Being too empathetic during the psychiatric interview?

[acuriousrabbit]

Hi all,

I'm a third year medical student on my inpatient psych rotation at a tertiary care hospital. My intern and my (junior) attending don't want the medical students coming with them on rounds, or for interviews. We do chart rounds and they see the patients by themselves. They say it's because it freaks the patients out -- which it might -- but most of the other teams on the floor round together, interview together (at least at the beginning), etc, including all of the senior attendings.

Because of this, I've never seen a psychiatric interview or mental status exam in person. Instead I've just taught myself and practiced a bunch of times. Today though I was practicing with a fellow medical student with a patient on the ward and she told me afterwards that I was too nice during the interview. She said her attending and resident don't really respond to patient's emotions, be it happiness, a joke, or something sad, and that this objective, analytical interaction with patients is preached as the best approach to the psychiatric interview. A few other students chimed in to agree when we were talking about this.

I guess this seems counterintuitive.. I thought we're supposed to gain rapport with our patients? For example, a patient last night was admitted after a serious suicide attempt who's never been in the hospital before... is depressed.. and thinks herself a VIP. She was put with the "crazies", and she was pissed about that. Then she yelled at the night team and ended up getting a 5/2. In the morning she refused to talk to anyone (sub-I, resident), so I got to see the attending interview. In the interview attempt, the attending was completely dispassionate, saying yes you got sedated because you were upset and needed to calm down. In response, the patient refused to talk to us. I went back an hour later and just said... you must be frustrated. She vented a little more. I said they're just doing their jobs, but I know it must be hard to be in this setting. She said yes, and then totally opened up and told me her story. Am I making psychiatric faux pas by recognizing and validating the feelings of my patients? Where is the line, and what's the reasoning for it?

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[splik]

This sounds terrible! you should complain to your clerkship director. Patients are used to having students and although it can change the dynamic somewhat we're talking about an inpatient unit not psychoanalysis here so you should be accompanying the residents and attending on rounds and observing interviews as well getting feedback on your interview and mental status examination skills. I even video some of my patients for medical student teaching and they are fine with this. As a medical student you should be part of the team and the go-to person for your assigned patients.

Of course you should respond to what patients say, what a silly approach they are taking. You can laugh with patients, share in their frustrations, sadness, and despair as long as you don't go overboard. Empathic validation is important. It sounds like youre doing a good job and trying to join the patient's where they are by recognizing their feelings and exploring their internal world. This is what psychiatry is all about. There is a balance, one has to be firm as well and often patients hate their inpatient team and that is okay too, but it is ridiculous to say that you should be dispassionate, you won't get anywhere like that. There are many approaches to working with patients but it sounds like you have discovered the best approach is to join them, show real interest and curiosity, and just take what they as the reality and responding to that.

Don't be discouraged, this is not how psychiatry is everywhere. Though I am curious where this is now so pm me if you feel comfortable sharing!

edit: have a look for Michel's and Mackinnon's The psychiatric interview in clinical practice, and the interview book by shawn christopher shea, the name of which i forget. The former is more psychodynamic but they never suggest a cold dispassionate approach, far from it. The latter is more how to be detective like in asking questions. Both are good in their own way

 

[OldPsychDoc]

Really briefly, there is "gaining rapport" and there is enabling splitting, particularly in a potentially entitled patient who "thinks herself a VIP". By letting her "totally open up" you're running the risk of being on the "good doc" side of the splitting. Watch and see how this turns out. (BTW, listening, recognizing, and validating feelings isn't wrong, or a faux pas. Appearing to take her side vs. the rest of the team, or trying to be her friend, would be.)

 

[splik]

Really briefly, there is "gaining rapport" and there is enabling splitting, particularly in a potentially entitled patient who "thinks herself a VIP". By letting her "totally open up" you're running the risk of being on the "good doc" side of the splitting. Watch and see how this turns out. (BTW, listening, recognizing, and validating feelings isn't wrong, or a faux pas. Appearing to take her side vs. the rest of the team, or trying to be her friend, would be.)

