Difficulty with “coercive” interventions

[sloop]

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I work on a forensic unit treating incompetent defendants and insanity acquittees. In a lot of ways, it is a great job. It is interesting. I get to treat very sick people and I find that rewarding. The overall pace is reasonable and I do not have to take call. I get paid reasonably well for what I do. I really can’t complain.

One thing I have been struggling with, though, is the overall “coercive” environment and the frequency with which I have to engage with patients in a pretty adversarial way. Of course I recognize that psychotic patients lack insight and this is just part of the job. I also intellectually understand that “dying with one’s rights on” is not true freedom, and that compassion can involve treating people over their objection. That being said, I find it pretty disheartening to deal with these dynamics with a majority of my patients. I find myself unsure whether my personal values and style are a natural fit for this kind of work.

Every day feels like a battle, and I’m constantly struggling to get patients to take medication for at least instrumental reasons (it will help you to get out of the hospital, etc.). Many of my patients seem to hate me. I will take people to court for treatment over objection, but this inevitably ruins any rapport I might have had. I also feel like I receive pushback from some of the staff because I really try to treat patients in the least restrictive way possible. For instance, I have had staff get mad at me for verbally deescalating patients rather than medicating them. I guess I just miss having patients who are sometimes grateful for the care I have provided them. I rarely get that here.

Overall, I just find this to be extremely draining and I am wondering if anybody has any tips on how to handle this on a personal level.

 

[tr]

I didn't like this aspect of psychiatry either, which is why I don't work inpatient. Outpatients are always there because on some level they want the help.

As far as making it through the day, I found that taking an MI based approach and trying to side with the patient in navigating the system (as it sounds like you are already doing) is helpful. There's really nothing wrong with focusing on short term, instrumental motivations.

E.g., what are the patient's goals? Rapid release? Great, I want that for you too. At the same time I want you to be safe and able to meet your basic needs met when you leave here. How can we work together to achieve that?

Verbal de-escalation is a critically important skill. I'm sorry to hear your colleagues don't recognize and applaud that. But I'm here to applaud you for it. Have an internet cookie 🙂

 

[sloop]

E.g., what are the patient's goals? Rapid release? Great, I want that for you too. At the same time I want you to be safe and able to meet your basic needs met when you leave here. How can we work together to achieve that?

Yeah, this is generally my approach. I make a conscious effort to appear particularly interested and friendly, especially during admissions, and establish rapport early. I try to quickly gauge insight and orientation towards treatment. If I can frankly discuss diagnosis and treatment, I will. If the patient seems to have no insight or be ambivalent towards treatment, I try to establish some sort of shared goal that treatment is linked to. I also often let the treatment work for a week or two before even starting to do things like probe delusions or coach people for competency. With this, I have been able to minimize the number of times I have had to take patients to court (it still happens, but I am able to get the majority of them to engage in treatment).

With the verbal deescalation issue, it is not really fellow physicians I get pushback from. It is mostly the treatment aides who seem to prefer that everybody is snowed.

 

[Bartelby]

I feel pretty much the same way. Similar to tr this issue is one of the major factors that moved me toward outpatient work. I don’t think coercive treatment is morally wrong but as you have described, I do find it more exhausting and less rewarding. I am interested to hear from some of our inpatient posters’ thoughts.

 

[splik]

Quit.

I'm serious but you have some options here:
1. Quit.
2. Explore your jobs options. I always recommend having one foot out the door and you will have a better appreciation of your job when you look at different options. either you will find it's not so bad, or realize that it's not a good fit for you.
3. Make a lateral move at the state hospital into administration, consulting, or forensic evals if available as options to you.
3. Diversify your work by doing some outpatient work as well, e.g. having a small private practice.

But your body is telling you that this isn't a healthy environment for you. You want to acknowledge that and respond according. I've had psychiatrist-patients who totally broke down and needed psych admission themselves because these hospital environments were not a good fit. All doing much better after changing their work setting.

 

[bashir]

This is easy for me to say because I work exclusively in outpatient, and while I have a number of patients who are on outpatient commitments, it's nowhere near the same thing.

But--it would be a shame if you quit. It sounds to me that the very things about you that make this sort of work difficult for you are what make you good at it. These patients need you.

