I must be doing something wrong? I guess?

[Psychobabbling]

I've noticed this recurrent issue that continues to pop up and it is kind of demoralizing.

1) I get criticized for identifying personality traits in people. "You focus too much on personality" is a common phrase I hear. Example: I have a pt in their late teens. Mom was depressed, alcoholic, verbally abusive, rejecting. Felt unloved. Started cutting at a young age. Went to the ER because her long distance boyfriend wasn't responding to texts "good enough" and became "suicidal." I, (at least I thought, unsurprisingly), identify certain borderline characteristics. I am then told I need to "read more about children of alcoholic parents" and that "some kids just cut these days growing up...." I note to my attending that in her counseling sessions, addressing these relationship issues/subsequent suicidal thoughts, may be fruitful. I am somewhat dismissed

Fast forward 3 months. Pt comes in "irritable" at her boyfriend, who had a loss recently, and wasn't making enough of an effort to stay in touch with her. Felt rejected. Began to get tearful, then started telling me her medication was no longer working (low dose SSRI) and she was having "thoughts" again, and I needed to do something. In the midst of the interview, my attending decides to enter the room, unannounced. Both I and the pt lost our train of thought as we were in the middle of something significant. Later, I am critiqued for "not continuing the interview" (possibly, because I was post call the night before, was working on little sleep, again, and she pops in at the end of a visit). Of note, she addressed the pt in the interview as she typically does for any borderline patient (your emotions are strong huh, are you interested in DBT, etc).

I was "focusing too much on personality" initially, which was wrong, because she wasn't "annoying" or "splitting" on visit 1 (the only one the attending has been apart of thus far), pops in during a visit I figured was inevitable, and then calls "cluster b" - but that's ok, and somehow, I wasn't doing enough in the interview. I was told I need to be "more motherly" for these patients, and that, my usual approach of allowing a person to express themselves, validating them appropriately, and working with a patient on a resolution, just doesn't cut it. THEN, I'm told I need to "giver her a break! It's hard being in a relationship!" (Smh....wtf....what are you even saying, I didn't say I didn't care!!!!!!)

#2 - I have a woman who I saw initially with my attending (same one as aboe). SHE encouraged me to "take her on as a therapy patient," (which may be contributing to the following, because she became a 'special' patient, she declined weekly therapy with me, however). In my interview, I took an approach as to where I allowed my patient to express themselves and provided empathy in the form of non verbal cues. I was told I did a "great interview, and really provided a safe, warm, holding environment...." But that I "could offer more 'motherly love'" if I felt it was warranted (which I did not). Subsequent visits with this patient has led to rather interesting encounters. She comes provocatively dressed, removes articles of clothing, touches my hand if I hand her a script/card. When I first addressed this with my attending after her first follow up visit (I was alone for that visit, as my attending was not in that day...) I was told I was "over-reacting" and that I needed to explore my "unconscious desires" (seriously?). Luckily, counselors that were there came to my defense, and noted she was dressed "like she was going to a club, and not a doctors visit" (keep in mind, some days it was like 20 degrees out, no, she is not hypomanic). The third visit, after talking to my psychotherapy supervisor for some amount of supervision (development/object relations analyst), he pointed to developmental theories behind HPD in an effort to promote further understanding, what may be considered rejecting/helpful to her, sort of "promote" empathy. I took a developmental history (brief) at our next visit, and my attending suggested I had "ulterior motives" in gathering a developmental history (WTF?). She then tells me I should keep appointments short and to the point, and if I do that, I then hear "oh, that was probably you're shortest interview ever, huh?" remarks.

----------
These are two brief examples, that happen rather often. I am accused of "focusing too much on axis II and not axis I" - even though I am rarely given negative feedback of my actual management of, or diagnosis of, axis I disorders (former axial system). I generally don't see axis II as this taboo neverland, but some of my attendings seem to only reserve it for that "annoying" patient, with me ever only seeing people comment on someone being "borderline, narcissistic, or antisocial..." To the point that you'd think only these 3 exist.

And I always leave open that I might actually be wrong. I ehave ven commented on my notes how X led me to believe Y, and after further data points, X seems more so related to Z instead. I then reframe my formulation, and if needed, alter my treatment plan.

In my mind, I feel like I'm trying to make an effort to identify patterns/behaviors/"axis I disorders"/etc to best help a patient. Not to dismiss them. A borderline who falls into depressive episodes following periods of abandonment/rejection...SSRI should help...but I can toss whatever drug on board, it's not going to fix the flat tire by just inflating it with air every 2 weeks. It is also allows me to relay that to the patient, in a therapeutic fashion.

