"I would like to schedule an appointment for..."

[F0nzie]

A family member calls your practice requesting an appointment for their son, their daughter, their husband, their friend.... somebody other than themselves. We're talking adults here. I am completely WEAK in this area and I get nailed every single time. This is how it goes down. The family member has an agenda and is looking for results. The patient has ZERO motivation, a big time attitude, and entitlement. I turn my focus on the patient while keeping the family member involved, but before I know it (like dude what the hell just happened) I get thrown into an pile of really messed up and twisted family dynamics that crush my soul. Advice?

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[watto]

Unless they are asking on behalf of a relative with dementia, I always say no. No, no, no, a thousand times no. "My treatment cannot help a person who feels coerced to take part in it." Did I mention, I say no?

The worst was a guy making an appt for his "unstable" wife who it turned out was just too tired after working a long day to have sex with him. OUT!

 

[F0nzie]

Unless they are asking on behalf of a relative with dementia, I always say no. No, no, no, a thousand times no. "My treatment cannot help a person who feels coerced to take part in it." Did I mention, I say no?

The worst was a guy making an appt for his "unstable" wife who it turned out was just too tired after working a long day to have sex with him. OUT!

I just started turning down these referrals (1/3 of my calls) because the situation will sometimes turn into hostility and it stresses me out. I do not know any other way to handle it.

 

[F0nzie]

Then the harassing non-emergent phone calls begin...he said, she said

 

[F0nzie]

Then the letter requests begin to bail them out of bad choices. "Please write a letter stating that my daughter needed to drop out of her classes because the med change affected her concentration". Never told me about that side effect. That's news to me! That happened 2 months ago?

 

[nitemagi]

1. Be upfront with expectations and that the prelim goal is to engage them in treatment
2. Ally with the patient.
3. Always decline to write letters when not appropriate
4. Review the nature of perpetuating problems in family. Family members should be educated as to how they're causing or perpetuating problems, sometimes by "saving" their family members. Family therapy sessions can be a good mode for this.

 

[Ceke2002]

Dear Gods, the entitlement I'm reading here is mind boggling! Do you have anything in your ethics charter that you could point to (conflict of interest, whatever else) as a reason for not being able to take on family members for treatment, if one of these idiots starts going off on too much of a rant?

 

[whopper]

You tell them the truth. The truth is that the real patient has no motivation to get better and that in an outpatient setting you cannot force anything. The patient is the real customer, not the family member.

I would try some motivational interviewing to attempt the person to get into treatment (provided they actually need it, sometimes families push members into treatment that really don't need it).

After that's been tried, I'd pretty much leave it there.

I've had patients like that. E.g. a patient that is heroin addicted and his family wants him on Suboxone, a patient that just sits around all day and doesn't look for a job, a patient who is a strict Catholic and so is his wife and his wife caught him checking out homosexual porn.

I'll just elaborate on the last one.

Guy is bisexual. He occasionally, on the order of once every 6 months occasionally checks out gay porn. Wife found out by seeing it on the browser history. She immediately demands the guy see a psychiatrist. So he sees psychiatrist #1. #1 puts him on Depakote an antipsychotic and an SSRI at maximum dosage and dx's him with a paraphilia and OCD saying he obsesses over it.

I talk to the guy, and it turns out the only thing he's obsessing over is feeling guilty about his bisexuality. He had no criteria of OCD whatsoever and the meds didn't do anything for him other than make him gain weight.

As for the porn, he only checked it out once in awhile, felt no desire or obsession to see it other than just that he was occasionally entertaining his sexual desires. I'd hardly call that a paraphilia.

Oh geez, I hate psychiatrists that pathologize crap like this. After a few sessions just to make sure I wasn't wrong, I told him to bring his wife in. She refused but the pt told me she kept insisting he get help. I told him this really was between him and his religious faith and to go see a Catholic priest about this because the scientific/medical guidelines are to accept who he is, his wife and his faith are causing conflict, the wife keeps giving him specific instructions to get treatment but won't be a part of that treatment, and I'm not supposed to tell him to walk away from his faith.

I terminated him as a patient after I realized the program in BASIC.