I wonder if having a side gig could help, maybe see even just a few outpatients on the side. It sounds like the culture of the institution leaves some...room for improvement. This is probably going to sound Pollyannaish because what you described with staff wanting patients snowed into submission is a pervasive and often pretty intractable problem even in acute care psychiatric hospitals, let alone state hospitals, but it strikes me that you might tolerate the situation better if you were making systemic attempts to improve that culture. Are there any opportunities in that vein?

 

[Stagg737]

I think OP needs to sit down and consciously and purposefully weigh the pros and cons of this job. You started the post with a bunch of things about the job that seem positive, so how much is this one thing really getting to you? Is this one thing completely ruining the experience? Or is it more like something that is bothersome just when it happens (which unfortunately sounds fairly common)? If you just need variety then a side gig may spice it up enough that it's less bothersome. Or maybe the side gig opens your eyes further to how much you actually dislike this job. Either way, agree with Splik that at least looking into other options would be good for your right now.

This is easy for me to say because I work exclusively in outpatient, and while I have a number of patients who are on outpatient commitments, it's nowhere near the same thing.

But--it would be a shame if you quit. It sounds to me that the very things about you that make this sort of work difficult for you are what make you good at it. These patients need you.

I wonder if having a side gig could help, maybe see even just a few outpatients on the side. It sounds like the culture of the institution leaves some...room for improvement. This is probably going to sound Pollyannaish because what you described with staff wanting patients snowed into submission is a pervasive and often pretty intractable problem even in acute care psychiatric hospitals, let alone state hospitals, but it strikes me that you might tolerate the situation better if you were making systemic attempts to improve that culture. Are there any opportunities in that vein?

While I don't disagree with the point about trying to make changes if possible, I don't completely agree with the bolded. As splik mentioned, a job helping others is not worth sacrificing your own physical and mental health. I'm doing that to a lesser extent with my current outpatient work that I dread (staying in the clinic "because the patients need me"). At least for meit's only 5-6 hours a week, so much more tolerable. I can't imagine that being my FT job.

I didn't like this aspect of psychiatry either, which is why I don't work inpatient. Outpatients are always there because on some level they want the help.

I guess? If you call drug-seeking, angling for disability, or showing up because someone (sometimes the court) says there'll be consequences if they don't see a psychiatrist "help", then sure. Maybe this isn't a ton of patients for some psychiatrists, but in more than one clinic I've worked in this made up a non-negligent number of patients (seemingly 1/4-1/3 of my patients in one clinic, thankfully not my current one).

 

[sloop]

Several of you have mentioned a side gig. I have actually thought about this and I think this may be something I should pursue. I don’t necessarily want a huge practice, and the purpose honestly is more about morale than money. I think it might be nice to have a small number of private patients who I treat for, say, depression. As an aside, I think I miss treating mood disorders because the patients often have better insight and are more often appreciative if you can get them better.

 

[Merovinge]

Yeah, this is generally my approach. I make a conscious effort to appear particularly interested and friendly, especially during admissions, and establish rapport early. I try to quickly gauge insight and orientation towards treatment. If I can frankly discuss diagnosis and treatment, I will. If the patient seems to have no insight or be ambivalent towards treatment, I try to establish some sort of shared goal that treatment is linked to. I also often let the treatment work for a week or two before even starting to do things like probe delusions or coach people for competency. With this, I have been able to minimize the number of times I have had to take patients to court (it still happens, but I am able to get the majority of them to engage in treatment).

With the verbal deescalation issue, it is not really fellow physicians I get pushback from. It is mostly the treatment aides who seem to prefer that everybody is snowed.

Look, you are clearly extremely good at your extremely difficult job. Imagine being the best sniper in the history of the world, you've never missed a target. You either accept that your job is killing people and you are the best at it, or you do something else. Now in this case, instead of killing people, you provide human's the most important thing they could ask for during the worst time of their life, someone who genuinely wants to (and has the skills to) understand them and can help bring them back some ability to rationally think.

