Everyday job stressors, the outpatient edition

[lockian]

---

Members don't see this ad.

This post is mostly coming from a place of having had had a kind of a bad week of poor sleep and worse patients, but it's revealed a few trends that I'm hoping to get input about.

--some bad patient interactions put me out of commission for a day or more. I spend my day after work crying or deep breathing, and trying to self-soothe with TV or my various favorite haunts on the internet. It takes forever to destress, then I need to finish notes, this cuts into my sleep time and it snowballs into burnout.

--A "bad interaction" can be anything from:
--me second-guessing how I addressed an acute issue in a moment of time-crunch and psychological pressure
--having to repeatedly say no to a patient who was actively trying to manipulate me into something.
--this isn't really a type of interaction, but me feeling like my treatment plan is hurting the patient by means of side effects. Even if the treatment is essential.
--general disagreement about treatment plan, depending on how vociferous the patient is being about it.


--I at times wish I could more easily say (In a polite way) "don't like my plan? Find another psychatrist." My colleague says that a perfectly acceptable course of action. In reality, though, with the objective shortage of psychiatrists everywhere turning a patient away, that is just... ugh. Even the below average community clinics and clinics staffed by NPs and PAs are super busy and have long wait times.

--after an appt, my notes are typically close to done because I type HPI and plan as I talk to the patient, but I still need to push buttons in Epic and do "cleanup" of the note, and that cleanup turns into rereading/editing the note, crosschecking the plan with prescriptions I wrote, and overexplaining things in the assessment. I need a kick in the butt to try and address this. I feel like it would change my life if I could not belabor my notes so much.

--I keep worrying "it's all going to come crashing down." I'll make a mistake and I'll be liable, disciplined by the board, etc, etc. I need to be paid at least twice what I am for the level of stress this causes me.

Which leads me to my next point:

I don't even work that much: 4 days a week, and see 2 new patients and 10 old patients a day on average. I have good nurses who do a lot to help put out fires between appointments, and hardly need to talk to patients or families outside of clinic time, though I do talk or message other MD's and other providers for coordination of care several times a week. As far as workplaces go, it's pretty good. I want to see more patients or work more days so I can reach my financial goals faster, but I feel like I physically can't with how much work takes out of me.

It got so bad by the end of the week I was considering a specialty change to something nonclinical. I could try to work as an insurance reviewer maybe. I need to find some bandwidth to actually research and apply for jobs.

 

[wellbutrin.girlfriend]

(Only a medical student with some experience in psych.) I just wanted to validate how hard the work you’re doing is and that it makes sense that it would have a toll on you. However, it sounds to me like you’re in a place where, even if you got some great suggestions for behavioral changes, it would be challenging to implement them because of your exhaustion and emotional strain. Maybe you should consider finding your own psych provider or if you already see one, might need to talk about adjusting the plan a bit.

 

[wolfvgang22]

This post is mostly coming from a place of having had had a kind of a bad week of poor sleep and worse patients, but it's revealed a few trends that I'm hoping to get input about.

--some bad patient interactions put me out of commission for a day or more. I spend my day after work crying or deep breathing, and trying to self-soothe with TV or my various favorite haunts on the internet. It takes forever to destress, then I need to finish notes, this cuts into my sleep time and it snowballs into burnout.

--A "bad interaction" can be anything from:
--me second-guessing how I addressed an acute issue in a moment of time-crunch and psychological pressure
--having to repeatedly say no to a patient who was actively trying to manipulate me into something.
--this isn't really a type of interaction, but me feeling like my treatment plan is hurting the patient by means of side effects. Even if the treatment is essential.
--general disagreement about treatment plan, depending on how vociferous the patient is being about it.


--I at times wish I could more easily say (In a polite way) "don't like my plan? Find another psychatrist." My colleague says that a perfectly acceptable course of action. In reality, though, with the objective shortage of psychiatrists everywhere turning a patient away, that is just... ugh. Even the below average community clinics and clinics staffed by NPs and PAs are super busy and have long wait times.

