Examples of Intellectual Stimulation in Psychiatry?

[LaGiardia]

Hey friends, I'm an MS3 who came to medical school interested in maybe doing psychiatry, but now I'm on my rotation I haven't found it as stimulating as I thought it would be. I was a humanities person in undergrad and enjoy thinking through issues, writing, deep thoughts, etc haha. I kind of thought psychiatry would be up my alley but I haven't observed a ton of critical thinking on the wards. A lot of it seems like medicine with a limited range of meds and a much nicer schedule . I do enjoy talking to patients and hearing stories but that's not exactly intellectually stimulating per se (or maybe I'm not approaching it right!).

I'm guessing the more thought-provoking work might be in outpatient where you get to do more psychotherapy. But I really have no way of getting significant exposure to that (at least for this year). I was wondering if some you pro's could give example of the kind of intellectually challenging work you do in psych. Like could somebody give a narrative of a dialog with a patient that made you feel you were really using your critical thinking/brain power? I know that's kind of a lot to ask, but I would appreciate it. Also if you have any books/resources you'd recommend to understand the deeper side of psychiatry, I'd appreciate it. Thanks!

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[nexus73]

Hey friends, I'm an MS3 who came to medical school interested in maybe doing psychiatry, but now I'm on my rotation I haven't found it as stimulating as I thought it would be. I was a humanities person in undergrad and enjoy thinking through issues, writing, deep thoughts, etc haha. I kind of thought psychiatry would be up my alley but I haven't observed a ton of critical thinking on the wards. A lot of it seems like medicine with a limited range of meds and a much nicer schedule . I do enjoy talking to patients and hearing stories but that's not exactly intellectually stimulating per se (or maybe I'm not approaching it right!).

I'm guessing the more thought-provoking work might be in outpatient where you get to do more psychotherapy. But I really have no way of getting significant exposure to that (at least for this year). I was wondering if some you pro's could give example of the kind of intellectually challenging work you do in psych. Like could somebody give a narrative of a dialog with a patient that made you feel you were really using your critical thinking/brain power? I know that's kind of a lot to ask, but I would appreciate it. Also if you have any books/resources you'd recommend to understand the deeper side of psychiatry, I'd appreciate it. Thanks!

It will definitely depend on the type of work you are doing within psychiatry, with psychotherapy perhaps being more stimulating and less reductionistic than a busy inpatient unit. However IMO, the stereotype of psychiatry being easy, or having a limited range, is inaccurate. Once you get into practice you will see that patients do not line themselves up into perfect diagnostic boxes (as opposed to say, a heart failure patient or DKA patient which are a dime a dozen on the medical unit and have fairly straightforward management). In psychiatry every patient can be unique and many are diagnostically challenging (borderline vs bipolar ...or perhaps borderline and bipolar plus some methamphetamine use). And often we see treatment resistant diagnoses, for example, a depressed patient who has been through every SSRI/SNRI/Wellbutrin/Remeron...so what do you turn to next? And after all of this, the social/psychological aspects which may be perpetuating factors for illness need to be addressed.

I have definitely seen inpatient psychiatry done very quickly and superficially (e.g. 16 follow up patients a day plus 4 new consults), which is not good psychiatry (though I fear the direction the field is headed), and would agree this is not intellectually stimulating. Ultimately it will depend on the where you practice and how you choose to practice.

Something to consider is getting your own psychotherapy.

 

[tr]

I agree that therapy is generally more complicated and challenging than psychopharmacology, although good psychopharmacology ( meaning staying current on the literature and practicing evidence based psychiatry) isn't trivial.

I think one of the most challenging situations is agenda setting or motivational interviewing with a patient who has conflicting drives regarding positive change. Phrasing things the wrong way can cause them to shut down, while phrasing them the right way can put you both on a collaborative path to positive change. The difference between the right and the wrong way to speak can be subtle. Rescuing a situation in which the patient is angry or oppositional is also challenging, and very rewarding to get right.

 

[FlowRate]

I like CL because it's a lot of that interpersonal challenge -- the patient may not have wanted to see psychiatry or may be undifferentiated, so there's more thought that goes into things.

I have not enjoyed inpatient very much because, while there can be some interesting cases worth a lot of thought, most cases are pretty straightforward. It can feel like a lot of waiting.

 

[OldPsychDoc]

I think that even the "straight-forward" inpatient cases can be intellectually rewarding when you see that each patient has a unique story--even a repeat admission of a "frequent flyer" may have a different flavor than the last one, a different problem to help them solve. As @nexus73 mentioned above, the real patients we see rarely fit into "textbook" categories. There is a lot of intellectual stimulation in the collaborative problem-solving process with each patient, and so much variety from one patient to the next.

 

[DJspreadsheet]

I personally don't find the work intellectually stimulating. I don't find anything in medicine intellectually stimulating. Modern medicine, and psychiatry, has been relegated to a grind for many of us. Unfortunately by the time one may realize this, their foot is too far in the ditch to change course.

That's not to say that I don't find obligation to do my job well. Many of these people who clamor with fascination are the same people providing awful care that I find myself undoing. I've resigned myself to find stimulation in areas outside of work. And I'm okay with that.

 

[LaGiardia]

Thanks all for the replies- very encouraging. I esp. appreciate the sort of cases nexus mentioned. I wonder if anyone would mind sharing a specific case that they found really interesting and kind of spell out the thinking that went into it and how you found it challenging?

I really want to love psych but I guess what I've seen so far on the wards hasn't been what I was imagining. It's encouraging to hear how many in this forum really enjoy and are stimulated by their practice. But I'm having a hard time understanding how I get a chance to flex my mental muscles? I would really appreciate any detailed examples people could share. I know it may be a thing where it's hard to explain until you experience it but I'm nervous about committing to a field where I haven't yet glimpsed the things that are really great about it.

