For those times when you just need to vent a bit

[sunlioness]

Contract required 120 days notice. I negotiated down to 90, (which is much appreciated). Of which, about 2 months remain. I pay tail.

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[Shikima]

Contract required 120 days notice. I negotiated down to 90, (which is much appreciated). Of which, about 2 months remain. I pay tail.

Where will you go in 2 months time? You're a short timer!! Breathe easy.... they think they have you on the ropes, but not really.

Be sure to take a vacation for a few weeks once you're done with the place... a good moment to line up new employment.

 

[sunlioness]

I'm going back to my old job. But not until mid July. I'll have time to do some nothing.


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[Shikima]

I'm going back to my old job. But not until mid July. I'll have time to do some nothing.


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[swisschard]

Sounds like a terrible situation, sorry you have to endure it for a bit longer. One option that someone already mentioned is to maximize your sick time. Speaking of being sick, it would be terrible if you became ill and had to take family medical leave for the next 60-120 days, no?

 

[sunlioness]

Tempting.

But nah, I don't have it in me to do it. I feel guilty enough taking mental health days. Plus I don't want short term disability on my record.

I do feel a bit better though. I slept a lot. And my apartment is cleaner than it's been in a good while.

 

[Ceke2002]

Tempting.

But nah, I don't have it in me to do it. I feel guilty enough taking mental health days. Plus I don't want short term disability on my record.

I do feel a bit better though. I slept a lot. And my apartment is cleaner than it's been in a good while.

You could always just passive aggressively start decorating your office walls with ribbons like this.

 

[DD214_DOC]

My system is similar. Ineffective therapists, entitled and demanding patients, and a constant stream of interruptions for administrative BS, plus other doctoral-level providers who don't understand I can't collaborate on a single case for 20 minutes because I have a million other things to do.

Oh, and the expectation of a magic pill to fix everything. I just tell patients if I had such a pill, I wouldn't be in this office and would be selling it on the street for a premium. I'm the dumping ground for incompetent LCSW's and expect to fix what they haven't been able to. I have since shut that down and defer anything non-med related back to the therapist. I can only take so much.

 

[Psyxh1]

There are many things at play in this scenario and in this response. Although your thinking is going to raise hair on many necks, it is not necessarily wholly unreasonable. Nonetheless, it requires cautious thought and exploration of treatment goals with patient before being settled upon.

• Firstly, it should be stressed, that this kind of split treatment should be handled differently. Never should a therapist tell a patient what meds they need or need adjusted, and never should a med provider tell the patient what they should be doing in therapy. It is not wrong, however, to explore the patient's concerns about the efficacy of their treatment on either end, and to encourage communication of these concerns. It is most prudent, however, if you have a feeling about how another provider is managing your patient, to communicate with them directly and to have discussed the boundaries of split treatment with written consent to do so, ideally up front before treating a patient. "I'm here because my therapist tells me I need more Xanax" is deplorable, as is "I'm here because my psychiatrist says you should be doing DBT instead" (provided these statements are to established patients, although they are still problematic in different ways for new patients).
• It is absolutely the responsibility of a non-medical provider of anxiety treatment to know a lot about medication treatments for anxiety, especially how they may interact with their treatment
• To the above, there are quite many expert CBT therapists that consider benzodiazepines absolutely contraindicated in their treatment of anxiety disorders. Treatments for anxiety typically involve an exposure methodology, wherein the patient is gradually exposed imaginally, in vivo, or in combination to stimulus that makes them anxious yet is actually not dangerous. The intent is to do so without providing any means of artificially reducing the anxiety. In fact, in the end, you want them to feel as though their worst fear is coming true. The goal here is to get them to the point where their anxiety has naturally peaked and is starting to resolve on its own without intervention. In this fashion, you eliminate means which reinforce through avoidance or medications that their anxiety is valid and that they cannot handle it on your own. The amount of anxiety experienced with subsequent trials goes down and down.
• Pharmacologically, benzodiazepines develop ready physiologic tolerance, and have little evidence to support benefit over chronic use. They do, however, create significant dependence (psychological > physiological), and do carry abuse potential, and may still have impairments in cognitive function in states of tolerance; Xanax, with its short half-life, carries the most abuse potential of BZDs
• In long-standing anxiety disorders, pharmacologic treatment is very unlikely to achieve remission of symptoms
• Additionally, oral benzodiazepines may take time to reach therapeutic efficacy; coupled with tolerance, you may often find situations in which someone takes a benzodiazepine and feels relief of anxiety merely because their anxiety had achieved its natural peak before the BZD kicked in (if it even would). In this case, it's not helpful for the patient to attribute efficacy to Xanax, and potentially promoting the illness due to reinforcing the idea of lack of control. Yet, if the patient had experienced remission of symptoms spontaneously, it would be very therapeutic to orient them to their ability to manage without.
• To use your hypertension example, say you were a counselor specializing in lifestyle modification (diet, exercise). Would you send your patient to PCP for HTN med adjustment if your pt. was non-adherent to diet and not exercising? The answer here may be yes because of the dangers of HTN and the likelihood of actually managing it by taking more meds. But it would be pretty fishy if that patient shows up to the PCP doorstep and said that their lifestyle counselor said you needed to fix me by increasing my amlodipine, and no of course I'm not exercising or cutting salt. There needs to be a collective understanding of the problem & treatment goals & responsibilities. Nonetheless, the PCP might actually be able to fix that # whereas the psychiatrist is, at best, limited, and at worst, able to provide a short-term solution with low efficacy and high dependence.
• All that said, there may be a patient that would benefit from a higher dose of PRN Xanax prior to encountering a necessary and not regularly recurrent high-intensity stressor, but it would be a carefully selected patient for me