--after an appt, my notes are typically close to done because I type HPI and plan as I talk to the patient, but I still need to push buttons in Epic and do "cleanup" of the note, and that cleanup turns into rereading/editing the note, crosschecking the plan with prescriptions I wrote, and overexplaining things in the assessment. I need a kick in the butt to try and address this. I feel like it would change my life if I could not belabor my notes so much.

--I keep worrying "it's all going to come crashing down." I'll make a mistake and I'll be liable, disciplined by the board, etc, etc. I need to be paid at least twice what I am for the level of stress this causes me.

Which leads me to my next point:

I don't even work that much: 4 days a week, and see 2 new patients and 10 old patients a day on average. I have good nurses who do a lot to help put out fires between appointments, and hardly need to talk to patients or families outside of clinic time, though I do talk or message other MD's and other providers for coordination of care several times a week. As far as workplaces go, it's pretty good. I want to see more patients or work more days so I can reach my financial goals faster, but I feel like I physically can't with how much work takes out of me.

It got so bad by the end of the week I was considering a specialty change to something nonclinical. I could try to work as an insurance reviewer maybe. I need to find some bandwidth to actually research and apply for jobs.

I just want you to know you aren't alone. I've had entire years like this after inheriting a large panel of poor managed patients on massive amounts of benzos with an administrative directive to wean them all off.

Don't worry about what some "iron man" tough person physician might say, jobs can be really tough and everyone doesn't specialize in psychiatry for a reason! Be sure and take time off and take care of yourself first. Keep in mind that a lot less patients will improve if you weren't around to help, and you are making an impact! Try not to work harder than your patients on their recovery...many patients just aren't ready for change and that's fine, regardless of any pressure administration might try to out on you. Sometimes you can be very surprised which ones come around when you just provide a little motivational interviewing but refuse to take in THEIR problems as your own.

 

[Fan_of_Meehl]

This post is mostly coming from a place of having had had a kind of a bad week of poor sleep and worse patients, but it's revealed a few trends that I'm hoping to get input about.

--some bad patient interactions put me out of commission for a day or more. I spend my day after work crying or deep breathing, and trying to self-soothe with TV or my various favorite haunts on the internet. It takes forever to destress, then I need to finish notes, this cuts into my sleep time and it snowballs into burnout.

--A "bad interaction" can be anything from:
--me second-guessing how I addressed an acute issue in a moment of time-crunch and psychological pressure
--having to repeatedly say no to a patient who was actively trying to manipulate me into something.
--this isn't really a type of interaction, but me feeling like my treatment plan is hurting the patient by means of side effects. Even if the treatment is essential.
--general disagreement about treatment plan, depending on how vociferous the patient is being about it.


--I at times wish I could more easily say (In a polite way) "don't like my plan? Find another psychatrist." My colleague says that a perfectly acceptable course of action. In reality, though, with the objective shortage of psychiatrists everywhere turning a patient away, that is just... ugh. Even the below average community clinics and clinics staffed by NPs and PAs are super busy and have long wait times.

--after an appt, my notes are typically close to done because I type HPI and plan as I talk to the patient, but I still need to push buttons in Epic and do "cleanup" of the note, and that cleanup turns into rereading/editing the note, crosschecking the plan with prescriptions I wrote, and overexplaining things in the assessment. I need a kick in the butt to try and address this. I feel like it would change my life if I could not belabor my notes so much.

--I keep worrying "it's all going to come crashing down." I'll make a mistake and I'll be liable, disciplined by the board, etc, etc. I need to be paid at least twice what I am for the level of stress this causes me.

Which leads me to my next point:

I don't even work that much: 4 days a week, and see 2 new patients and 10 old patients a day on average. I have good nurses who do a lot to help put out fires between appointments, and hardly need to talk to patients or families outside of clinic time, though I do talk or message other MD's and other providers for coordination of care several times a week. As far as workplaces go, it's pretty good. I want to see more patients or work more days so I can reach my financial goals faster, but I feel like I physically can't with how much work takes out of me.