 

[LaGiardia]

I personally don't find the work intellectually stimulating. I don't find anything in medicine intellectually stimulating. Modern medicine, and psychiatry, has been relegated to a grind for many of us. Unfortunately by the time one may realize this, their foot is too far in the ditch to change course.

That's not to say that I don't find obligation to do my job well. Many of these people who clamor with fascination are the same people providing awful care that I find myself undoing. I've resigned myself to find stimulation in areas outside of work. And I'm okay with that.

Thanks for the honest response! I think that's fair and there's probably a lot who feel that way too.

 

[DJspreadsheet]

Thanks for the honest response! I think that's fair and there's probably a lot who feel that way too.

No problem. And I can assure you there are. One thing you'll run into is people trying to elevate the rigor of what they're doing, both for their own sanity as well as to perpetuate the mystery of their vocation to you younger ones. Not suggesting anyone here is guilty of that, how would I know. But it's a real phenomenon. Medicine suffers from a lot of feigned motives and dialogue, when in the quiet cockles of the halls, you realize that it's just like any other job. Stressful and burdensome - not a dance with the fairies of intrigue. But guess what? That's life for nearly everyone. The benefit of medicine is it pays you enough cash to pursue outside interests. And the benefit of psych is it gives you the free time to utilize both.

One caveat, I'm in my last year of residency, so it may be burnout talking. But I think by now I'd know if anything about my work fascinated me.

 

[abcdior]

lol first of all, what does it even mean ? [intellectually stimulating] does that mean you are bored? I could be fishing and not bored but does that make fishing an intellectually stimulating pursuit?

anyways man, lets be real here, nothing in general that people do within any field of medicine, yes even neurosurgery, is "intellectually stimulating", certainly not on a day-day basis. If you want intellectually stimulation look to field like physics/math/CS and try to wrap your head around the Birch and Swinnerton-Dyer conjecture or the Riemann hypothesis, take a dip in the world of abstract algebra or numerical analysis. One of the smartest person I know originally went to Cornell for biology and half a semester in he was like "lol i already know everything there is to know in this field" and went into math instead.

at the end of the day, its all about whether or not you enjoy what you do. you sound like you don't particularly enjoy psychiatry and the day-day tasks of a psychiatrist. it has almost nothing to do with whether or not psychiatry, or medicine in general is "intellectually stimulating", its you.

maybe you need to do "stuff" and to"find yourself"

 

[LasVagus]

Medicine is difficult, but I think that it is a different kind of "difficult" than it is made out to be in media and popular culture. It's not House recognizing an incredibly rare presentation of an incredibly rare condition, nor is it the supermodels on Grey's Anatomy creating a never-before-seen surgery to solve a novel defect. It's a rote memorization marathon and lots of sleepless nights. To the OP: you, like me, spent much of your time in the humanities in undergrad and, therefore, I suspect you will always be a bit underwhelmed as to how little "deep thinking" actually goes on anywhere in medicine by comparison. I know I am. But, as the goal of medicine is to apply reliable interventions that can predictably improve human conditions, there probably shouldn't be much room for pondering or creativity on the practice side of it (research may be a more likely place for that kind of stimulation).

For me, personally, I find the greatest intellectual stimulation in psychiatry when I try to tease out precisely what a patient is struggling with. It's all well and good to take a patient's words at face value, but as best I can tell, every sentient being on earth perceives themselves as suffering from "anxiety" and "depression". Unfortunately, they often don't know what these words really mean in a clinical sense. They know that they feel bad and they have heard other people use these words before so they feel comfortable using them as well. But what are the patients actually experiencing? Did "depression" mysteriously appear for the first time in a childless man at the age of 55 who had always imagined he'd be a father? Does her "anxiety" somehow only come up after she has a fight with her boss. Does he use alcohol to "self-medicate" for "depression" and "anxiety", even though he didn't start to feel "anxious" or "depressed" until 8 years after he started drinking heavily? The digging is what I find fun. As you surmised, though, this definitely comes up more in outpatient situations where you have a bit more time and are not so focused on safety issues.

 

[Jules A]

I agree that therapy is generally more complicated and challenging than psychopharmacology, although good psychopharmacology ( meaning staying current on the literature and practicing evidence based psychiatry) isn't trivial.

Very interesting and I feel the opposite that skillful diagnosing and prescribing is the more intellectually challenging part of this job. Therapy although I believe if done well is what actually results in the long term growth seems less intense, less risky and with fewer chances of harming someone? Perhaps this is because I do medication management with only the briefest attempts at therapeutic communication. I thank the stars on a daily basis for the therapists and psychologists who do the emotional heavy lifting however because neither my patients or myself would benefit if I had to do the therapy.

 

[tr]

Very interesting and I feel the opposite that skillful diagnosing and prescribing is the more intellectually challenging part of this job. Therapy although I believe if done well is what actually results in the long term growth seems less intense, less risky and with fewer chances of harming someone? Perhaps this is because I do medication management with only the briefest attempts at therapeutic communication. I thank the stars on a daily basis for the therapists and psychologists who do the emotional heavy lifting however because neither my patients or myself would benefit if I had to do the therapy.

Definitely agree that potential for harm is greater with psychopharm. I think I feel that therapy is more challenging because the potential range of outcomes seems broader. You have to think carefully about everything you say and what the potential results might be. In that sense it's a little like chess in that you have to think about how the thing you are saying currently will affect the sequence of events five or ten moves down the road.

In psychopharm, the decision tree is less complex in that future events don't depend so intensely on past ones. If you try a medication and it doesn't work, you can always try a different one (barring rare terrible events like a patient death). Conversely, if you say the wrong thing in therapy you may not get the chance again to say the right thing.

 

[nancysinatra]

I personally don't find the work intellectually stimulating. I don't find anything in medicine intellectually stimulating. Modern medicine, and psychiatry, has been relegated to a grind for many of us. Unfortunately by the time one may realize this, their foot is too far in the ditch to change course.