Thank you for this detailed post(and to everyone else who addressed my question). I really appreciate it. First of all, I am not vistaril. I honestly needed more clarification on this subject. I know that benzodiazepines create physiologic tolerance, are implicated in cognitive impairment over long term use and that they have ready abuse potential. That is why I stated in my response that it is important to prescribe benzodiazepines judiciously. I admit that I was going on several assumptions here. One was that the patient only suffered from panic attacks in certain situations that were not frequently encountered(i.e. plane ride) and that the Xanax is PRN to be used just at those times and not on a regular basis(as in your very last bullet point). Secondly, since the patient is already on Xanax I assumed that he is a compliant person with a low likelihood of abusing the Xanax(or why would he have been prescribed it in the first place was what my thinking was). On my inpatient Psychiatry rotations, it seemed to me that benzodiazepines were prescribed more frequently than your explanation implies that they should be. Why is that and what situations would it truly be appropriate to prescribe benzos?

I was also unaware that therapists are so familiar with psychotropics that they should know if a patient will need medications or not. I assumed that the therapist sent the patient to the psychiatrist because she was unsure if his medications needed to be adjusted after a major panic attack. I also did not assume that the therapist wanted the patient to be on a higher dose of Xanax specifically or that she told the patient such but merely that perhaps he needed to be re-evaluated by a psychiatrist after having this episode to see if his condition warranted a change in his medications(any of them not just Xanax). In regards to your first bullet point, I have witnessed attendings who did specifically tell patients that they needed certain forms of therapy for their condition and should seek out someone who would work with them in that capacity. Would it be better to tell patients in these situations that they need to see a therapist without delving into what specific modalities you think would be useful for them?

 

[smalltownpsych]

Thank you for this detailed post(and to everyone else who addressed my question). I really appreciate it. First of all, I am not vistaril. I honestly needed more clarification on this subject. I know that benzodiazepines create physiologic tolerance, are implicated in cognitive impairment over long term use and that they have ready abuse potential. That is why I stated in my response that it is important to prescribe benzodiazepines judiciously. I admit that I was going on several assumptions here. One was that the patient only suffered from panic attacks in certain situations that were not frequently encountered(i.e. plane ride) and that the Xanax is PRN to be used just at those times and not on a regular basis(as in your very last bullet point). Secondly, since the patient is already on Xanax I assumed that he is a compliant person with a low likelihood of abusing the Xanax(or why would he have been prescribed it in the first place was what my thinking was). On my inpatient Psychiatry rotations, it seemed to me that benzodiazepines were prescribed more frequently than your explanation implies that they should be. Why is that and what situations would it truly be appropriate to prescribe benzos?