It got so bad by the end of the week I was considering a specialty change to something nonclinical. I could try to work as an insurance reviewer maybe. I need to find some bandwidth to actually research and apply for jobs.

Burnout?

Management says you need to learn mindfulness.

 

[lockian]

(Only a medical student with some experience in psych.) I just wanted to validate how hard the work you’re doing is and that it makes sense that it would have a toll on you. However, it sounds to me like you’re in a place where, even if you got some great suggestions for behavioral changes, it would be challenging to implement them because of your exhaustion and emotional strain. Maybe you should consider finding your own psych provider or if you already see one, might need to talk about adjusting the plan a bit.

I just fired my psych provider, lol, and am in search of one that can better fit my needs. I’m actually kind of happy about that. I’m generally conflict averse but I couldn’t afford to keep wasting my time. I kept giving them feedback and they would not change. It makes sense, not all working relationships are the right fit.

 

[lockian]

I just want you to know you aren't alone. I've had entire years like this after inheriting a large panel of poor managed patients on massive amounts of benzos with an administrative directive to wean them all off.

Don't worry about what some "iron man" tough person physician might say, jobs can be really tough and everyone doesn't specialize in psychiatry for a reason! Be sure and take time off and take care of yourself first. Keep in mind that a lot less patients will improve if you weren't around to help, and you are making an impact! Try not to work harder than your patients on their recovery...many patients just aren't ready for change and that's fine, regardless of any pressure administration might try to out on you. Sometimes you can be very surprised which ones come around when you just provide a little motivational interviewing but refuse to take in THEIR problems as your own.

I feel grateful that our admin doesn’t try to direct care one way or another. Do you work at a VA? That seems to come with its own set of headaches vis a vis the institutional agenda.

I keep wondering if psychiatry is not a good fit since I may be too sensitive, and it’s like pulling teeth trying to get less so. I’ve thought about a specialty change. After 2 years I taught myself to not immediately go to worrying about board action or lawsuits. But that was 2 years!

One thing I’ve learned in outpatient is that people’s state does ebb and flow, so like you said some do come around, and sometimes people who are stable decompensate. Sometimes it seems completely random though, and not directly related to anything I say or do, but who knows what thought and other processes really go on behind the scenes.

 

[lockian]

Burnout?

Management says you need to learn mindfulness.

In all seriousness, mindfulness does help slow down when you are feeling too frazzled and too pulled into different directions. It does help not make mistakes and get clarity on what is important. But the problem is, when there is so much on your plate, slowing down can… well, slow you down.

 

[nexus73]

I've had many patients who want something I don't recommend, and I say to them I'm working with them as an advisor. And I have to advise them to do what is in their best interest based on my expertise. Usually there are many reasonable options, it's not just do this one thing, my way or the highway. But if I'm recommending various antidepressants as options and they're fixated on Xanax, I tell them they can get another doctor as a second opinion, and actually encourage it. Most don't take that advice, but usually stop pushing for something I don't recommend.

I too find outpatient to be a grind. I have been lucky to have a 4-day clinic week broken up with various administrative obligations (which actually aren't that great), but I also do collaborative care with primary care clinics two afternoons a week and supervise therapists overseeing treatment groups in our outpatient program. This leaves me about 3 actual clinic days split up through the week. I think it would be hard to do 4 full clinic days straight, let alone 5-day week, or being in a super busy practice with 16-18-20 patients per day.

I think inpatient can be an escape from the outpatient doldrums (it's interesting how some psychiatrists can't wait to get out of the hospital after their last inpatient residency rotation, and others can't stand being in clinic). But if inpatient isn't your thing, looking for an IOP or partial hospital program could be interesting

Or if there is a local residency program, especially a community program, those jobs can be more chill with less direct patient care time. Family medicine or internal medicine residencies around you (or pediatrics if you are a child psychiatrist), those programs often are thrilled to have a psychiatrist 1-2 days a week to do a mix of didactics, resident process groups (T-group, Balint group), collaborative care, or direct patient assessments that residents can sit in on. And this can serve as a break from clinic with patient after patient all day every day.