10 Patient is told he has a problem that really isn't a problem
20 Patient is demanded by controlling wife to get mental health treatment when the science says he doesn't need it
30 I tell him he doesn't need it so his wife screams at him saying he has to try harder with his psychiatrist
40 goto 10

When I got patients like this, occasionally they literally just sat in the chair while we ignored each other and I surfed the Internet telling them that they're wasting their time because I'm making money while seeing really cool youtube videos.

 

[Shikima]

Whopper, do you have alternative therapists in the community to work with - have them engage in family/marital therapy for example?

 

[F0nzie]

1. Be upfront with expectations and that the prelim goal is to engage them in treatment
2. Ally with the patient.
3. Always decline to write letters when not appropriate
4. Review the nature of perpetuating problems in family. Family members should be educated as to how they're causing or perpetuating problems, sometimes by "saving" their family members. Family therapy sessions can be a good mode for this.

I struggle with #2. I remember being taught this in residency and getting a low grade for not being able to establishing an alliance with a guy who had tried to kill himself with CO poisoning in his garage. Wife called me saying he was making suicidal statements and she found a stockpile of meds in the garage. I immediately called the patient and he acted like nothing was going on. I then confronted him about the stockpiling of meds his wife reported. Wife calls back saying she never said he was stockpiling his meds. Then he accuses me of lying about what his wife said to me and told me I was unprofessional. Ended up referring out and closing the chart.

I feel a lot of times both parties are avoiding their issues by using me as a punching bag, displacing blame on me, and expecting me to bail them out of their problems.

I have not been successful referring to a family therapist because they never call to make an appointment. If I did the family therapy would that put me in a weird spot? Not sure what else to do other make recommendations, set boundaries, call them out on their behaviors, and then fire them if they do not comply.

Hopefully with more experience I will have a better handle on this. Right now it really stresses me out and I am running away from it.

 

[F0nzie]

Whopper-- interesting breakdown. Helps me better conceptualize how simple it is when I am getting lost and feeling like I am going insane.

The sand art video is magical lol

 

[nitemagi]

I struggle with #2. I remember being taught this in residency and getting a low grade for not being able to establishing an alliance with a guy who had tried to kill himself with CO poisoning in his garage. Wife called me saying he was making suicidal statements and she found a stockpile of meds in the garage. I immediately called the patient and he acted like nothing was going on. I then confronted him about the stockpiling of meds his wife reported. Wife calls back saying she never said he was stockpiling his meds. Then he accuses me of lying about what his wife said to me and told me I was unprofessional. Ended up referring out and closing the chart.

I feel a lot of times both parties are avoiding their issues by using me as a punching bag, displacing blame on me, and expecting me to bail them out of their problems.

I have not been successful referring to a family therapist because they never call to make an appointment. If I did the family therapy would that put me in a weird spot? Not sure what else to do other make recommendations, set boundaries, call them out on their behaviors, and then fire them if they do not comply.

Hopefully with more experience I will have a better handle on this. Right now it really stresses me out and I am running away from it.

Honestly I think the model of a one-person psychology is very limited. We need to be able to work with families and understand family dynamics, including how to change them, and how to engage everyone in the process. Not to mention always getting collateral information rather than limited-self-report.

As for allying with the patient, it comes down to extending empathy. Just convey to them how you could understand why they would want to poison themselves. Meet them where they are, rather than requiring them to come to you. I will never forget when I was an intern, watching an attending do a demo interview and trying to force the patient to use his words for her depression. She didn't want to do it, and he pushed to the point that there was little rapport left.

Start where they are, even if they're delusional.

 

[alina_s]

Then the letter requests begin to bail them out of bad choices. "Please write a letter stating that my daughter needed to drop out of her classes because the med change affected her concentration". Never told me about that side effect. That's news to me! That happened 2 months ago?

I'm so relieved to hear that I'm not the only one getting these kinds of requests, or the only one who thinks they're unreasonable. I was beginning to wonder if my training program had been some particularly hard-line CBT orientation, or my compassion had been extremely eroded by experiences. It just seems counter-therapeutic to attribute so much to a diagnosis or a medication.