I was also unaware that therapists are so familiar with psychotropics that they should know if a patient will need medications or not. I assumed that the therapist sent the patient to the psychiatrist because she was unsure if his medications needed to be adjusted after a major panic attack. I also did not assume that the therapist wanted the patient to be on a higher dose of Xanax specifically or that she told the patient such but merely that perhaps he needed to be re-evaluated by a psychiatrist after having this episode to see if his condition warranted a change in his medications(any of them not just Xanax). In regards to your first bullet point, I have witnessed attendings who did specifically tell patients that they needed certain forms of therapy for their condition and should seek out someone who would work with them in that capacity. Would it be better to tell patients in these situations that they need to see a therapist without delving into what specific modalities you think would be useful for them?

In my experience, licensed psychologists will typically be familiar with psychotropic medications, common side effects, indications, not so much with midlevels. I must confess that as they keep adding new variants, it is getting more difficult to keep track of though, especially when you consider the wide variability of response to medications and the fact that medications are not my focus. I don't think psychiatrists should refer for a specific type of psychotherapy anymore than I should refer for a certain medication. Obviously, for certain diagnoses certain medications and treatments are indicated, but doesn't mean we automatically go there. For example, a patient may have OCD and need ERP treatment for that, but they might also have comorbid conditions that complicate the picture and might not have sufficient motivation to address the compulsive behaviors, so ERP might not be initiated for months down the road. For psychiatry, a couple examples of this that comes to mind are patients with bipolar who do well on lithium but it's not prescribed because of renal problems or patient has compliance issues or overdose potential.

 

[Doctor Bagel]

In my experience, licensed psychologists will typically be familiar with psychotropic medications, common side effects, indications, not so much with midlevels. I must confess that as they keep adding new variants, it is getting more difficult to keep track of though, especially when you consider the wide variability of response to medications and the fact that medications are not my focus. I don't think psychiatrists should refer for a specific type of psychotherapy anymore than I should refer for a certain medication. Obviously, for certain diagnoses certain medications and treatments are indicated, but doesn't mean we automatically go there. For example, a patient may have OCD and need ERP treatment for that, but they might also have comorbid conditions that complicate the picture and might not have sufficient motivation to address the compulsive behaviors, so ERP might not be initiated for months down the road. For psychiatry, a couple examples of this that comes to mind are patients with bipolar who do well on lithium but it's not prescribed because of renal problems or patient has compliance issues or overdose potential.

Psychiatry training does include training in psychotherapy, so I'd argue it's more in our scope to refer to a particular type of therapy than in a psychologist's scope to refer for a particular type of medication. Certainly if someone already has a therapist and is working on something, I wouldn't want to interfere in that process or create any sort of splitting. However, I don't think it's unreasonable to recommend a specific therapeutic modality if we have knowledge and training in that modality (theoretically, we should all have competency in supportive psychotherapy, psychodynamic psychotherapy and CBT).

 

[Doctor Bagel]

My system is similar. Ineffective therapists, entitled and demanding patients, and a constant stream of interruptions for administrative BS, plus other doctoral-level providers who don't understand I can't collaborate on a single case for 20 minutes because I have a million other things to do.

Oh, and the expectation of a magic pill to fix everything. I just tell patients if I had such a pill, I wouldn't be in this office and would be selling it on the street for a premium. I'm the dumping ground for incompetent LCSW's and expect to fix what they haven't been able to. I have since shut that down and defer anything non-med related back to the therapist. I can only take so much.

The norm at the community job I had was for patients to meet maybe once a month with a very green master's level therapist (who would change frequently due to turnover). I'm not sure that accomplishes much of anything.

 

[carlosc1dbz]

Have you guys ever been in a clinic run by social workers?

One thing that I really dislike is when office staff is not helpful when it comes to getting patients their paperwork filed or setting boundaries for patients.