If you want to think about it from a medical perspective, it's a bit like being an amazing trauma surgeon. Even the best trauma surgeons will have cases that have single digit survival rates. You might be able to be a few points better than average, but lots of people will die with your hands being the last thing to touch them. Either you go home at night sleeping and feeling great about the work you do, the people you save, and knowing that everyone had the best chance possible at living, or you go home at night and get eaten up by the people who die. If you fall into the later camp, you can change back to being a general surgeon.

I might suggest some journaling to collect some data points on where your head is actually at and to see if you can appreciate the wins more than the losses get you down. The great part about psych is you can just switch your job and things really will be entirely different.

 

[smalltownpsych]

The coercive system is toxic and makes it more difficult to treat our patients. There do need to be legal stops in place, but the system ends up treating all the patients with the same hammer. I found that in a small system where I was making the decisions with the patient, about 90% of the people I recommended to be admitted to the locked unit agreed that is what they wanted. Half the time, someone else would unravel that alliance and agreement to receive treatment by being a coercive jerk for no reason other than power and control dynamics.
If you are able to begin to have influence or leadership in the system, then you might actually make some headway.

 

[sloop]

The coercive system is toxic and makes it more difficult to treat our patients. There do need to be legal stops in place, but the system ends up treating all the patients with the same hammer. I found that in a small system where I was making the decisions with the patient, about 90% of the people I recommended to be admitted to the locked unit agreed that is what they wanted. Half the time, someone else would unravel that alliance and agreement to receive treatment by being a coercive jerk for no reason other than power and control dynamics.
If you are able to begin to have influence or leadership in the system, then you might actually make some headway.

Regarding some of the systems issues, I have also been struggling with the ways in which the forensic goals sometimes seem to be at odds with the ethical imperatives of a treating psychiatrist. I used to think that the forensic goals and clinical goals were largely parallel, but I am no longer fully convinced that this is the case.

A fairly common situation I encounter is a patient who is chronically psychotic, treatment refractory, and, while not asymptomatic, under fairly good control with treatment with minimal side effects. If the patient is not competent, there is a pressure to trial increasingly intrusive options (I.e. high doses of clozapine with atropine/glycopyrrolate/metoprolol/aggressive bowel regimens to treat the inevitable side effects). This has always made me uneasy, because I struggle to accept that a person’s external legal situation fundamentally changes the risk-benefit calculus to justify heroic measures when they wouldn’t otherwise be warranted.

This also sometimes relates to treatment over objection because the hospital generally uses the standard treatment over objection avenues to secure orders for the treatment of patients, but in some instances I feel like what is really being pursued is a Sell order in disguise.

 

[mistafab]

To me it sounds like this is not a good fit for you.

Some people are just not as naturally suited to inpatient/forensic work with violent/psychotic patients. Not a good or bad thing, just is. Treating over objection and medicating liberally is commonplace, and frankly required in many of these settings. You're just never going to feel great about your work if you morally object to the thrust of the treatment setting. Forensic work in these settings does set up a 'dual-role' problem in certain instances that can be uncomfortable or frankly unwanted by people who came to psychiatry to be a single role (healer). Others have no issue dealing with the dual-role, or even find it fun.

It sounds like you're kind of swimming upstream in this environment, and it simply may not be a good fit for you. Hard to like any job where you morally object to the thrust of treatment.

If you can align your values with your work, I'm sure you'll find it much more rewarding. Life's not just about a paycheck and not taking call. There are better jobs out there for you. The way you wrote this - you're already on your way out. Just got to admit it and move on.

Best of luck.

 

[aim-agm]

When I am working with patients struggling with grief, one key element is asking them "would you prefer if it didn't hurt to lose [that person]?" The answer has been universally "no", because it would be inhuman not to feel hurt when bad things happen to people you care about.

In your case, I expect you wouldn't want to not feel bad when bad things (e.g. abrogations of liberty and bodily autonomy) happen to patients under your care. If you stopped feeling uncomfortable, it would be a good sign that you need to get out of that environment (and I suspect some of your discomfort is how callous those treatment aides are to the humanity of your patients). It sounds like you are responding appropriately to the discomfort, by putting in effort to preserve the rights of your patients as much as you can (e.g. verbal de-escalation rather than IMs) and questioning whether the rights and well being of your patients are being fully protected (e.g. identifying conflicts between clinical goals and values, and legal ones).