 

[Armadillos]

I'm so relieved to hear that I'm not the only one getting these kinds of requests, or the only one who thinks they're unreasonable. I was beginning to wonder if my training program had been some particularly hard-line CBT orientation, or my compassion had been extremely eroded by experiences. It just seems counter-therapeutic to attribute so much to a diagnosis or a medication.

Yeah its kinda disturbing how much some people latch onto a diagnosis, they start blogging with the diagnosis as the backbone and selling point of their blog, every story they tell incorporates the diagnosis, etc. They kind of define themselves by their diagnosis and wear their treatments as a badge of honor. Don't get me wrong, I'm 120% in favor of decreasing stigma of mental illness, but I honestly think it would be better for some patients if they strived to live in a way such that they were so functional that nobody knew they had a diagnosis.

 

[vistaril]

Another thing that matters A LOT that nobody has mentioned yet: this is a cash pay private practice and it matters who is paying.

In these kinds of situations the pt is almost never forking out the money themselves, but the concerned family member is. The goal in these cases is to work to help the pt of course, but don't piss off the person paying. Because if you piss off the person paying then you won't be able to help the pt at all.

 

[PikminOC]

Great thread and replies.

 

[Ceke2002]

Reading through this thread reminds me of a current family situation, and god help the therapist who ends up having to wade through that tangled mess. Long story short, one of my Aunties has severe (presumed) late onset Anorexia Nervosa - lowest weight of 28 kgs at 5'4 (currently 38 kilos and dropping again), already suffered cardiac arrest due laxative abuse tipping an already blocked/damaged heart over the edge, pretty much ticks every single box on the diagnostic list. One third of the family is basically sticking their fingers in their collective ears and going 'lalalala there's nothing wrong, everything's fine', another third seem to think the best way to help is by yelling or lecturing her on the importance of bootstraps and how she really needs to pull hers up, and the final third have decided cooking is the way to go (cooking and delivering a daily plethora of food that never gets eaten). Oh and of course everyone has an answer and knows exactly why and how and what to do, even if that does involve sticking their heads in the sand, and none of them are afraid to express their 'expert' opinion.

Like I said, if she ever does actually make into treatment, god help the therapist who ends up having to wade through that tangled mess. I'd almost be tempted to send him a pre-emptive sympathy basket.

 

[F0nzie]

Well I took the advice here and applied it to a case a couple of days ago and it turned out better than I had expected. Flat out told them my perspective.

Case in a nutshell: Pt has anger outbursts, mom wants to medicate. Had pt and mom come in for a session. Empathized with the pt and told him he is an adult needed to take on more responsibility to express himself when he feels invalidated by mom and makes him upset. Told him his mother freaks out and thinks he needs to be on meds when he gets upset because he doesn't tell her why he is upset. I told mom he struggles with self expression because of his hx of abuse. Also recommended she offer more positive praise, give him space, stop telling him he needs to be on more meds everytime he gets upset (highlighted that would sabotage his efforts towards independence), and that she should encourage him to express himself. Told him to continue individual therapy and that they also needed family therapy. They agreed and felt we were getting somewhere. I immediately felt a huge weight lift off my shoulders.

Best 15 minute med check ever.

 

[smalltownpsych]

A family member calls your practice requesting an appointment for their son, their daughter, their husband, their friend.... somebody other than themselves. We're talking adults here. I am completely WEAK in this area and I get nailed every single time. This is how it goes down. The family member has an agenda and is looking for results. The patient has ZERO motivation, a big time attitude, and entitlement. I turn my focus on the patient while keeping the family member involved, but before I know it (like dude what the hell just happened) I get thrown into an pile of really messed up and twisted family dynamics that crush my soul. Advice?

I feel you on this one. I have found that I have more success working with the concerned family member than the "problem" family member. In other words, I can help you learn how to cope with that other person who doesn't want treatment. Also, these types of dynamics are more common with behavioral issues such as aggression, substance abuse, promiscuity, etc. that are not going to be cured by a medication which I think is the false hope that the concerned family member has. It is pretty saddening when they begin arguing for why it really is schizoaffective disorder that is causing the loved one to use meth and why can't they just stay on their meds.