I have worked in a University Counseling Center that is run by psychology. I get notes with me as a cosigner from the front desk staff, telling me that the patient called and said that he needs a refill on stimulants because they are running out and they missed the last appointment. They tell the patient that they will tell me, so that I will call in their medication to the pharmacy. Another situation I have encountered is when the patient shows up over an hour late for their appointment, and I am only there half day and they call me to tell me about it, "well doctor, can't you just see him really quick, pt is running out of meds." Very frustrating as you can imagine.

One thing that I hate doing, and may just be me, but I hate looking for charts when I need to put the patient's paperwork in it . It is very time consuming. Staff is unhelpful in this regard as well. I ask I could find the patient's chart, and they answer with something like, "the chart is probably somewhere in that stack." -.- FML

 

[sunlioness]

I like it when a case manager puts a patient I've never met before on my schedule for a fifteen minute check so he can have his papers for the welfare office filled out certifying that he can't work. Those are fun.


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[deleted343839]

Psychiatry training does include training in psychotherapy, so I'd argue it's more in our scope to refer to a particular type of therapy than in a psychologist's scope to refer for a particular type of medication. Certainly if someone already has a therapist and is working on something, I wouldn't want to interfere in that process or create any sort of splitting. However, I don't think it's unreasonable to recommend a specific therapeutic modality if we have knowledge and training in that modality (theoretically, we should all have competency in supportive psychotherapy, psychodynamic psychotherapy and CBT).

You could recommend a particular type of therapy based on treatment guidelines (eg, prolonged exposure for PTSD) with modest competence in psychotherapy. But if you're able to develop a case formulation or working hypothesis that informs your recommendation for a specific psychotherapy, you're ahead of the game (though one might ask in that case why you're not providing the therapy).

 

[Doctor Bagel]

You could recommend a particular type of therapy based on treatment guidelines (eg, prolonged exposure for PTSD) with modest competence in psychotherapy. But if you're able to develop a case formulation or working hypothesis that informs your recommendation for a specific psychotherapy, you're ahead of the game (though one might ask in that case why you're not providing the therapy).

Lack of available time, working in a setting where psychiatrists are discouraged from doing therapy, seeing a patient on a consultation basis, etc..

 

[notdeadyet]

You could recommend a particular type of therapy based on treatment guidelines (eg, prolonged exposure for PTSD) with modest competence in psychotherapy. But if you're able to develop a case formulation or working hypothesis that informs your recommendation for a specific psychotherapy, you're ahead of the game (though one might ask in that case why you're not providing the therapy).

In fairness, I could also restore my patient's 1972 Chevelle, but....


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[FlowRate]

Have you guys ever been in a clinic run by social workers?

One thing that I really dislike is when office staff is not helpful when it comes to getting patients their paperwork filed or setting boundaries for patients.

I have worked in a University Counseling Center that is run by psychology. I get notes with me as a cosigner from the front desk staff, telling me that the patient called and said that he needs a refill on stimulants because they are running out and they missed the last appointment. They tell the patient that they will tell me, so that I will call in their medication to the pharmacy. Another situation I have encountered is when the patient shows up over an hour late for their appointment, and I am only there half day and they call me to tell me about it, "well doctor, can't you just see him really quick, pt is running out of meds." Very frustrating as you can imagine.

One thing that I hate doing, and may just be me, but I hate looking for charts when I need to put the patient's paperwork in it . It is very time consuming. Staff is unhelpful in this regard as well. I ask I could find the patient's chart, and they answer with something like, "the chart is probably somewhere in that stack." -.- FML

Not unique to psychiatry, I've heard a number of outpatient, employed docs (academics) lament the separation of physician and support heirarchies. One of the top reasons I can think of to do PP is the ability to actually give "orders" ("guidance" if you want to be gentle) to the support staff.

 

[Shikima]

I like it when a case manager puts a patient I've never met before on my schedule for a fifteen minute check so he can have his papers for the welfare office filled out certifying that he can't work. Those are fun.


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Start telling the case manager, anyone who can walk into the clinic and carry on a conversation - can work.

 

[deleted343839]

Lack of available time, working in a setting where psychiatrists are discouraged from doing therapy, seeing a patient on a consultation basis, etc..