That's not to say that I don't find obligation to do my job well. Many of these people who clamor with fascination are the same people providing awful care that I find myself undoing. I've resigned myself to find stimulation in areas outside of work. And I'm okay with that.

Many of those who clamor with fascination are also just easily impressed, and not that smart, I'm afraid to say. I'm not ok with that, but it's how it is...

 

[clozareal]

Also if you have any books/resources you'd recommend to understand the deeper side of psychiatry, I'd appreciate it. Thanks!

Not all psychiatrists practice psychotherapy in this way, but I found Dr. Irvin Yalom's books to be extremely intellectually stimulating (people start off with Love's Executioner and The Gift of Therapy). Any psychodynamic psychotherapy book will go through cases and are extremely fascinating as well. You can find some of these books online if you have access to Clinical Key or other medical eBook services. I also found the show In Treatment (HBO, Amazon Prime Video) entertaining for psychotherapy, although it of course is dramatized and ends up giving wild inaccurate pictures of boundary violations between therapist and patient.

 

[deleted736562]

The day to day job in psychiatry is always challenging and stimulating, including very much inpatient psych. It's not as easy to gather data in psychiatry as it is in other specialties. You can't just ask about hearing voices the same way you ask about abdominal pain. And if you do it just won't get the job done. Establishing rapport and a therapeutic relationship with patients is a day-to-day ongoing challenge, not to mention having to adjust to the myriad of personalities and narratives that are out there. The level of skill needed is limitless and it's on-going learning experience. And I believe that is true whether you are doing therapy or "med management". Then again, the division is artificial as your exploration of patient's symptoms to provide to them the best care should be therapeutic in itself. People tend to think of it as a "grind" when they are overworked, under pressure to see as many patients as fast as they could, as that is unfortunately one of the systemic problems in modern medicine, especially in residency, since with residents basically anything goes.

 

[postbacpremed87]

I think that even the "straight-forward" inpatient cases can be intellectually rewarding when you see that each patient has a unique story--even a repeat admission of a "frequent flyer" may have a different flavor than the last one, a different problem to help them solve. As @nexus73 mentioned above, the real patients we see rarely fit into "textbook" categories. There is a lot of intellectual stimulation in the collaborative problem-solving process with each patient, and so much variety from one patient to the next.

This is the reason I ultimately chose Psychiatry. All of the medical patients had the same story, same diagnoses, same treatment. All of the Psych patients had a different journey through life. The unique stories make it interesting.

 

[Armadillos]

All of the medical patients had the same story, same diagnoses, same treatment. All of the Psych patients had a different journey through life. The unique stories make it interesting.

You either are still a medstudent or one of the most optimistic residents I've ever met. As an intern about a third of my inpatients HPI/plan could accurately be summarized as "crack, the usual" or "alcohol, the usual".

That being said, I definitely find intellectually interesting cases on inpatient, seems to average about 25% of the patients in my anecdotal experience.

 

[postbacpremed87]

You either are still a medstudent or one of the most optimistic residents I've ever met. As an intern about a third of my inpatients HPI/plan could accurately be summarized as "crack, the usual" or "alcohol, the usual".

That being said, I definitely find intellectually interesting cases on inpatient, seems to average about 25% of the patients in my anecdotal experience.

MS3. I understand that a lot of it will suck.

 

[AcronymAllergy]

Random suggestion: if the clinical work isn't as "stimulating" as you'd expected, you could always also try to get involved in some research. You don't have to go out and be the PI on a large grant; plenty of existing research teams could benefit from the input and participation of a psychiatrist. Downside being you may not get paid for it.

 

[Jules A]

You either are still a medstudent or one of the most optimistic residents I've ever met. As an intern about a third of my inpatients HPI/plan could accurately be summarized as "crack, the usual" or "alcohol, the usual".

That being said, I definitely find intellectually interesting cases on inpatient, seems to average about 25% of the patients in my anecdotal experience.

I find inpatient far more interesting than outpatient possibly because I view the acute presentation as more precarious and agree about 25% are intellectually stimulating which is plenty to keep my attention. I also like the light version of dealing with their nonpsych ills on a limited basis.

Yeah no shortage of crack the usual, alcohol the usual and especially opiates, the usual although when treating long term interesting when the rare patient who actually abstains for a period of time comes up real deal manic and not just the ever prevalent Cluster B version of "my Bipolar".

 

[raf1ki]

I agree that therapy is generally more complicated and challenging than psychopharmacology, although good psychopharmacology ( meaning staying current on the literature and practicing evidence based psychiatry) isn't trivial.

I think one of the most challenging situations is agenda setting or motivational interviewing with a patient who has conflicting drives regarding positive change. Phrasing things the wrong way can cause them to shut down, while phrasing them the right way can put you both on a collaborative path to positive change. The difference between the right and the wrong way to speak can be subtle. Rescuing a situation in which the patient is angry or oppositional is also challenging, and very rewarding to get right.

Can you elaborate on this? Is it ever as simple as using phrases like "you could" instead of "you should?" Do you have any examples?

 

[tr]

Can you elaborate on this? Is it ever as simple as using phrases like "you could" instead of "you should?" Do you have any examples?

Those are definitely different, but I can't imagine a therapeutic context in which I'd say either. I don't give advice in therapy and 'should statements' are a classic cognitive distortion.

I'll try to give some generic/composite examples.

Patient debates re-entering the work force, cites various roadblocks, complains of lack of motivation. Effective response could be reflection/paradoxing to highlight contradictions between short term drives and long term goals. Ineffective response could be to suggest therapeutic approaches to improving motivation, which patient could perceive as pushy or insufficiently sympathetic, and shut down/ pull back from contemplation.

One half of a couple accuses therapist of taking the other spouse's side. Ineffective response could be for therapist to try to clarify their intentions, which could be perceived as defensive and escalate the situation. Effective response could be to use disarming and I-feel to reduce the interpersonal tension and inquiry/Socratic questioning to uncover the train of thought that led patient to perceive favoritism.