In fairness this would be avoided if the team let her round with them in the first place!

 

[wolfvgang22]

Hi all,

I'm a third year medical student on my inpatient psych rotation at a tertiary care hospital. My intern and my (junior) attending don't want the medical students coming with them on rounds, or for interviews. We do chart rounds and they see the patients by themselves. They say it's because it freaks the patients out -- which it might -- but most of the other teams on the floor round together, interview together (at least at the beginning), etc, including all of the senior attendings.

That's too bad. How many people are on the treatment team when the attending rounds? 3 or 4 people in the room is often fine, but trying to interview a patient with 10 clinicians in a room (attending, resident, 4 students, a social worker, a nurse, etc) can be overwhelming to a patient.

You should let your attending know you want to be more involved interviewing patients and receiving feed back from him or her afterward, and that you would like to see how it's supposed to be done by observing him or her. If the attending doesn't make an effort to get you more involved, you should might consider talking to your medical school advisor or rotation coordinator about your concerns. Sometimes junior attending physicians just aren't really ready to teach. Perhaps you can arrange to follow a different attending.

Because of this, I've never seen a psychiatric interview or mental status exam in person. Instead I've just taught myself and practiced a bunch of times. Today though I was practicing with a fellow medical student with a patient on the ward and she told me afterwards that I was too nice during the interview. She said her attending and resident don't really respond to patient's emotions, be it happiness, a joke, or something sad, and that this objective, analytical interaction with patients is preached as the best approach to the psychiatric interview. A few other students chimed in to agree when we were talking about this.

I guess this seems counterintuitive.. I thought we're supposed to gain rapport with our patients? For example, a patient last night was admitted after a serious suicide attempt who's never been in the hospital before... is depressed.. and thinks herself a VIP. She was put with the "crazies", and she was pissed about that. Then she yelled at the night team and ended up getting a 5/2. In the morning she refused to talk to anyone (sub-I, resident), so I got to see the attending I saw the interview attempt, the attending was completely dispassionate, saying yes you got sedated because you were upset and needed to calm down. In response, the patient refused to talk to us. I went back an hour later and just said... you must be frustrated. She vented a little more. I said they're just doing their jobs, but I know it must be hard to be in this setting. She said yes, and then totally opened up and told me her story. Am I making psychiatric faux pas by recognizing and validating the feelings of my patients? Where is the line, and what's the reasoning for it?

Sometimes as a psychiatrist you have to do some appropriate limit setting with patients, and that may have been what was going on when your attending's interview attempt with the patient.

It sounds like you did the right thing by approaching the patient with empathy and respect once she had a chance to calm down some, and she was able to be receptive to building a rapport with you. That's a good thing. Stay objective, though, and don't get sucked into a situation where it is you and the patient vs. the attending. Splitting does occur, and some patients will do it on purpose.

You are correct, the psychiatric interview does not have to be robotic, and you certainly do not have to ignore the patient's emotions or point of view. The patient needs to know he or she is heard and understood. There is a certain curative power in therapeutic rapport. At the same time, you are correct that there is a "line." You have to maintain professionalism, recalling that you are their doctor, not their best friend or anything else. You are always modeling a normal, doctor-patient relationship for the patient who may lack social skills.

 

[Ceke2002]

The Psychiatric Interview Evaluation and Diagnosis (Expanded from Psychiatry, Third Edition, edited by Allan Tasman, Jerald Kay,Jeffrey A. Lieberman, Michael B. First and Mario Maj.)" is a text I'd recommend as wel. I'm reading it now from the point of view of a patient, and the lessons it teaches in relation to hearing, listening, interpreting, empathising, and so on, seem like a solid foundation for the development of an excellent therapist.

 

[Armadillos]

Hi all,

I'm a third year medical student on my inpatient psych rotation at a tertiary care hospital. My intern and my (junior) attending don't want the medical students coming with them on rounds, or for interviews. We do chart rounds and they see the patients by themselves. They say it's because it freaks the patients out -- which it might -- but most of the other teams on the floor round together, interview together (at least at the beginning), etc, including all of the senior attendings.