 

[TheRightMedication]

I strongly recommend a coach or supervisor, ideally a fellow psychiatrist. You've described conflicts with patients, and conflicts with yourself. The sooner you sort that out the better.

You can run from it by switching jobs, but it could be you find the same issues with boundaries and self-confidence showing up again.

Edit - I speak from experience as one who benefits from it. I'm not sure we all need a private analysis like in the old days, but supervision is invaluable.

 

[Fan_of_Meehl]

In all seriousness, mindfulness does help slow down when you are feeling too frazzled and too pulled into different directions. It does help not make mistakes and get clarity on what is important. But the problem is, when there is so much on your plate, slowing down can… well, slow you down.

Quite true.

I remember as a grad student in the 1990s working closely with a mentor/prof who was really into mindfulness research and clinical practice in a largely cognitive-behavioral PhD program ('before mindfulness was cool') and we were shunned as doing some sort of 'wacky' stuff out of the mainstream...I was even discouraged from pursuing certain research angles in the area. It was an interesting awakening to 'tribalism' and closed-mindedness in academia. So, back in the day, I had to 'hide' or downplay my interest in and knowledge of mindfulness, the Jon Kabat-Zinn reasearch, etc.

Now that mindfulness (and often McMindfulness [TM]) is common knowledge as the obvious cure for everything mental health related--including stress from a system that is inherently dysfunctional and poorly managed--I find myself 'hiding' or downplaying my interest in and knowledge of mindfulness for opposite reasons. It's really bizarre to have everyone from the butcher, baker, and candlestick maker (some non-clinical bureaucratic functionary) perpetually emailing me about 'mindfulness.' Wild world.

 

[TheRightMedication]

Mindfulness is a good tool, but can be used to distract rather than to engage with the world. In this way it becomes an instrument for the corporation to help its employees bear exploitation with less complaining, or by governments to steady the hand of the rifleman.

 

[lockian]

I strongly recommend a coach or supervisor, ideally a fellow psychiatrist. You've described conflicts with patients, and conflicts with yourself. The sooner you sort that out the better.

You can run from it by switching jobs, but it could be you find the same issues with boundaries and self-confidence showing up again.

Edit - I speak from experience as one who benefits from it. I'm not sure we all need a private analysis like in the old days, but supervision is invaluable.

How would you recommend finding someone like this? I have a senior colleague I talk cases with at times. They are assigned as my go to person to help me get used to the system, but I don’t believe they are paid or anything, so I don’t like to rely on them too heavily.

 

[lockian]

I've had many patients who want something I don't recommend, and I say to them I'm working with them as an advisor. And I have to advise them to do what is in their best interest based on my expertise. Usually there are many reasonable options, it's not just do this one thing, my way or the highway. But if I'm recommending various antidepressants as options and they're fixated on Xanax, I tell them they can get another doctor as a second opinion, and actually encourage it. Most don't take that advice, but usually stop pushing for something I don't recommend.

I too find outpatient to be a grind. I have been lucky to have a 4-day clinic week broken up with various administrative obligations (which actually aren't that great), but I also do collaborative care with primary care clinics two afternoons a week and supervise therapists overseeing treatment groups in our outpatient program. This leaves me about 3 actual clinic days split up through the week. I think it would be hard to do 4 full clinic days straight, let alone 5-day week, or being in a super busy practice with 16-18-20 patients per day.

I think inpatient can be an escape from the outpatient doldrums (it's interesting how some psychiatrists can't wait to get out of the hospital after their last inpatient residency rotation, and others can't stand being in clinic). But if inpatient isn't your thing, looking for an IOP or partial hospital program could be interesting

Or if there is a local residency program, especially a community program, those jobs can be more chill with less direct patient care time. Family medicine or internal medicine residencies around you (or pediatrics if you are a child psychiatrist), those programs often are thrilled to have a psychiatrist 1-2 days a week to do a mix of didactics, resident process groups (T-group, Balint group), collaborative care, or direct patient assessments that residents can sit in on. And this can serve as a break from clinic with patient after patient all day every day.