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[Armadillos]

What year are you?

Your thread title is "I must be doing something wrong" but then your whole post is defending yourself and basically begging the forum to say your not doing anything wrong.

Do you believe your doing something wrong? Why not just make a thread titled my attending is crazy?

 

[WhoisJohnGalt]

I've noticed this recurrent issue that continues to pop up and it is kind of demoralizing.

1) I get criticized for identifying personality traits in people. "You focus too much on personality" is a common phrase I hear. Example: I have a pt in their late teens. Mom was depressed, alcoholic, verbally abusive, rejecting. Felt unloved. Started cutting at a young age. Went to the ER because her long distance boyfriend wasn't responding to texts "good enough" and became "suicidal." I, (at least I thought, unsurprisingly), identify certain borderline characteristics. I am then told I need to "read more about children of alcoholic parents" and that "some kids just cut these days growing up...." I note to my attending that in her counseling sessions, addressing these relationship issues/subsequent suicidal thoughts, may be fruitful. I am somewhat dismissed

Fast forward 3 months. Pt comes in "irritable" at her boyfriend, who had a loss recently, and wasn't making enough of an effort to stay in touch with her. Felt rejected. Began to get tearful, then started telling me her medication was no longer working (low dose SSRI) and she was having "thoughts" again, and I needed to do something. In the midst of the interview, my attending decides to enter the room, unannounced. Both I and the pt lost our train of thought as we were in the middle of something significant. Later, I am critiqued for "not continuing the interview" (possibly, because I was post call the night before, was working on little sleep, again, and she pops in at the end of a visit). Of note, she addressed the pt in the interview as she typically does for any borderline patient (your emotions are strong huh, are you interested in DBT, etc).

I was "focusing too much on personality" initially, which was wrong, because she wasn't "annoying" or "splitting" on visit 1 (the only one the attending has been apart of thus far), pops in during a visit I figured was inevitable, and then calls "cluster b" - but that's ok, and somehow, I wasn't doing enough in the interview. I was told I need to be "more motherly" for these patients, and that, my usual approach of allowing a person to express themselves, validating them appropriately, and working with a patient on a resolution, just doesn't cut it. THEN, I'm told I need to "giver her a break! It's hard being in a relationship!" (Smh....wtf....what are you even saying, I didn't say I didn't care!!!!!!)

#2 - I have a woman who I saw initially with my attending (same one as aboe). SHE encouraged me to "take her on as a therapy patient," (which may be contributing to the following, because she became a 'special' patient, she declined weekly therapy with me, however). In my interview, I took an approach as to where I allowed my patient to express themselves and provided empathy in the form of non verbal cues. I was told I did a "great interview, and really provided a safe, warm, holding environment...." But that I "could offer more 'motherly love'" if I felt it was warranted (which I did not). Subsequent visits with this patient has led to rather interesting encounters. She comes provocatively dressed, removes articles of clothing, touches my hand if I hand her a script/card. When I first addressed this with my attending after her first follow up visit (I was alone for that visit, as my attending was not in that day...) I was told I was "over-reacting" and that I needed to explore my "unconscious desires" (seriously?). Luckily, counselors that were there came to my defense, and noted she was dressed "like she was going to a club, and not a doctors visit" (keep in mind, some days it was like 20 degrees out, no, she is not hypomanic). The third visit, after talking to my psychotherapy supervisor for some amount of supervision (development/object relations analyst), he pointed to developmental theories behind HPD in an effort to promote further understanding, what may be considered rejecting/helpful to her, sort of "promote" empathy. I took a developmental history (brief) at our next visit, and my attending suggested I had "ulterior motives" in gathering a developmental history (WTF?). She then tells me I should keep appointments short and to the point, and if I do that, I then hear "oh, that was probably you're shortest interview ever, huh?" remarks.

----------
These are two brief examples, that happen rather often. I am accused of "focusing too much on axis II and not axis I" - even though I am rarely given negative feedback of my actual management of, or diagnosis of, axis I disorders (former axial system). I generally don't see axis II as this taboo neverland, but some of my attendings seem to only reserve it for that "annoying" patient, with me ever only seeing people comment on someone being "borderline, narcissistic, or antisocial..." To the point that you'd think only these 3 exist.

And I always leave open that I might actually be wrong. I ehave ven commented on my notes how X led me to believe Y, and after further data points, X seems more so related to Z instead. I then reframe my formulation, and if needed, alter my treatment plan.

In my mind, I feel like I'm trying to make an effort to identify patterns/behaviors/"axis I disorders"/etc to best help a patient. Not to dismiss them. A borderline who falls into depressive episodes following periods of abandonment/rejection...SSRI should help...but I can toss whatever drug on board, it's not going to fix the flat tire by just inflating it with air every 2 weeks. It is also allows me to relay that to the patient, in a therapeutic fashion.