These aren't super complicated but they illustrate the point of having to overcome what might be your natural instinct to respond in a particular way (as if in conversation with a friend) and replace it with something that is calculated to produce a beneficial response in the patient.

 

[smalltownpsych]

Those are definitely different, but I can't imagine a therapeutic context in which I'd say either. I don't give advice in therapy and 'should statements' are a classic cognitive distortion.

I'll try to give some generic/composite examples.

Patient debates re-entering the work force, cites various roadblocks, complains of lack of motivation. Effective response could be reflection/paradoxing to highlight contradictions between short term drives and long term goals. Ineffective response could be to suggest therapeutic approaches to improving motivation, which patient could perceive as pushy or insufficiently sympathetic, and shut down/ pull back from contemplation.

One half of a couple accuses therapist of taking the other spouse's side. Ineffective response could be for therapist to try to clarify their intentions, which could be perceived as defensive and escalate the situation. Effective response could be to use disarming and I-feel to reduce the interpersonal tension and inquiry/Socratic questioning to uncover the train of thought that led patient to perceive favoritism.

These aren't super complicated but they illustrate the point of having to overcome what might be your natural instinct to respond in a particular way (as if in conversation with a friend) and replace it with something that is calculated to produce a beneficial response in the patient.

Good examples. Most people, even many 'therapists" of various ilks don't realize that effective psychotherapy rarely involves the giving of advice. If the patient wants advice, they can get that from pretty much anyone else in their life whether it's sought or not. I also second that it is often not the natural response that is the most effective psychotherapuetic response. If I react the same as the other people in the patient's life, that is likely a reenactment of the same old problematic interpersonal pattern. For the more intellectually inclined, learning about object relations and the interpersonal matrix and the neurobiological underpinnings of this is all great stuff. I love that word "stuff", don't want to get too intellectual.

A good example that comes to my mind of how to think about psychotherapy from an object relations theory comes from a social worker trainee that I was working with quite a few years back. Her patient had returned to college and was struggling. Therapist told me that she tried to encourage the patient by making statements such as "you can do this because you did this other thing". As she continued to try to provide encouragement, she noticed that patient was withdrawing and almost huddling up as far from therapist as possible. Being a trainee with some potential skills, she commented on this and asked patient what was going on for patient in the moment and patient responded that she was afraid that therapist was going to hit her the way that her dad used to. Apparently, that was how he encouraged her by pointing out that since he knew that she could do it she damn well better do it. Most people in this patient's life were trying to encourage her all the time by pointing out what she was capable of, no wonder she was in a constant state of fear.

For the more pharmaceutically inclined psychiatrists, just ask yourself what meaning does the medicine and your role as a physician and your relationship with the patient play in the patient's life. It doesn't even have to be all that deep either and I would argue that more straightforward interpretations are typically better, but to ignore it altogether would be the opposite of intellectually stimulating.

 

[Ceke2002]

In Treatment is pretty accurate actually, I wouldn't say the boundary violations are wild [sic] inaccurate by any stretch...

From the little I know of the therapist's side of things I too thought the issues of boundary violations in the show 'In Treatment' weren't exactly 'wildly inaccurate' either. A therapist confronted with an attractive, high functioning borderline patient (aka Laura in the show), who proceeds to start flirting up a storm and making quite graphic declarations of both sexual and romantic interest, right at a time when the therapist is going through his own relational issues and may be more prone to get swept up in flattery, precipitating a need to seek supervision/support because he starts to feel as if the patient's feelings may just be reciprocated by him (ie he feels as if he's falling in love with the patient, or at the very least there's a potential mutual attraction there) to me at least seemed very accurate. I mean my understanding is that therapy can be an extremely intense type of relationship, and I think it would be naive to think that in the entire history of therapists that no one has ever developed countertransferential feelings of love, or even sexual attraction towards a patient. The only part I thought was perhaps a tad inaccurate was when Paul turned up to Laura's house ready to consumate their (non existent) relationship. Granted he ran out and proceeded to have a panic attack at the thought of how close he'd come to crossing that particular line, but that part of the show at least felt a bit more like fan service for the Paul/Laura shippers than anything else.

 

[splik]

From the little I know of the therapist's side of things I too thought the issues of boundary violations in the show 'In Treatment' weren't exactly 'wildly inaccurate' either. A therapist confronted with an attractive, high functioning borderline patient (aka Laura in the show), who proceeds to start flirting up a storm and making quite graphic declarations of both sexual and romantic interest, right at a time when the therapist is going through his own relational issues and may be more prone to get swept up in flattery, precipitating a need to seek supervision/support because he starts to feel as if the patient's feelings may just be reciprocated by him (ie he feels as if he's falling in love with the patient, or at the very least there's a potential mutual attraction there) to me at least seemed very accurate. I mean my understanding is that therapy can be an extremely intense type of relationship, and I think it would be naive to think that in the entire history of therapists that no one has ever developed countertransferential feelings of love, or even sexual attraction towards a patient. The only part I thought was perhaps a tad inaccurate was when Paul turned up to Laura's house ready to consumate their (non existent) relationship. Granted he ran out and proceeded to have a panic attack at the thought of how close he'd come to crossing that particular line, but that part of the show at least felt a bit more like fan service for the Paul/Laura shippers than anything else.

It's pretty common. In surveys 10% of therapists report having had sex with their patients (so the number is probably higher than that). In the old days it was not even frowned up to have a romantic or sexual relationship with your patient. Where therapists run into trouble in terms of complaints is when they try to break it off. Less commonly, some patients might be aggrieved to be billed when they are just having sex during the therapy sessions and that can lead to complaint/lawsuit too.

 

[Mad Jack]

In the end, everything is routine 95% of the time. Pick a routine you can stand.