What’s interesting is that the volume does not bother me as long as patients are not demanding, manipulative or aggressively pushing boundaries. But you can’t avoid those sorts of dynamics completely, in any field and in any profession.

 

[Sushirolls]

Don't take on people's ability to have stress in finding a new psychiatrist. Not your problem.
Insurance companies can help locate.
Psychology today can help locate.
They can google.
They can pay cash to find one.
Or they can go to their PCP to get meds.

 

[calvnandhobbs68]

Don't take on people's ability to have stress in finding a new psychiatrist. Not your problem.
Insurance companies can help locate.
Psychology today can help locate.
They can google.
They can pay cash to find one.
Or they can go to their PCP to get meds.

100% agree. People also know that it's hard to get into psychiatry. Honestly, unless this is done maliciously frequently, I see little downside to telling an obviously problematic patient you'd be happy to give them 30 days of meds, discharge them and send their records their new psychiatrist if they're having problems.

 

[lockian]

100% agree. People also know that it's hard to get into psychiatry. Honestly, unless this is done maliciously frequently, I see little downside to telling an obviously problematic patient you'd be happy to give them 30 days of meds, discharge them and send their records their new psychiatrist if they're having problems.

Lol, and then you get, “I waited three months just to see you! Everyone just keeps passing me off! I’m tired of asking for help and getting nothing!”

In all seriousness though I guess it is correct that I’m not responsible for the system sucking and it does not mean I should take on patients in a way that overextends me.

 

[deleted1100659]

for sure it gets exhausting.

Encounter I had friday.

Patient presented in "crisis". Second time seeing him, he is somehow getting disability for "schizoaffective disorder" and has never been on an antipsychotic and has no symptoms of a psychotic disorder at all. The first time I saw him, he was only there so I could write a letter for him to be his own payee. I basically wrote a note saying I cant predict the future and dont know the patient or his family. Well anywho, on this second time, hes being evicted from his house and now again wants me to write a letter to ensure his check for "schizoaffective disorder" goes to him. I get fed up and tell him and my staff im not signing anything and im done with attaching my name to anything. Of course im a pariah at my current job because i dont fall in line and thank them for sticking 34343 midlevels under me.

Where im going with that is, you gotta stand your ground and dont even feel bad about it. There are people out there who have the mentality that every is a beautiful rose in the garden of life. I am not one of these people. You get limited time/energy and directing it at the people who actually are there for the right reasons is what keeps me going, if it wasnt for the good patients my days would be full of complete suck. Theres not so good patients out there who will try to manipulate and deceive to get what they want for some hidden motive. You are obviously a very smart person, when you see the red flags of this, stand your ground, be professional, and explain calmly "they aint gettin it here". Theres a private psychiatrist down the road who writes xanax like candy, if thats what they want, then thats on them.

Also I have 3 patients with primary progressive MS working a FULL TIME JOB while getting IV infusions. I have a schizoaffective patient in his 20s, working at a grocery store 30 hours a week. I have another schizoprehnic patient, on clozapine, who is a college professor. So when they come wanting disability for something thats obviously BS, im just honest and say "Sure, ill document everything you said and how there is no objective way for anyone to decide that you cant work and this is all based upon your report. Furthermore, I do have to document that you had the ability to make the phone call to get an appointment here, see the intake eval beforehand, and nursing eval, drive yourself here, and drive yourself home and that despite all this, you do not have the ability to work, per your report".

I am ranting back at you with my own experiences but also basically saying, I think developing ways to cope with these kind of patients is useful otherwise they will burn you out hardcore.

Heck, I had one guy abusing rectal valium that he was getting from a urologist, then he came to see me because he wanted me to keep prescribing it because the urologist took him off. You gotta make it crystal clear you arent the provider for them, but you have to do in a tactful way is the key.