You need to talk to your attending. You're a December third year, I guarantee you have plenty to learn about therapy but it seems like you don't feel comfortable asking your attending for more specific feedback and why would you want it anyway since clearly, you got this. I'm practicing on my own and still seek advice from others on my therapy patients on a regular basis. There's something going on that you can't see and your attending is trying to help you see it. Try to be open minded to that. Good luck.

 

[Nasrudin]

You need to talk to your attending. You're a December third year, I guarantee you have plenty to learn about therapy but it seems like you don't feel comfortable asking your attending for more specific feedback and why would you want it anyway since clearly, you got this. I'm practicing on my own and still seek advice from others on my therapy patients on a regular basis. There's something going on that you can't see and your attending is trying to help you see it. Try to be open minded to that. Good luck.

How do you come to conclusions like this. I read this and get one perspective on an attending with personality issues. Does your attending status give you windows into the souls of other human beings after a narrow slice of Internet interaction? How do you assume this supervisor isn't the problem?

I just want know if I'm really gonna be a Jedi after training. Because it sounds f'n awesome.

 

[member2721]

One reaction I have is I have noted attendings have very diverse opinions on Axis II: how and when it should be diagnosed, how it should be approached with the pt in terms of disclosure-. Part of it may be due to the fact that our conceptualization of personality disorders, particularly borderline, has changed a lot in recent years. For example, recent studies showing majority of pts with BPD remit in terms of their symptoms within 3 years is contrary the classical teaching that personality disorders are stable. Overall, I think psychiatrists tend to over-stigmatize personality disorders, and the resulting reluctance to approach it with pts, ultimately leads to less than optimal care for many patients. Perhaps try to understand how your attendings conceptualize and prefer to approach these patients, so you can learn this different approach and ultimately be able to "flex" better- adapting different approaches to specific patients.

 

[F0nzie]

What about fatherly love?

Meet frequently. PHQ9. Antidepressant algorithm. Psychodynamic pharmacology. Get that score under 10. Do not waste your time with meds that do not work or get overly distracted by their situation. Validate while simultaneously hammer away at reality. Work with attending and colleagues that are also imperfect. Be a champion psychiatrist.

 

[wolfvgang22]

Sounds like you're getting mixed messages from an attending who might be a little confused, or maybe just being a bit condescending to you. You might be getting hazed a little.
Don't sweat the coaching and criticism too much. You are doing your job by listening thoughtfully to your supervisor and applying what makes sense and is congruent with your other studies to help your patient the best you can.

Keep working hard, keep compassion and the well being of your patient as your #1 priority, be professional at all times with both your attending and patient. Don't argue with either of them, as it's not effective. Your actions will demand respect by themselves.

You can use your developing psychotherapeutic skills respectfully not just when you are talking to patients, but with everyone. You can sort of form a better therapeutic alliance with your difficult attending, purposefully, without being direct or obvious. Practice gradually integrating the best psychological interview techniques into your everyday interactions (mirroring, clarifying, observing, etc) in a natural way. It's challenging, fun, and good practice.

 

[erg923]

"Motherly love?!" Is this serious?

If the attending is talking about accurate empathy, that's worst analogy for it I have ever heard. If she is being more literal, I think she may be the one with "issues"

 

[nitemagi]

While the message and even the message giver might not be a perfect fit, look for the "note behind the note," meaning the intention behind the comment. Think less about the suggested change in your behavior and that maybe there's something the attending witnessed that could be improved.

Off the top of my head -
When you notice personality traits, does it impair your ability to empathize with the patient?
In that same vein, is it possible that chalking things up as "axis II" moves it mentally into a category of "not fixable," or "not my problem?"

All that being said, psychiatrists are not perfect and can bring in their own biases. Particularly there's a risk in supervision if they aren't witnessing the situation, so they fill things in with their assumptions. We all generalize from our experience. For supervision, consider videotaping sessions. It gives more direct evidence to discuss.

 

[Psychobabbling]

Thanks for the replies. I have seriously been told I need to exhibit more motherly love, and when I see said attending(s) exhibit "motherly love" it comes across as if they are speaking to a child (both child psychiatrists). So I hear them talk like this "oh my! It sounds like you are REALLYYYYYYY struggling! I'm soooo sorry!" - yeah, I'm not gonna do that...in that way..