 

[Ceke2002]

It's pretty common. In surveys 10% of therapists report having had sex with their patients (so the number is probably higher than that). In the old days it was not even frowned up to have a romantic or sexual relationship with your patient. Where therapists run into trouble in terms of complaints is when they try to break it off. Less commonly, some patients might be aggrieved to be billed when they are just having sex during the therapy sessions and that can lead to complaint/lawsuit too.

Oh I have no doubt it happens, I just thought it didn't seem realistic for the actual show itself, more like fanservice so fans could write really bad fan fiction and make really soppy fan vids about how totally in lurve Paul and Laura really were.

But no I do agree with you, of course it happens, I'm sure it happens in other medical fields as well -- not that it makes it right in the vast majority of cases, which is an entire 'nother discussion in itself. I suppose there's a piece of intellectual stimulation in Psychiatry, how do you deal with such an emotionally charged issue in an intellectual and objective way. I imagine it's easier when it's the patient directing interest at you (general 'you') than it is when you're the one sitting on the other side of the desk experiencing these sorts of feelings.

 

[splik]

Oh I have no doubt it happens, I just thought it didn't seem realistic for the actual show itself, more like fanservice so fans could write really bad fan fiction and make really soppy fan vids about how totally in lurve Paul and Laura really were.

But no I do agree with you, of course it happens, I'm sure it happens in other medical fields as well -- not that it makes it right in the vast majority of cases, which is an entire 'nother discussion in itself. I suppose there's a piece of intellectual stimulation in Psychiatry, how do you deal with such an emotionally charged issue in an intellectual and objective way. I imagine it's easier when it's the patient directing interest at you (general 'you') than it is when you're the one sitting on the other side of the desk experiencing these sorts of feelings.

I do think it is completely possible, despite all the murkiness of it, the clear differential of power etc, and the powerful feelings that are generated in therapy, for a therapist and patient to genuinely fall in love with each other beyond any transference/countertransference. however we have decided that this is entirely forbidden for psychiatrists (which might make it even more appealing!!) and in some states it is even a criminal offense for a psychiatrist to have sex with a patient. Interestingly, the american psychological association says its fine for psychologists to enter into a relationship with a patient if more than a year has passed following termination...

 

[Ceke2002]

I do think it is completely possible, despite all the murkiness of it, the clear differential of power etc, and the powerful feelings that are generated in therapy, for a therapist and patient to genuinely fall in love with each other beyond any transference/countertransference. however we have decided that this is entirely forbidden for psychiatrists (which might make it even more appealing!!) and in some states it is even a criminal offense for a psychiatrist to have sex with a patient. Interestingly, the american psychological association says its fine for psychologists to enter into a relationship with a patient if more than a year has passed following termination...

I think you and I might agree on this. Although the chances of me ever falling in love with someone who's my treating Doctor, or a treating Doctor falling in love with me, are somewhere between zero and none (as in 'aint gonna happen'), that doesn't mean I automatically think that a Doctor and (former) patient can't fall in love, ever, without it automatically being abusive, and an abuse of power, and so on so forth. I actually think it's pretty infantilising for some patients to say they're completely incapable of consenting to a relationship just because the person they wish to have a relationship with once treated them for issues related to their emotional well being. Of course I don't agree with a therapist and patient entering a relationship while therapy is ongoing, but the idea that 'once a patient always a patient', even if 20 years have passed, and therefore you are permanently and forever incapable of reasoning your way through the possibility of a romantic relationship with a former doctor/therapist and consenting to said relationship as an adult does seem to be tad bit of a knee jerk response to me. And yes I realise that's a controversial position to take.

 

[WisNeuro]

I do think it is completely possible, despite all the murkiness of it, the clear differential of power etc, and the powerful feelings that are generated in therapy, for a therapist and patient to genuinely fall in love with each other beyond any transference/countertransference. however we have decided that this is entirely forbidden for psychiatrists (which might make it even more appealing!!) and in some states it is even a criminal offense for a psychiatrist to have sex with a patient. Interestingly, the american psychological association says its fine for psychologists to enter into a relationship with a patient if more than a year has passed following termination...

Two years, actually. But it's more nuanced than that.

"(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient. (See also Standard 3.05, Multiple Relationships.)

 

[F0nzie]

I have seen these romantic relationships sprout between case managers and patients at the CMHC clinic. IIRC none of them had a fairytale ending.


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[WisNeuro]

Personally, I've seen multiple nurse/patient relationships, but nothing with other types of providers.

 

[nexus73]

Seen it more with family docs

 

[splik]

back to the OP - general psychiatry blows. the settings in which much of psychiatry is practiced in is sufficiently constraining to sap the soul of the profession, to reduce human experience to DSM diagnoses, to pare down treatment to drugs, and relegate the role of the psychiatrist to "prescriber" and risk manager. There is nothing intellectually stimulating about any of this. There is no intellectual challenge to the race to bottom that has become the profession.

But there is more to psychiatry than general psychiatry, there is a choice in how you practice and what you focus on. For me the fun of psychiatry is in the formulation - making sense of people's problems. Psychiatry encompasses disorders of emotion, thought, behavior, memory, human relations and living. There is not, nor will there ever be a uniform framework or monochromatic lens through which we can view such a disparate array of problems. So we consider a neurobiological, psychodynamic (within which there are ego, object relations, self, relational and postmodern psychological perspectives etc), cognitive, behavioral, systemic, social realist, cultural, or social constructionist approach depending on the case at hand. I will never stop being fascinated by trying to make sense of how we became who we are and why we do the things we do.