The question is whether the discomfort other adverse experiences of this job are of a manageable degree. If so, then the focus is on how better to manage it (e.g. getting a side gig) and come to peace with it; if not, then the focus is when and how do you transition to something else.

It is important to remember that the onus of this moral obligation to provide this care and protect the rights of these patients falls on society, not you. That is to say, if you are doing this job you have a responsibility to do it right, but you have no particular responsibility to do the job in the first place. If there is something more right for you, there is no failure as a psychiatrist or as a person if you pursue that.

 

[sloop]

To me it sounds like this is not a good fit for you.

Some people are just not as naturally suited to inpatient/forensic work with violent/psychotic patients. Not a good or bad thing, just is. Treating over objection and medicating liberally is commonplace, and frankly required in many of these settings. You're just never going to feel great about your work if you morally object to the thrust of the treatment setting. Forensic work in these settings does set up a 'dual-role' problem in certain instances that can be uncomfortable or frankly unwanted by people who came to psychiatry to be a single role (healer). Others have no issue dealing with the dual-role, or even find it fun.

It sounds like you're kind of swimming upstream in this environment, and it simply may not be a good fit for you. Hard to like any job where you morally object to the thrust of treatment.

If you can align your values with your work, I'm sure you'll find it much more rewarding. Life's not just about a paycheck and not taking call. There are better jobs out there for you. The way you wrote this - you're already on your way out. Just got to admit it and move on.

Best of luck.

Maybe my opinions were framed too strongly in my initial post, or perhaps I was unclear about them.

In reality, I do not have moral objections to the treatment itself. I do not find treatment over objection or emergency use of medication immoral. I also frequently use high doses of medication when I think it is indicated. Many of my patients are on clozapine, an augmenting antipsychotic, one or two mood stabilizers, plus or minus benzos, etc. I will seclude people or use restraints when I think it is warranted and I sleep well at night. I do have moral issues with what I see as excessive use of these restrictive measures, and what at times seems to approach punitive “treatment” or use of medication as a form of aversive conditioning.

The forensic role is also something I’m familiar and comfortable with. I am a forensic psychiatrist, after all, and part of my job involves performing evaluations. Again, my issue is more with the way that the dual role issue is handled here. I was once asked (more told) to perform a forensic evaluation on a patient I was admitting to my unit. There were some specific circumstances involved, but I had to tell my boss in no uncertain terms that I would not do that again. There are also a lot of bull**** reports that get written here to achieve results that are expeditious for the hospital, and I refuse to participate in that.

I appreciate aspects of this job that go beyond the paycheck and having call. I really like some of the people I work with. I take a lot of pride in working with a marginalized population and trying to treat them with dignity and respect. It really is mostly this one aspect that is kind of a drag for me.

 

[mistafab]

Maybe my opinions were framed too strongly in my initial post, or perhaps I was unclear about them.

In reality, I do not have moral objections to the treatment itself. I do not find treatment over objection or emergency use of medication immoral. I also frequently use high doses of medication when I think it is indicated. Many of my patients are on clozapine, an augmenting antipsychotic, one or two mood stabilizers, plus or minus benzos, etc. I will seclude people or use restraints when I think it is warranted and I sleep well at night. I do have moral issues with what I see as excessive use of these restrictive measures, and what at times seems to approach punitive “treatment” or use of medication as a form of aversive conditioning.

The forensic role is also something I’m familiar and comfortable with. I am a forensic psychiatrist, after all, and part of my job involves performing evaluations. Again, my issue is more with the way that the dual role issue is handled here. I was once asked (more told) to perform a forensic evaluation on a patient I was admitting to my unit. There were some specific circumstances involved, but I had to tell my boss in no uncertain terms that I would not do that again. There are also a lot of bull**** reports that get written here to achieve results that are expeditious for the hospital, and I refuse to participate in that.

I appreciate aspects of this job that go beyond the paycheck and having call. I really like some of the people I work with. I take a lot of pride in working with a marginalized population and trying to treat them with dignity and respect. It really is mostly this one aspect that is kind of a drag for me.

If this is the case, then it sounds like perhaps others were right. A different treatment setting through a side gig may provide a bit of fresh air for you.