Because of this, I've never seen a psychiatric interview or mental status exam in person.

If Im understanding the situation properly, I would be furious if I were you. You need to learn how to be doctor which involves caring for patients. On all inpatient psych rotations I've been on the medstudents always lead the interviewing with the patients they were following and then the resident or attending would jump in as needed. If a patient was expected to present a challenging interview for whatever reason the attending would coach up the medstudents ahead of time. How else are you supposed to learn to be a doctor other than taking care of patients?

 

[Mass Effect]

You should be complaining to your clerkship director immediately. It's inexcusable that they won't let you round on the patients.

 

[acuriousrabbit]

Thanks for all the responses, I'm encouraged that the standard approach does not seem to be a dispassionate, analytical interview. A couple things. First, the clerkship director is the attending of my friend who said I was being too nice. She previously corrected my friend for the same thing. Her resident has the same approach. Second, it's not that I can't round on the patients on our list, but that both the intern and attending round without us (and specifically noted they'd rather we not come with them).

Unfortunately I've just finished my two week inpatient rotation, so I probably won't complain to the clerkship director. As someone noted above, I do feel like this really was a missed opportunity, but it's encouraging to see it was specific to my attending/intern pairing and not generalized to the field! Thanks all.

 

[nitemagi]

This interview approach stems from the "blank screen" approach to psychoanalysis, with the idea that by not emoting or revealing anything, the patient is freer to project all of their internalized conflicts onto you and thus embody a transference relationship. I think that's silly on inpatient units, and outdated in all other settings. Some patients will project onto you no matter how you behave. Developing an authentic response is more likely to teach them alternative ways to behave and feel than this old school ego psychology approach. Furthermore few psychiatrists practice this way.

I would not be surprised if your school is in NYC.

 

[masterofmonkeys]

Even most modern psychodynamically oriented practitioners don't recommend the robotic approach.

 

[Ceke2002]

Really briefly, there is "gaining rapport" and there is enabling splitting, particularly in a potentially entitled patient who "thinks herself a VIP". By letting her "totally open up" you're running the risk of being on the "good doc" side of the splitting. Watch and see how this turns out. (BTW, listening, recognizing, and validating feelings isn't wrong, or a faux pas. Appearing to take her side vs. the rest of the team, or trying to be her friend, would be.)

I agree with OldPsychDoc, but I also agree with others who have said this is the sort of thing you should have learnt/or be learning had you actually been allowed to treat patients and go on rounds. The idea that it 'freaks the patients' out sounds like a load of baloney to me - you know most of us aren't delicate little vases that will shatter if you so much as look at us the wrong way (oh and way to inadvertently *not* encourage resilience in patients with that sort of attitude as well). 🙄

The thing with splitting is something you have to watch out for, especially if you have an Axis II patient with a history of abuse. Some children, when they're abused, learn to become very attuned to those around them, and will hone in on the person or persons they feel most able to elicit a caring response from, usually via some semblance of emotional manipulation (think of it as a protective mechanism, you kind of learn to align yourself with the person who's *not* hitting you, for example). Unfortunately because it is a learned behaviour, it's one you can get stuck in and carry through to teenage years or adulthood. If that becomes the case then the patient, when they're in treatment, needs to have firm boundaries and limitations set that tell them 'this is a safe environment, you are safe here, and you don't need to act out in order to protect yourself' - and yes, you can do that whilst still showing appropriate and balanced empathy.

 

[erg923]

I think there is such a thing as being too nice during an interview, although I personally wouldn't use the word "nice." I do look for misplaced empathy, validation of clearly dumb or antisocial behavior, as well as times when a student may be "identifying" a bit too much ("wounded warrior" stuff). None of this has anything to do with blank slate, transference/counter transference, Oedipal complex, psychoanalytic nonsense though.