I have found myself attracted to the netherparts of psychiatry that most psychiatrists balk at: the intersections between psychiatry, neurology, society, culture, humanities, and the law. There is great fun to be had working with patients with functional neurological symptoms or somatization; there is a challenge in distinguishing between somatoform, factitious disorders, compensation neurosis, and malingering in personal injury cases; there is diagnostic complexity to working up a rapidly-progressive dementia and correctly distinguishing a neurodegenerative disease from a primary psychiatric disorder; reconstructing someone's mental state at the time of the offense for an insanity evaluation is detective work at its purest; developing hypnotic language and metaphors to shape the therapeutic process is creative; to work with psychopathic serial killers who are now psychotic is humbling; to "treat" sexually violent predators who test the limits of the nature of mental disorder is illuminating; to work with dissociative disorders and see how trauma can fragment the mind is fascinating.

And yet, there is something unnerving about confronting so much mental alienation. There is some frightening about acknowledging that which lurks beneath the surface in ourselves. There is something draining about connecting with people who know only despair. Done right, psychiatry is exhausting. This might be one reason some people end up disengaging from their patients, or why psychiatry so readily found itself moving into the more mechanistic model of becoming superannuated drug dealers, deadening ourselves to the pain of others. There is a reason why we work fewer hours than other docs and it's not just about "lifestyle."

Most of any job is dull and routinized. You need to awaken the curiosity in you while all around you are deadened to it if you are looking intellectual stimulation. And you need to allow yourself to really allow yourself to connect with the people you encounter rather than hiding between formalities and boundaries if you are to see the challenges in the field. And finally, you should take the time to explore the vast array of different subspecialities and areas of practice in psychiatry far away from the general psychiatric inpatient unit

 

[Ceke2002]

back to the OP - general psychiatry blows. the settings in which much of psychiatry is practiced in is sufficiently constraining to sap the soul of the profession, to reduce human experience to DSM diagnoses, to pare down treatment to drugs, and relegate the role of the psychiatrist to "prescriber" and risk manager. There is nothing intellectually stimulating about any of this. There is no intellectual challenge to the race to bottom that has become the profession.

But there is more to psychiatry than general psychiatry, there is a choice in how you practice and what you focus on. For me the fun of psychiatry is in the formulation - making sense of people's problems. Psychiatry encompasses disorders of emotion, thought, behavior, memory, human relations and living. There is not, nor will there ever be a uniform framework or monochromatic lens through which we can view such a disparate array of problems. So we consider a neurobiological, psychodynamic (within which there are ego, object relations, self, relational and postmodern psychological perspectives etc), cognitive, behavioral, systemic, social realist, cultural, or social constructionist approach depending on the case at hand. I will never stop being fascinated by trying to make sense of how we became who we are and why we do the things we do.

I have found myself attracted to the netherparts of psychiatry that most psychiatrists balk at: the intersections between psychiatry, neurology, society, culture, humanities, and the law. There is great fun to be had working with patients with functional neurological symptoms or somatization; there is a challenge in distinguishing between somatoform, factitious disorders, compensation neurosis, and malingering in personal injury cases; there is diagnostic complexity to working up a rapidly-progressive dementia and correctly distinguishing a neurodegenerative disease from a primary psychiatric disorder; reconstructing someone's mental state at the time of the offense for an insanity evaluation is detective work at its purest; developing hypnotic language and metaphors to shape the therapeutic process is creative; to work with psychopathic serial killers who are now psychotic is humbling; to "treat" sexually violent predators who test the limits of the nature of mental disorder is illuminating; to work with dissociative disorders and see how trauma can fragment the mind is fascinating.

And yet, there is something unnerving about confronting so much mental alienation. There is some frightening about acknowledging that which lurks beneath the surface in ourselves. There is something draining about connecting with people who know only despair. Done right, psychiatry is exhausting. This might be one reason some people end up disengaging from their patients, or why psychiatry so readily found itself moving into the more mechanistic model of becoming superannuated drug dealers, deadening ourselves to the pain of others. There is a reason why we work fewer hours than other docs and it's not just about "lifestyle."

Most of any job is dull and routinized. You need to awaken the curiosity in you while all around you are deadened to it if you are looking intellectual stimulation. And you need to allow yourself to really allow yourself to connect with the people you encounter rather than hiding between formalities and boundaries if you are to see the challenges in the field. And finally, you should take the time to explore the vast array of different subspecialities and areas of practice in psychiatry far away from the general psychiatric inpatient unit

This was just so amazingly well put, a simple press of a like button won't suffice to express the proper amount of appreciation. Thank you, so much, for always taking the time to write such inspiring and beautifully crafted (and intelligent) responses on this forum.

 

[Merovinge]

back to the OP - general psychiatry blows. the settings in which much of psychiatry is practiced in is sufficiently constraining to sap the soul of the profession, to reduce human experience to DSM diagnoses, to pare down treatment to drugs, and relegate the role of the psychiatrist to "prescriber" and risk manager. There is nothing intellectually stimulating about any of this. There is no intellectual challenge to the race to bottom that has become the profession.

But there is more to psychiatry than general psychiatry, there is a choice in how you practice and what you focus on. For me the fun of psychiatry is in the formulation - making sense of people's problems. Psychiatry encompasses disorders of emotion, thought, behavior, memory, human relations and living. There is not, nor will there ever be a uniform framework or monochromatic lens through which we can view such a disparate array of problems. So we consider a neurobiological, psychodynamic (within which there are ego, object relations, self, relational and postmodern psychological perspectives etc), cognitive, behavioral, systemic, social realist, cultural, or social constructionist approach depending on the case at hand. I will never stop being fascinated by trying to make sense of how we became who we are and why we do the things we do.

I have found myself attracted to the netherparts of psychiatry that most psychiatrists balk at: the intersections between psychiatry, neurology, society, culture, humanities, and the law. There is great fun to be had working with patients with functional neurological symptoms or somatization; there is a challenge in distinguishing between somatoform, factitious disorders, compensation neurosis, and malingering in personal injury cases; there is diagnostic complexity to working up a rapidly-progressive dementia and correctly distinguishing a neurodegenerative disease from a primary psychiatric disorder; reconstructing someone's mental state at the time of the offense for an insanity evaluation is detective work at its purest; developing hypnotic language and metaphors to shape the therapeutic process is creative; to work with psychopathic serial killers who are now psychotic is humbling; to "treat" sexually violent predators who test the limits of the nature of mental disorder is illuminating; to work with dissociative disorders and see how trauma can fragment the mind is fascinating.