Short version: you cant save the world, but you can save some people

 

[splik]

It got so bad by the end of the week I was considering a specialty change to something nonclinical. I could try to work as an insurance reviewer maybe. I need to find some bandwidth to actually research and apply for jobs.

You would definitely not be suited to utilization review work. You have to be able to deal with angry physicians shouting at you because you're denying their request for extra inpatient days or residential treatment or what not, and guilting you by claiming that you'll be on the hook if the pt kills themselves etc.

You need to have weekly supervision with a psychodynamically oriented psychiatrist who can help you to review and navigate the kinds of challenges you are struggling with in the clinical setting. There are also some physicians who specialize in coaching other physicians and that might be a helpful approach for you too.

 

[lockian]

You would definitely not be suited to utilization review work. You have to be able to deal with angry physicians shouting at you because you're denying their request for extra inpatient days or residential treatment or what not, and guilting you by claiming that you'll be on the hook if the pt kills themselves etc.

You need to have weekly supervision with a psychodynamically oriented psychiatrist who can help you to review and navigate the kinds of challenges you are struggling with in the clinical setting. There are also some physicians who specialize in coaching other physicians and that might be a helpful approach for you too.

You are correct. Not sure where to start looking for someone like that. Doctor social networks like doximity or local chapter of APA, asking colleagues?

 

[TheRightMedication]

I would ask colleagues. Find a good psychodynamic therapist and they'll know exactly what you mean by supervision.

 

[TheRightMedication]

I'd like to add that, with some supervision, you can come to see that these angry, boundary-pushing patients are best served by a firm "no," not because you're acting out your resentment at them or the system, but because saying "no" can be the most caring and helpful thing you can do.

If you can do that sort of thing you don't need to choose between saving the world vs saving some people, as an above poster said. You can just do the right thing most of the time and feel integrated and stronger every day, not diminished and weakened by the effort.

 

[lockian]

I would ask colleagues. Find a good psychodynamic therapist and they'll know exactly what you mean by supervision.

I’m confused, does this need to be a fellow MD psychiatrist or a psychotherapist? I feel like I need some sort of hybrid of personal psychotherapy and case consultation.

 

[TheRightMedication]

I think either a psychologist or a physician would do. The psychodynamic orientation is the key.

 

[forchinet121]

You would definitely not be suited to utilization review work. You have to be able to deal with angry physicians shouting at you because you're denying their request for extra inpatient days or residential treatment or what not, and guilting you by claiming that you'll be on the hook if the pt kills themselves etc.

You need to have weekly supervision with a psychodynamically oriented psychiatrist who can help you to review and navigate the kinds of challenges you are struggling with in the clinical setting. There are also some physicians who specialize in coaching other physicians and that might be a helpful approach for you too.

Is it true the insurance doc is on the hook if pt does kill themselves?

 

[deleted1100659]

Is it true the insurance doc is on the hook if pt does kill themselves?

I don't believe so, my understanding is that the insurance doctor only decides if their stay is covered. Ultimately they dont tell you to discharge or make that call, its your name on the discharge paperwork, so even if the stay is not covered you are the one discharging them. Which could be not fun, if the stay isnt covered so the hospital is pressuring you to discharge and breathing down your neck.

 

[erg923]

I don't believe so, my understanding is that the insurance doctor only decides if their stay is covered. Ultimately they dont tell you to discharge or make that call, its your name on the discharge paperwork, so even if the stay is not covered you are the one discharging them. Which could be not fun, if the stay isnt covered so the hospital is pressuring you to discharge and breathing down your neck.

There are some states in which the Utilization Management is considered the practice of medicine, so it is not out of the realm of possibility that someone could make that argument. But the role is ultimately authorizing payment or nonpayment of requested services, not making discharge decisions.