 

[smalltownpsych]

On a related note, I also get referrals like that from our PMHNP because the patients will show up for her med appointments, but won't make any changes in their lives and can't figure out why the medication isn't working. They come to my office and have no intention of making any type of change in either thinking or behavior. Ugh.

 

[nitemagi]

I feel you on this one. I have found that I have more success working with the concerned family member than the "problem" family member. In other words, I can help you learn how to cope with that other person who doesn't want treatment. Also, these types of dynamics are more common with behavioral issues such as aggression, substance abuse, promiscuity, etc. that are not going to be cured by a medication which I think is the false hope that the concerned family member has. It is pretty saddening when they begin arguing for why it really is schizoaffective disorder that is causing the loved one to use meth and why can't they just stay on their meds.

This is the challenge of doing good therapy. One must simultaneously empathize with the patient, no matter where they are, with others concerned, and keep an eye on the larger picture (the dynamic as a whole). Sometimes both sides are right, in their way, and the process that they fight each other perpetuates the problem.

 

[PsyDr]

My office is instructed to tell the caller that we only allow the patient to make the appointment, but that they are more than welcome to stand by the phone and help walk the patient through making the appointment. The only ones that get mad are the parents of college aged. It's been a good teaching tool for family members and patients alike.

 

[smalltownpsych]

My office is instructed to tell the caller that we only allow the patient to make the appointment, but that they are more than welcome to stand by the phone and help walk the patient through making the appointment. The only ones that get mad are the parents of college aged. It's been a good teaching tool for family members and patients alike.

I understand this policy to an extent; however, my wife and I made the initial appointment for her technically adult daughter when she was struggling with some relational issues. Parenting doesn't stop when a child turns 18 and part of my general parenting philosophy is that the first time we do it for you, the second time alongside you, then you are on your own. This was her first time asking for psychological help so we did it for her.

 

[smalltownpsych]

This is the challenge of doing good therapy. One must simultaneously empathize with the patient, no matter where they are, with others concerned, and keep an eye on the larger picture (the dynamic as a whole). Sometimes both sides are right, in their way, and the process that they fight each other perpetuates the problem.

I also like pointing out to any of the individuals in the family system that if one person in the system changes, then that changes the dynamic. Of course, how that change manifests can be unpredictable and the system tends to resist the change. I love family systems work.

 

[whopper]

Whopper, do you have alternative therapists in the community to work with - have them engage in family/marital therapy for example?

Yes. I've always tried to refer patients like this to someone that I think can help but like I said, I even declare to the patient and family that the treatment is not going to work unless the the patient himself wants to be a part of it. For some reason, they still wanted me to be the person's doctor.

I chose the Catholic priest in my above example because the person's problem wasn't technically a medical problem, but more of an internal problem with his sexuality and his religious beliefs. Medical science isn't supposed to point towards bisexuality as a sin or mental illness yet that's what his wife wanted me to do.

I had another guy where I used "sandart therapy" as I'm calling it. The guy told me he wanted to "love like no man loved before" and then told me about all of his sexual escapades in vivid detail. I'm not trying to be intentionally funny here but it was things to the effect of "then he grabbed my penis and it felt so good. Then he opened up my..." well you can figure it out but the entire interview was about 30 minutes of this.

So I'd say after about 5 minutes of this, "I'm not sure what exactly you want me to do here. You're not depressed, manic, psychotic, anxious, or anything else I usually treat. What do you want me to do to help?
Him: I need you to help me to love.
Me: Okay, can you explain this more?
Him: Okay, so then he opened up my anus, and he took out his finger.......(you can imagine the rest, about 5 more minutes of this)
Me: I don't know where you're going with this.

Well 4 30-minute sessions later I still am not anywhere close to even figuring out what he wants me to do, and I don't even have a dx for him that I believe in and wrote Adjustment Disorder. I told him time and time again that I don't even know what he wants out of our treatment sessions other than that he wants to "love," and I don't even know what he means by that.

I told the guy to see a psychotherapist (a psychologist or counselor), and not a psychiatrist because there was no need for meds. The guy insisted on seeing me, telling me that I was the only guy that could help him but he had no explanation as to why.