And yet, there is something unnerving about confronting so much mental alienation. There is some frightening about acknowledging that which lurks beneath the surface in ourselves. There is something draining about connecting with people who know only despair. Done right, psychiatry is exhausting. This might be one reason some people end up disengaging from their patients, or why psychiatry so readily found itself moving into the more mechanistic model of becoming superannuated drug dealers, deadening ourselves to the pain of others. There is a reason why we work fewer hours than other docs and it's not just about "lifestyle."

Most of any job is dull and routinized. You need to awaken the curiosity in you while all around you are deadened to it if you are looking intellectual stimulation. And you need to allow yourself to really allow yourself to connect with the people you encounter rather than hiding between formalities and boundaries if you are to see the challenges in the field. And finally, you should take the time to explore the vast array of different subspecialities and areas of practice in psychiatry far away from the general psychiatric inpatient unit

There's a lot of truth to the above for many psychiatrists who view the field as being driven by outpatient psychiatric evaluation, therapy, and sometimes meds. I personally find inpatient psychiatry very stimulating. Sure most cases are not crazy neuropsychiatric illness (but when they are, its incredible to lead their workup); but basically everyone who comes to inpatient psychiatry has a fascinating story to tell. The majority of patients I've seen on inpatient psychiatry actually appreciate a doctor listening to them and helping them make sense out of what got their life to where it is and maybe a few things you can do to improve it. Further, you get to see real deal psychosis that very few other people get a chance to experience from the horse's mouth. I have only been doing it for half a decade but psychosis never gets old to me. Then there is the careful management of the severe personality disordered folks trying to split all the staff which is intellectually challenging if not maddening. It is certainly not everyone's cup of tea, but if you approach inpatient psychiatry inquisitively I think there is a lot of satisfaction to be had.

 

[splik]

There's a lot of truth to the above for many psychiatrists who view the field as being driven by outpatient psychiatric evaluation, therapy, and sometimes meds.

i think i hate outpatient general psychiatry more than inpatient! I think it would probably be happy to do a few months of inpatient a year just not all the time. Inpatient can be fun depending the way you approach it (like anything) and the team you work with. I did not mean to suggest that inpatient psychiatry sucks, simply that it is probably not the place to attract students into the field.

 

[SmallBird]

back to the OP - general psychiatry blows. the settings in which much of psychiatry is practiced in is sufficiently constraining to sap the soul of the profession, to reduce human experience to DSM diagnoses, to pare down treatment to drugs, and relegate the role of the psychiatrist to "prescriber" and risk manager. There is nothing intellectually stimulating about any of this. There is no intellectual challenge to the race to bottom that has become the profession.

But there is more to psychiatry than general psychiatry, there is a choice in how you practice and what you focus on. For me the fun of psychiatry is in the formulation - making sense of people's problems. Psychiatry encompasses disorders of emotion, thought, behavior, memory, human relations and living. There is not, nor will there ever be a uniform framework or monochromatic lens through which we can view such a disparate array of problems. So we consider a neurobiological, psychodynamic (within which there are ego, object relations, self, relational and postmodern psychological perspectives etc), cognitive, behavioral, systemic, social realist, cultural, or social constructionist approach depending on the case at hand. I will never stop being fascinated by trying to make sense of how we became who we are and why we do the things we do.

I have found myself attracted to the netherparts of psychiatry that most psychiatrists balk at: the intersections between psychiatry, neurology, society, culture, humanities, and the law. There is great fun to be had working with patients with functional neurological symptoms or somatization; there is a challenge in distinguishing between somatoform, factitious disorders, compensation neurosis, and malingering in personal injury cases; there is diagnostic complexity to working up a rapidly-progressive dementia and correctly distinguishing a neurodegenerative disease from a primary psychiatric disorder; reconstructing someone's mental state at the time of the offense for an insanity evaluation is detective work at its purest; developing hypnotic language and metaphors to shape the therapeutic process is creative; to work with psychopathic serial killers who are now psychotic is humbling; to "treat" sexually violent predators who test the limits of the nature of mental disorder is illuminating; to work with dissociative disorders and see how trauma can fragment the mind is fascinating.

And yet, there is something unnerving about confronting so much mental alienation. There is some frightening about acknowledging that which lurks beneath the surface in ourselves. There is something draining about connecting with people who know only despair. Done right, psychiatry is exhausting. This might be one reason some people end up disengaging from their patients, or why psychiatry so readily found itself moving into the more mechanistic model of becoming superannuated drug dealers, deadening ourselves to the pain of others. There is a reason why we work fewer hours than other docs and it's not just about "lifestyle."

Most of any job is dull and routinized. You need to awaken the curiosity in you while all around you are deadened to it if you are looking intellectual stimulation. And you need to allow yourself to really allow yourself to connect with the people you encounter rather than hiding between formalities and boundaries if you are to see the challenges in the field. And finally, you should take the time to explore the vast array of different subspecialities and areas of practice in psychiatry far away from the general psychiatric inpatient unit

This is a great post, and I think this warrants further discussion in professional settings. Formulation is the richest part of my work; it is the one place where I pull on all of my training, and have the skills and knowledge to do a better job than anyone coming at the field from a different direction (of course this is not to say an NP or whoever can't to a good formulation, just that this is an area where we are the best prepared by a long shot). The most difficult thing I deal with on a daily basis is that the system has no appreciation for good formulations, and this is where we are in a 'race to the bottom'. Formulation is not some esoteric process, it is the crux of how we identify good treatment goals and paradigms; and yet, in so many settings, nobody seems to care about the quality of the formulation, the suitability of the plan and its nuances, and just want to move the patient into the next part of the awful crisis management machine. And so people end up being transferred to services that happen to have availability, or offer more 'containment', and there is not consideration for how the specifics of their presentation may be informative.