Yes, of course. My point was that you don't need to be proficient in psychotherapy to have a general sense of who might benefit from it, and refer appropriately. In other words, the division of labor is not merely a matter of time and reimbursement. It's a very sensible division of labor. I suspect that more often than not referring physicians are not highly competent in psychotherapy because other skills are emphasized and incentivized.

The problem (which I also encounter also) is that it's hard to find therapists who can deliver well on your order for a given therapy. And if a therapist is competent enough to deliver, the chances are high that he or she can also choose an appropriate psychotherapeutic strategy to begin with.

 

[Bartelby]

The problem (which I also encounter also) is that it's hard to find therapists who can deliver well on your order for a given therapy. And if a therapist is competent enough to deliver, the chances are high that he or she can also choose an appropriate psychotherapeutic strategy to begin with.

This is one of the biggest reasons I'm considering a private practice setup with the option to conduct psychotherapy myself. I don't want to be responsible for patient outcomes when they are seeing therapists who aren't very good. If I can find therapists I trust and work only with them that would be a different story.

 

[smalltownpsych]

Psychiatry training does include training in psychotherapy, so I'd argue it's more in our scope to refer to a particular type of therapy than in a psychologist's scope to refer for a particular type of medication. Certainly if someone already has a therapist and is working on something, I wouldn't want to interfere in that process or create any sort of splitting. However, I don't think it's unreasonable to recommend a specific therapeutic modality if we have knowledge and training in that modality (theoretically, we should all have competency in supportive psychotherapy, psychodynamic psychotherapy and CBT).

Completely agree with first couple of statements and of course you will know which types of treatments are going to be most effective in general, but since what I do tends to look different depending on each patients needs, it's more helpful when the referrer gives more general information about how psychotherapy works. Just as in any referral. Referral to neuro, you might be sure that an eeg or CAT is indicated, but wouldn't you still couch it a bit just so that the neuro doc, if he sees something else or has a slightly different plan or approach can implement that without the patient saying, "but Dr. Bagel said you were going to do this?"

 

[Doctor Bagel]

Completely agree with first couple of statements and of course you will know which types of treatments are going to be most effective in general, but since what I do tends to look different depending on each patients needs, it's more helpful when the referrer gives more general information about how psychotherapy works. Just as in any referral. Referral to neuro, you might be sure that an eeg or CAT is indicated, but wouldn't you still couch it a bit just so that the neuro doc, if he sees something else or has a slightly different plan or approach can implement that without the patient saying, "but Dr. Bagel said you were going to do this?"

Totally, and that's the upside of referring to people you trust. With seeing a patient a few times or just once in consultation, I certainly wouldn't be able to know what week by week psychotherapy sessions should look like.

 

[deleted343839]

This is one of the biggest reasons I'm considering a private practice setup with the option to conduct psychotherapy myself. I don't want to be responsible for patient outcomes when they are seeing therapists who aren't very good.

A friend of mine left an AMC for private practice to do this very thing and seems quite happy with the decision.

 

[sunlioness]

I gotta go back tomorrow.

I feel ill.

 

[carlosc1dbz]

Not unique to psychiatry, I've heard a number of outpatient, employed docs (academics) lament the separation of physician and support heirarchies. One of the top reasons I can think of to do PP is the ability to actually give "orders" ("guidance" if you want to be gentle) to the support staff.

To add to this, I also feel that at times there is this sort of an "us vs them," type of attitude in the staff which to me is very strange. Don't get me started on nursing staff also having some sort of complex when it comes to following orders.

 

[smalltownpsych]

To add to this, I also feel that at times there is this sort of an "us vs them," type of attitude in the staff which to me is very strange. Don't get me started on nursing staff also having some sort of complex when it comes to following orders.

"We know more about the patients than the doctors because..." Fill in the blank with a number of reasons and whenever there is a problem, it's the doctors fault because it's a medication issue. The various staff at institutions tend to not see their own thinking errors especially not the fundamental attribution error or groupthink. They also tend to have limited awareness of how their own defenses play out in patient interactions. It can be a really big problem with patients with Borderline PD because they can appear the most "normal/like me" or patients with substance abuse for the same reason and because of high prevalence and likelihood of personal experience.

 

[thoffen]

I was trying to limit my point to when providers are splitting treatment and already established care. More complicated than that for all the reasons described by everyone else if recommending initiating treatment.