The program, and the clinic I'm at, predominately expect this "motherly love." For example, a patient comes in to the clinic. My co-resident sees them, and says "Malingering, HPD." She is told she is wrong (by the main attending at the clinic, attending she saw the pt with agreed with her). Main attending says "let's start an SSRI." Resident says "for what??" Main attending says "well if we start a medicine they want to be on, maybe we can engage them in therapy." But again...FOR WHAT? Pt was clearly angling for disability.

I see a patient (workers comp, posted about it previously). I am told I can only diagnose Adjustment Disorder so I don't "screw up her workers comp case." I felt dismissed, and like I was being told to collude with the patient. I also voiced the patient was not appropriate for the clinic at this time, and needed to go to Partial. The patient requested a different doctor because on her third visit she remarked "well maybe some of this has been bothering me for a lot longer than a few months..." And actually begins to identify symptoms. I commend her for her actions, and noted that it seemed that her workers comp seemed to really be causing a lot of problems, as the first two evals were focused primarily on that. She then said I was the "worst doctor ever....if you don't want me here just tell me and I'll go somewhere else..." It felt like I got hit By a truck. My attending took the patient's side. Later, referencing this patient, It was suggested upon me to start therapy and that another attending saw the patient, and that she's had a "really hard life." (Most of my patients have had a hard life)

My program looks down on anyone who confronts a patient, because it's "mean." I have spoken to a few attendings about this, and they have told me of their similar experience.

Thankfully, I have one attending at my clinic who was in the same boat as me (and another supervisor elsewhere I talk to as well). It's been pointed out that there is an unhealthy "rescue fantasy" with many of the people there, that they went through the same thing, and they never understood why people treated patients like that. That you shouldn't try to force yourself to "like/love" all of your patients, to recognize when you dislike a patient, so that you can work on building an alliance over time and so that you don't 'not' do something, that could be detrimental to a patient's care.

And...the title of my thread was meant to be passive aggressive, lol.

 

[Psychobabbling]

While the message and even the message giver might not be a perfect fit, look for the "note behind the note," meaning the intention behind the comment. Think less about the suggested change in your behavior and that maybe there's something the attending witnessed that could be improved.

Off the top of my head -
When you notice personality traits, does it impair your ability to empathize with the patient?
In that same vein, is it possible that chalking things up as "axis II" moves it mentally into a category of "not fixable," or "not my problem?"

All that being said, psychiatrists are not perfect and can bring in their own biases. Particularly there's a risk in supervision if they aren't witnessing the situation, so they fill things in with their assumptions. We all generalize from our experience. For supervision, consider videotaping sessions. It gives more direct evidence to discuss.

There are times where I may "vent" to an attending, but I do so NOT because I don't care about the patient. I'm venting to brainstorm what to do about X, how could I have handled Y better, etc. I am far from knowing anything. I seek out whoever may have more experience than me to soak up as much as I can and integrate it with things I have learned, to modify my approach, etc. I have even sat down to discuss this. At times I feel like there's nothing I can do because my voice gets shot down..with certain attendings.

 

[jakeislove]

I'm still stuck on "motherly love". Can someone please explain how it's supposed to work? Are you supposed to validate everything and then make gentle corrections?

 

[erg923]

There are certainly setting that lend themselves to a more warm and fuzzy bunch than others, I just think that term is grossly flawed description of what they are actually trying to convey. At least, I hope.

The bigger question for me is: what treatment is actually being done here? I do not been just empathizing, dynamic explorations and ill timed attempts at corrective emotional experience. Are we following any empirically based treatment guidelines here?

 

[Psychobabbling]

These are never formally gone over. However, I use them. There are some areas I could improve upon, and am doing a PBLI to help

 

[deleted314290]

That must be a terrible position to be in. It is your job to call things as you see it, especially people malingering to get disability. Document everything as you see it and the reasons for your decisions, as you have been doing. I would ignore the advice of these attendings it seems that they are coasting and dont want to deal with the can of worms your insight might bring. There are good and bad psychiatrists...you can learn a great deal from both of them. Take this opportunity to remind yourself what type of psychiatrist you DONT want to be. In the meantime keep your head low and play the game, bend but dont break.

 

[Ceke2002]

Thanks for the replies. I have seriously been told I need to exhibit more motherly love, and when I see said attending(s) exhibit "motherly love" it comes across as if they are speaking to a child (both child psychiatrists). So I hear them talk like this "oh my! It sounds like you are REALLYYYYYYY struggling! I'm soooo sorry!" - yeah, I'm not gonna do that...in that way..

My program looks down on anyone who confronts a patient, because it's "mean." I have spoken to a few attendings about this, and they have told me of their similar experience.