And yet, I keep doing good formulations because its what I believe is right. But it would be so much easier if this was positively reinforced at more levels. Alas everything suggests that we will be moving in a direction where we rely on metrics for quality assessment and billing that have an entirely different (and less relevant) focus.

At an individual level, I have worked hard in my job search to find a setting where I will have the space to practice in a way I feel is appropriate, and have enough of a leadership mandate to orient the team towards operating in a similar way. The challenge remains in fostering a broader professional identity where psychiatrists are viewed as unique experts in integrating clinical data of multiple types, and from multiple sources, and where proficiency and sustained commitment to this approach becomes the norm.

 

[SmallBird]

There's a lot of truth to the above for many psychiatrists who view the field as being driven by outpatient psychiatric evaluation, therapy, and sometimes meds. I personally find inpatient psychiatry very stimulating. Sure most cases are not crazy neuropsychiatric illness (but when they are, its incredible to lead their workup); but basically everyone who comes to inpatient psychiatry has a fascinating story to tell. The majority of patients I've seen on inpatient psychiatry actually appreciate a doctor listening to them and helping them make sense out of what got their life to where it is and maybe a few things you can do to improve it. Further, you get to see real deal psychosis that very few other people get a chance to experience from the horse's mouth. I have only been doing it for half a decade but psychosis never gets old to me. Then there is the careful management of the severe personality disordered folks trying to split all the staff which is intellectually challenging if not maddening. It is certainly not everyone's cup of tea, but if you approach inpatient psychiatry inquisitively I think there is a lot of satisfaction to be had.

I think there is a sense in which the consequences of diluting the inpatient assessment would be more obvious. In outpatient settings its very hard to demonstrate how facile practice impacts outcomes. In inpatient settings, when patients lack a sophisticated and accurate formulation, they may never improve to the point of being stable for discharge, or may return recurrently. Sadly even this does occur and some systems appear to not care, but generally there is more of a sense of when doctors are doing a good or bad job on inpatient settings.

 

[northernpsy]

There are some really interesting reflections on this thread. To the OP, I would suggest trying to get an elective rotation in consult psychiatry at a place with a good consult-liaison psychiatry service. I feel like in a good environment (somewhere that the consult service is respected and used to its full capabilities), consult psych can involve some interesting ethical questions, diagnostic dilemmas, and psychopharm challenges.

As far as the issue of boundaries with patients that came up in this thread, I really like this psychologist's explanation on why he isn't friends with ex-patients. I think a lot of what he says can easily apply to romance too:
https://drgeraldstein.wordpress.com/2014/07/27/friendships-with-ex-patients-why-i-say-no/

 

[Ceke2002]

This is a great post, and I think this warrants further discussion in professional settings. Formulation is the richest part of my work; it is the one place where I pull on all of my training, and have the skills and knowledge to do a better job than anyone coming at the field from a different direction (of course this is not to say an NP or whoever can't to a good formulation, just that this is an area where we are the best prepared by a long shot). The most difficult thing I deal with on a daily basis is that the system has no appreciation for good formulations, and this is where we are in a 'race to the bottom'. Formulation is not some esoteric process, it is the crux of how we identify good treatment goals and paradigms; and yet, in so many settings, nobody seems to care about the quality of the formulation, the suitability of the plan and its nuances, and just want to move the patient into the next part of the awful crisis management machine. And so people end up being transferred to services that happen to have availability, or offer more 'containment', and there is not consideration for how the specifics of their presentation may be informative.

And yet, I keep doing good formulations because its what I believe is right. But it would be so much easier if this was positively reinforced at more levels. Alas everything suggests that we will be moving in a direction where we rely on metrics for quality assessment and billing that have an entirely different (and less relevant) focus.

At an individual level, I have worked hard in my job search to find a setting where I will have the space to practice in a way I feel is appropriate, and have enough of a leadership mandate to orient the team towards operating in a similar way. The challenge remains in fostering a broader professional identity where psychiatrists are viewed as unique experts in integrating clinical data of multiple types, and from multiple sources, and where proficiency and sustained commitment to this approach becomes the norm.

Yes, I can see the richness and fulfillment that one must get from this aspect of the work. It's one of the things that attracts me to the field of mental health work, even observing how many own therapy sessions are conducted is a fascinating insight into how a particular case and the progression of treatment is formulated and then enacted. Fingers crossed I'll be starting my BA in Psychology mid year, once I've made it through the pre-requisite subjects for enrollment, and will get to experience this side of the field for myself.

 

[Tom4705]

I agree that therapy is generally more complicated and challenging than psychopharmacology, although good psychopharmacology ( meaning staying current on the literature and practicing evidence based psychiatry) isn't trivial.

Are you sure? I mean, bad psychotherapy can cause a patient to shut down and not open up, sure. But bad psychopharmacology can literally kill someone.

 

[TexasPhysician]

Are you sure? I mean, bad psychotherapy can cause a patient to shut down and not open up, sure. But bad psychopharmacology can literally kill someone.

The only thing I’m sure of is that tr’s ex hacked an account to bring up this 7 year old argument. 😂

 

[nexus73]

Are you sure? I mean, bad psychotherapy can cause a patient to shut down and not open up, sure. But bad psychopharmacology can literally kill someone.

I've seen patients become suicidal with bad therapy, thankfully they got admitted before killing themselves

 

[hamstergang]

Are you sure? I mean, bad psychotherapy can cause a patient to shut down and not open up, sure. But bad psychopharmacology can literally kill someone.

You seem to be conflating how complicated and challenging something is to how dangerous it can be. I don't view skydiving as more complicated than chess, but it is generally more prone to causing death.

 

[R. Matey]

DV and EDs are other areas in psychotherapy where poor treatment can have disastrous consequences.