 

[calvnandhobbs68]

There are some states in which the Utilization Management is considered the practice of medicine, so it is not out of the realm of possibility that someone could make that argument. But the role is ultimately authorizing payment or nonpayment of requested services, not making discharge decisions.

Yup which is exactly what they'll tell you. "doctor I leave it up to your clinical judgement whether to discharge the patient or not I'm just telling you we won't pay for it anymore"

 

[splik]

Is it true the insurance doc is on the hook if pt does kill themselves?

No. It it is up to the requesting physician to appeal any denial and exhaust that. Also ir you don’t want to discharge a pt then it doesn’t matter if the insurance won’t cover it as you can bill the pt or the hospital can eat the cost. Finally if the pt has an ERISA plan (ie employer sponsored) then they are basically immune from liability under the law.

 

[Merovinge]

I’m confused, does this need to be a fellow MD psychiatrist or a psychotherapist? I feel like I need some sort of hybrid of personal psychotherapy and case consultation.

I would definitely recommend a fellow MD psychiatrist. Psychotherapists clearly share things in common, but their day-to-day practice is a lot different than ours. You can certainly be getting regular therapy with a psychologist but I would set-up and pay for supervision from a psychiatrist. If you live near a psychodynamic institute, that would be a slam dunk place to find someone.

 

[calvnandhobbs68]

I would definitely recommend a fellow MD psychiatrist. Psychotherapists clearly share things in common, but their day-to-day practice is a lot different than ours. You can certainly be getting regular therapy with a psychologist but I would set-up and pay for supervision from a psychiatrist. If you live near a psychodynamic institute, that would be a slam dunk place to find someone.

Agree, a psychiatrist will be OPs best bet. If this was purely a therapy technique or therapy modality supervision issue, psychotherapist only would be totally appropriate but (absolutely nothing against psychologists/pure psychotherapists) they just don't have the experience of some of these demanding patient interactions around medications or worries about patient welfare based on r/b of medication side effects.

 

[smalltownpsych]

As a psychologist that is psychodynamic and has worked with some MDs and been helpful to them, I would second the recommendation to try and get the supervision from an MD. I am actually pretty good at helping people set boundaries and it has been a lot of my own work and getting better at that will likley be a big help to you, but the truth is I don’t have to say no to people who want medications. I am close enough to it and even involved in the process at times as they try to practice their arguments on me or get me to help them get their psychiatrist to give them what they “need” to be grateful that I don’t have to deal with it much. It isn’t just the addicts either, although they can obviously be the worst. I get a few passive patients that don’t understand how therapy works and want me to fix them and I have seen the patients play this out with medications even more so. After all, the commercials show the people magically happy so….

I also think that as a highly skilled and experienced psychotherapist, I have an entirely different relationship and approach that is quite a bit different from highly skilled psychiatrists that I have known. The skillset overlaps, but it’s definitely different and if I tried to help, it might make it worse. If I was coaching a psychiatrist, I would have to guard against that and be very keyed into the differences. Even in supervising and training other psychologists, I have to recognize their personality and style. A common supervision error is to think the way I do it is the way you should do it.

 

[smalltownpsych]

The patient is the one with the illness. If they aren’t nice, don’t give them anything and what I mean by that is no emotional reaction or engagement. No is a complete sentence. Broken record technique. Use of silence and non-reactivity. These are all some of the things I use to deal with the difficult patients and days. I also try to save my tears for the emotional distress of patients that I have appropriate empathy for. I also don’t have to like all or even the majority of my patients and putting more energy and time into the ones I do like is completely appropriate.

For the fear of it all crashing down because I screw up somehow, I struggle with that one too. I think stress makes that one worse. Right now I started my own practice so I just added the I’m going to fail at business impending doom on top of it along with a lot of added stress. Then people invalidate me by saying don’t worry because you are so good, competent, you’ll do fine, etc. Same stupid crap they tell my patients. It’s why I don’t tell people much. The thing that actually does help me feel more secure is when other people share their own insecurities and vulnerabilities and then I realize they’re probably going to be ok and I’m probably going to be ok too.