So the next session, he then went on his usual 30 minute sexual escapade that could've been an article in Penthouse Forum, except that this is gay male sex, and I again had no idea where he was going with this. I opened up the sand art video and played it in his presence.

He demanded to know why I wasn't paying attention to him. I told him that my theory was that for reasons I did not yet understand, I didn't think he wanted treatment but simply an audience to hear of his sexual exploits. I told him that if I was wrong, I wanted to hear why he thought so. He didn't say anything. He stopped seeing me after that session.

I'm still not certain as to why he wanted me to be his psychiatrist or what he wanted. I'm not saying I was right, but I knew that I had to put an end to that infinity-loop.

 

[Ceke2002]

Yes. I've always tried to refer patients like this to someone that I think can help but like I said, I even declare to the patient and family that the treatment is not going to work unless the the patient himself wants to be a part of it. For some reason, they still wanted me to be the person's doctor.

I chose the Catholic priest in my above example because the person's problem wasn't technically a medical problem, but more of an internal problem with his sexuality and his religious beliefs. Medical science isn't supposed to point towards bisexuality as a sin or mental illness yet that's what his wife wanted me to do.

I had another guy where I used "sandart therapy" as I'm calling it. The guy told me he wanted to "love like no man loved before" and then told me about all of his sexual escapades in vivid detail. I'm not trying to be intentionally funny here but it was things to the effect of "then he grabbed my penis and it felt so good. Then he opened up my..." well you can figure it out but the entire interview was about 30 minutes of this.

So I'd say after about 5 minutes of this, "I'm not sure what exactly you want me to do here. You're not depressed, manic, psychotic, anxious, or anything else I usually treat. What do you want me to do to help?
Him: I need you to help me to love.
Me: Okay, can you explain this more?
Him: Okay, so then he opened up my anus, and he took out his finger.......(you can imagine the rest, about 5 more minutes of this)
Me: I don't know where you're going with this.

Well 4 30-minute sessions later I still am not anywhere close to even figuring out what he wants me to do, and I don't even have a dx for him that I believe in and wrote Adjustment Disorder. I told him time and time again that I don't even know what he wants out of our treatment sessions other than that he wants to "love," and I don't even know what he means by that.

I told the guy to see a psychotherapist (a psychologist or counselor), and not a psychiatrist because there was no need for meds. The guy insisted on seeing me, telling me that I was the only guy that could help him but he had no explanation as to why.

So the next session, he then went on his usual 30 minute sexual escapade that could've been an article in Penthouse Forum, except that this is gay male sex, and I again had no idea where he was going with this. I opened up the sand art video and played it in his presence.

He demanded to know why I wasn't paying attention to him. I told him that my theory was that for reasons I did not yet understand, I didn't think he wanted treatment but simply an audience to hear of his sexual exploits. I told him that if I was wrong, I wanted to hear why he thought so. He didn't say anything. He stopped seeing me after that session.

I'm still not certain as to why he wanted me to be his psychiatrist or what he wanted. I'm not saying I was right, but I knew that I had to put an end to that infinity-loop.

Sounds like a possible Medical Fetish. Psychiatrist/patient roleplay scenarios aren't generally as popular as the more typical Doctors and Nurses type scenes, but they are a subset. Scenarios played out can be anything from patient/Psychiatrist seduction (patient reveals there deepest darkest sexual secrets in 'session', Psychiatrist gets turned on, sex ensues - or vice versa with the Psychiatrist in the role of seducer), to humiliation scenarios where the 'patient' is 'forced' to recount their sexual history and is then humiliated or shamed for it, right through to full old school asylum style roleplaying with straitjacket restraint and (faked) lobotomies or ECT. Now of course most of this takes place between consenting couples who share a common kink, or between professional Dom(mes) and paying clients, but there are a few people who like to push the boundaries even further and who will actually visit real Psychiatrists under false pretences in order to play out their fantasies with an unwitting partner. Of course doing so contravenes the 'consensual' part laid out in the typical guidelines/rules of BDSM play, including Safe, Sane, Consenual - Consensual Non Consent - Risk Aware Consensual Kink - and Personal Responsibility Informed Consensual Kink', but for these people they don't seem to really care, they're not satisfied with just roleplaying they want the real deal. Personally I find these sorts of situations incredibly disturbing and creepy, I mean I get the whole notion of 'your kink is not my kink, and that's okay', but not when you're trying to drag non consenting participants into it it's not. I should also point out this is definitely not anything I'm into myself either, at all, ever! (but I do have some friends in the Medical Fetish scene - no one who actually goes to the lengths of seeking out real Doctors- and I'm open minded enough to accept that it's something they happen to enjoy, even if hearing them talk about it makes me go 'Bwwwaahhh???' )