Thankfully, I have one attending at my clinic who was in the same boat as me (and another supervisor elsewhere I talk to as well). It's been pointed out that there is an unhealthy "rescue fantasy" with many of the people there, that they went through the same thing, and they never understood why people treated patients like that.

Oh yeah, being patronisingly infantilised is totally what I want out of my therapy sessions. Perhaps you could score extra brownie points by adding patty cakes and horsies to your therapeutic strategies. </sarcasm>

By the way, speaking from a patient's point of view, I abhor rescuer types in therapy. Most of the time, in my experience at least, rescuers seem to invariably become frustrated when their objects of rescue don't always respond in a nice, neatly scripted manner, thereby ruining the fantasy and more often than not leaving the patient to be thrown into the 'too hard' basket.

 

[Psychobabbling]

Infantilizing! You hit the nail on the coffin.

I appreciate all of the replies and feedback. I could go on and on, but then it will really just turn into a rant session (more than it was). This year is certainly a learning experience.

Thanks again everyone!

 

[PistolPete]

For example, reent studies showing majority of pts with BPD remit in terms of their symptoms within 3 years is contrary the classical teaching that personality disorders are stable.

Do you have a reference for a study, or source, for this? I wasn't aware of this.

 

[member2721]

Do you have a reference for a study, or source, for this? I wasn't aware of this.

Gunderson, John G. Handbook of Good Psychiatric Management for Borderline Personality Disorder. American Psychiatric Pub, 2014. Page 9. "At 3 yrs, 62% of patients in both groups (DBT and general psychiatric management) had remitted to fewer than two criteria for a year or more, a rate 20% higher than for borderline patients who did not receive these BPD-specific therapies".


Gunderson, John G., et al. "Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study." Archives of general psychiatry 68.8 (2011): 827-837.

McMain, Shelley F., et al. "Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up." American Journal of Psychiatry 169.6 (2012): 650-661.

 

[OldPsychDoc]

^^^ Which is why it is so important to educate these patients that their mood swings and impulsive acts are not "bipolar", to be treated with toxic chemicals for the rest of their life, but something ultimately understandable, treatable, and nearly curable.

 

[Doctor Bagel]

It seems like a lot of this stuff has been covered, but I'm curious what the treatment frame is for the clinic you're working in. It sounds like the common experience for lots of us -- it's kind of unclear, which makes it harder for everyone. Developmental histories are often useful, and 100% appropriate in some situations and maybe not so useful in other settings, so your attending might or might not be right depending on what you're doing. It also sounds like you're in the situation where you have multiple attendings (off and on site), which while potentially useful is hard to navigate especially if the attendings disagree. It seems you feel like this one clinic attending is being unfair to you, which is possible as well. It's hard to know. A thing that's hard to keep site of in training is that we all develop our own style in working with people and bring in our own personalities. Also patients can spot when you're faking it -- so gushing "motherly love" or whatever at a patient because your attending told you to is probably going to feel pretty bad for both you and the patient.

My other thought about the personality issues -- it's unclear what's happening, but I do think people can be both too willing to label something as a personality disorder and too unwilling to do so. I think it's a common developmental mode in training to think everything is Axis II for a while without appreciating that basic decompensation in the face of significant stressors is pretty common and doesn't need to be pathologized. It's also true that some people are really hesitant to say anything is a personality disorder and instead make these stupid, inappropriate bipolar and ADHD diagnoses that imo have the potential to cause much more harm.

 

[smalltownpsych]

Motherly love? Really? If there is a strong maternal or paternal transference or counter-transference, that is something to be understood how that plays out in other relationships and then think about what to do about it. In other words, when I give a patient appropriate and accurate praise for an accomplishment that might be something they didn't get from their parents, and the patient learns that they are deserving of praise. If they do something dumb, we'll talk about that too and they will learn to persist when they make a mistake. I find it more effective when this type of communication when it is in the context of the therapeutic relationship of two adults as opposed to some recreation of an infantile experience. In my opinion, the latter is more characteristic of potentially harmful fringe therapies.

 

[sunlioness]

"Motherly love?!" Is this serious?

If the attending is talking about accurate empathy, that's worst analogy for it I have ever heard. If she is being more literal, I think she may be the one with "issues"

Agreed. I read the "motherly love" thing and threw up in my mouth a little bit .

 

[Doctor Bagel]

By the way, speaking from a patient's point of view, I abhor rescuer types in therapy. Most of the time, in my experience at least, rescuers seem to invariably become frustrated when their objects of rescue don't always respond in a nice, neatly scripted manner, thereby ruining the fantasy and more often than not leaving the patient to be thrown into the 'too hard' basket.

And they're more likely to create boundary violations.