I am continuously floored that this approach/clinical belief has continued to march on despite the massive paradigm shift over the past 4o years.

 

[Salpingo]

This interview approach stems from the "blank screen" approach to psychoanalysis, with the idea that by not emoting or revealing anything, the patient is freer to project all of their internalized conflicts onto you and thus embody a transference relationship. I think that's silly on inpatient units, and outdated in all other settings. Some patients will project onto you no matter how you behave. Developing an authentic response is more likely to teach them alternative ways to behave and feel than this old school ego psychology approach. Furthermore few psychiatrists practice this way.

I would not be surprised if your school is in NYC.

I would be very surprised.

The problem isn't the modality thats being taught. If the program was psychodynamic, they would be encouraging the students to explore the dynamics (either the transference or the enactment/regression of the patient) in their interactions, and not simply stifling them; they would be quick to note the amazing feeling you felt taking care of the patient while others neglected her dispassionately. If the program was behaviorist, you could argue that the clinicians should maintain some degree of neutrality so as not to reenforce maladaptive behaviors (although presumably there would be some form of behavioral chain analysis around the event, and you could still validate the experience). The most likely explanation is that these are inpatient clinicians somewhat jaded around severe personality pathology, waiting her out until she calms down enough to tolerate outpatient treatment, which is still shocking to those who haven't been exposed to it (e.g. medical students).

The real problem is that the feedback received has the word "too nice" in it, which is not in anyway clinical. I'm not sure if that's exactly how it was given, or how it was heard by either the OP or the friend. Say what you want about NYC programs, but they're generally pretty high caliber learning institutions. This sounds like a very interesting and important case that will replay itself in various ways in almost every rotation involving patient care, and you were left with questions.

As for the rounding part, that could be a safety issue. If the service has a significant amount of paranoid pathology, that could be one reason to limit the size of rounds, although that's no reason why you shouldn't have the resident or attending watch you. It did sound like you were able to see the attending perform an interview after all, although weren't too impressed with the results. To answer the original question, the utility of validating feelings varies. When you're trying to get a depressed cancer patient back on their feet, the answer is easy. This case is a little more complicated, because your goal is mostly getting a history and understanding of psych patients. As a clinician, you could argue for validating her experience while challenging some of her beliefs that she is somehow better than "the crazies" (presumably she was the only one IM'd that night, and was thus the sickest/"craziest").

 

[MacDonaldTriad]

This one really smells like we have half of the information and although the OP is honest about what they perceive as to these events, I have to wonder. Never the less, to keep a medical student out of rounds because they might allow splitting is unacceptable unless several attempts at instruction and correction have been attempted. I am always pointing out that the primary cause of psychiatry’s poor PR is a lack of effort in experience in the undergraduate medical education level. I can’t believe that this treatment team is so fragile as to have to preclude medical student contact because their ability to handle an entitled patient would be so completely flummoxed by a green horn coming into the mix. If that is the case, this rotation has little to offer and the tail has been wagging this dog long before the OP entered the picture.

Just my two cents: to the OP, please excuse your medical school and go and get a real psych rotation before you pass judgment on the field of psychiatry.

 

[Ibid]

Just fake sincerity..... thats all their is to it..... once you can fake it, its job and finish..... its like smile and you will feel happy..... sincerity is the same..... act sincere and eventually you will be sincere.... insincerity will be your internal state all the while outwardly you will appear sincere.... eventually all this will pass and you will learn to live with your fraudulence..... just like everyone does..... you will be an imposter among imposters..... see imposter syndrome....

 

[Ceke2002]

Just fake sincerity..... thats all their is to it..... once you can fake it, its job and finish..... its like smile and you will feel happy..... sincerity is the same..... act sincere and eventually you will be sincere.... insincerity will be your internal state all the while outwardly you will appear sincere.... eventually all this will pass and you will learn to live with your fraudulence..... just like everyone does..... you will be an imposter among imposters..... see imposter syndrome....