 

[strangeglove]

Always have the patient call to make the first appointment. If it's a relative, ask them to tell the patient to call.

 

[OldPsychDoc]

...
Well 4 30-minute sessions later I still am not anywhere close to even figuring out what he wants me to do, and I don't even have a dx for him that I believe in and wrote Adjustment Disorder. I told him time and time again that I don't even know what he wants out of our treatment sessions other than that he wants to "love," and I don't even know what he means by that.

I told the guy to see a psychotherapist (a psychologist or counselor), and not a psychiatrist because there was no need for meds. The guy insisted on seeing me, telling me that I was the only guy that could help him but he had no explanation as to why.
....

I'm still not certain as to why he wanted me to be his psychiatrist or what he wanted. I'm not saying I was right, but I knew that I had to put an end to that infinity-loop.

 

[jakeislove]

Reading Whopper's post makes me wonder how many people would sincerely be helped by Dennis Leary's idea of therapy from "No cure for cancer".

 

[whopper]

I had a theory that the guy I mentioned that wanted to "love" had a very different concept of what therapy was vs what I thought it was.

If he were a cash-only patient, I would've told him that if all he wanted me to to do was listen, I would've done it. Heck he's paying, but to be upfront and transparent, I'd tell the person upfront unless he mentions something to fix, he's really just paying me hundreds of dollars an hour to listen.

The problem with this guy is that 1-He had insurance and was using it. I cannot come up with a false dx, and adjustment disorder-that he likely didn't have I put in because I was in a 50-50 "there's got to something wrong with him because he seems to dedicated to showing up and talking about this" situation, but the more and more I heard him the less I could even give him a dx, and I wasn't going to fake one just to bill. I told him upfront that if he needs to see me he needs something to fix that I could dx, and the guy didn't have much money.

Again, I did refer him to counselors and psychotherapists that have more wiggle room to manage these things.
The other problem 2- is that there is a shortage of psychiatrists in most areas and I believe I have a community-model based duty to open myself up to people who need my help. This guy, if he just wanted someone to listen to him, shouldn't have been seen by me. I am completely of the belief that psychiatrists should do psychotherapy but given our shortage, we should let the ones that don't need the meds be seen by people that don't prescribe the meds since there isn't a shortage of them.

Add to the odd picture that this guy had a slight lisp so hearing his sexual escapades was like being in a John Waters film--odd, somewhere between creepy and funny but neither.

A few months after he stopped seeing me, I saw him at the PES (the local psych ER in U of Cincinnati) because he just broke up with his boyfriend so he wanted to talk about it....for hours, with a psychiatrist. When I saw him on the list, I told the nurses we just got to discharge this guy ASAP and refer him to a non-psychiatric therapist.

 

[Ceke2002]

A few months after he stopped seeing me, I saw him at the PES (the local psych ER in U of Cincinnati) because he just broke up with his boyfriend so he wanted to talk about it....for hours, with a psychiatrist.

Oh yeah, I bet he did

 

[PikminOC]

Very interesting thread. Thanks cece for you input. We all learn from each other!

 

[F0nzie]

Update: 1 month follow up

They did not do family therapy but pt is doing much better. He is no longer acting out. Mom is staying out of his hair and he is more independent in many ways. They are getting along better and setting healthier boundaries with each other. He has since moved out of the house and will be starting college in January.

Thanks for the awesome advice everyone. This psych forum is full of rockstars.