very taxing, though we may not always realize it. In the interview, I've perfected biting my cheek, not my tongue, or coughing as a way to conceal a snicker.

 

[StECT]

coughing as a way to conceal a snicker

Oh how many times have I done this!

 

[Tza]

I'm an international graduate and in my school, no one laughs at all. It is considered culturally very rude and greatly frowned upon if you were to so much as snicker in front of the patients.

 

[Chimed]

I'm an international graduate and in my school, no one laughs at all. It is considered culturally very rude and greatly frowned upon if you were to so much as snicker in front of the patients.

It's considered rude to laugh at a patient in any setting. But adding humor in an interview can be extremely effective if done with respect, with the right patient, and in the right setting. It can show your humanity and that you're not a cold psychiatrist. But snickering in front of a patient when they're clearly troubled and telling you painful things is extremely rude regardless of the cultural background.