Yes, absolutely. The OP should definitely adopt this approach because no patient in the history of ever will see straight through it and call BS.

 

[Ibid]

Yes, absolutely. The OP should definitely adopt this approach because no patient in the history of ever will see straight through it and call BS.

You will give that little man repetitive strain injury if you take everything I write literally.... I'm using word magic to elucidate a point about the necessity of the superficiality of human relations in everyday life.... if this was not the case then the streets would be full of people shouting BS BS BS at the top of their little lungs all day long.... instead we repeat BS BS in our heads all day long and then pretend not to be hypocrits...... which is BS BS BS..... its and endless regress of BS BS BS..... thats just how it is on planet lunatic asylum....

 

[Ceke2002]

You will give that little man repetitive strain injury if you take everything I write literally.... I'm using word magic to elucidate a point about the necessity of the superficiality of human relations in everyday life.... if this was not the case then the streets would be full of people shouting BS BS BS at the top of their little lungs all day long.... instead we repeat BS BS in our heads all day long and then pretend not to be hypocrits...... which is BS BS BS..... its and endless regress of BS BS BS..... thats just how it is on planet lunatic asylum....

Sorry, I'm a tad tetchy at the moment, nuance in word comprehension probably not one of my strong points right now. 😉

 

[Ibid]

Sorry, I'm a tad tetchy at the moment, nuance in word comprehension probably not one of my strong points right now. 😉

No worries..... sometimes I don't even know what the point is i'm trying to make when I start writing..... the death of the writer being the birth of the reader..... but when the writer isn't born yet..... it gets dark.....

 

[acuriousrabbit]

Thanks again all. I stuck to my normal approach per the suggestions here. We had a graded interview and while I don't think I did well on diagnosis, the PGY4 said I was among the most appropriately empathetic people he'd seen. Meanwhile my poor friend got dinged for being too analytical, and warned me about it! So... there are definitely different styles and preferences about the clinical approach among the residents and attendings. I suppose I shouldn't be surprised!

 

[Ceke2002]

Thanks again all. I stuck to my normal approach per the suggestions here. We had a graded interview and while I don't think I did well on diagnosis, the PGY4 said I was among the most appropriately empathetic people he'd seen. Meanwhile my poor friend got dinged for being too analytical, and warned me about it! So... there are definitely different styles and preferences about the clinical approach among the residents and attendings. I suppose I shouldn't be surprised!

Well from a patient's point of view I know I'd much rather have a Psychiatrist who was able to be appropriately empathetic than one who was able to just dot all the i's and cross the t's when it came to handing out a diagnosis. You sound like you're heading down the right path to being a good therapist. 🙂

 

[Armadillos]

Well from a patient's point of view I know I'd much rather have a Psychiatrist who was able to be appropriately empathetic than one who was able to just dot all the i's and cross the t's when it came to handing out a diagnosis. You sound like you're heading down the right path to being a good therapist. 🙂

After seeing all the "Bipolar" borderlines out there I think I would choose a psychiatrist with the bedside manner of a honey-badger if it meant they could get the right diagnosis, and would choose a honey-badger spitting killer bees if they could nail diagnoses AND show some restraint with the Rx pad.

Edit- Point of clarification if anyone thought I was being critical, medstudents need not worry, you can teach someone medicine, much harder to teach them how to be a good person.

 

[Ceke2002]

After seeing all the "Bipolar" borderlines out there I think I would choose a psychiatrist with the bedside manner of a honey-badger if it meant they could get the right diagnosis, and would choose a honey-badger spitting killer bees if they could nail diagnoses AND show some restraint with the Rx pad.

Sorry, I probably wasn't clear enough, I was talking about the sorts of Psychiatrists who are so behooven to playing paint by numbers with a diagnosis that actual diagnosis get missed - as with the borderlines who are misdiagnosed as 'Bipolar' because the Psych can't take the time to actually talk to the patient and realise their 'rapid cycling' is emotional disregulation, not Bipolar Subtype whatever.