Although, I think it's pretty evident that you should keep your recommendations within the realm of your expertise, and you should avoid placing expectations of treatment on to other providers, and you should collaborate independent of the patient (with consent) when warranted.

RE: work environments of other provider types...well...I certainly wouldn't want to work anywhere that I wasn't allied with my staff. Docs often get the short end of the stick on this because we have power and represent authority, even though lots of other providers tend to act more authoritatively than us. Other than that, I hope people can recognize that splitting of staff is not helpful to patient care, and that you can still follow a doctor's orders if you disagree (unless you feel it places a patient in imminent danger).

 

[nancysinatra]

Youngly, please read up on physiological dependency and psychological dependency. Then read about Xanax both biochemically and onset of action.

Next, please consider this next point carefully; Benzo's are an unsustainable resource for controlling anxiety.

I may regret saying this because I haven't finished reading the whole thread, but isn't Xanax actually indicated for specific phobias? Isn't that, like, it's only actual useful purpose? And isn't one of the most common, most discrete, and most debilitating specific phobias the fear of flying on an airplane? Has that condition been ruled out in this patient? Maybe the therapist was actually doing the appropriate thing by triaging the case to psychiatry. Maybe the guy has another flight coming up soon.

Fear of flying might be the one situation where I would actually want to use Xanax. Assuming the patient doesn't have the usual 4 or 5 other questionable diagnoses related to anxiety. The other good use for xanax is people with fear of MRIs, or needle sticks.

I also wouldn't automatically send a patient with a fear of flying to a therapist. The airlines have programs that nervous flyers can attend (for a fee), and for all I know they may be more effective than CBT, DBT, or any other BT. The last time I read about it, they go into the mechanics of flight and what makes it safe. Show me a therapist who can do that.

 

[nancysinatra]

Also, a bad enough panic attack, and the flight that patient is on just may have to land early, mainly because the patient will complain of chest pain, which is a dreaded scenario onboard flights. Are all of you on here who are against Xanax THAT opposed to it? For the patient who cannot fly otherwise, or who might disrupt air traffic?

 

[FlowRate]

As an aside, it seems like splitting is used more commonly incorrectly than correctly, unless I'm misunderstanding what splitting is. Patients playing staff against each other is manipulation. Staff not being good parents (unified) is just a bad workplace. Patients who overvalue/undervalue and see some people as all-good and others as all-bad is splitting.

 

[clausewitz2]

As an aside, it seems like splitting is used more commonly incorrectly than correctly, unless I'm misunderstanding what splitting is. Patients playing staff against each other is manipulation. Staff not being good parents (unified) is just a bad workplace. Patients who overvalue/undervalue and see some people as all-good and others as all-bad is splitting.

That splitting on the personal level tends to interact with staff in the way that is being talked about:

http://www.highconflictinstitute.co...cles/published-articles/139-splitting-at-work

 

[Shikima]

I may regret saying this because I haven't finished reading the whole thread, but isn't Xanax actually indicated for specific phobias? Isn't that, like, it's only actual useful purpose? And isn't one of the most common, most discrete, and most debilitating specific phobias the fear of flying on an airplane? Has that condition been ruled out in this patient? Maybe the therapist was actually doing the appropriate thing by triaging the case to psychiatry. Maybe the guy has another flight coming up soon.

Fear of flying might be the one situation where I would actually want to use Xanax. Assuming the patient doesn't have the usual 4 or 5 other questionable diagnoses related to anxiety. The other good use for xanax is people with fear of MRIs, or needle sticks.

I also wouldn't automatically send a patient with a fear of flying to a therapist. The airlines have programs that nervous flyers can attend (for a fee), and for all I know they may be more effective than CBT, DBT, or any other BT. The last time I read about it, they go into the mechanics of flight and what makes it safe. Show me a therapist who can do that.

That's the difference with giving 1/4mg to the tune of 10-15 tabs every 2-3 months compared to higher dosages scheduled.

 

[FlowRate]

That splitting on the personal level tends to interact with staff in the way that is being talked about:

http://www.highconflictinstitute.co...cles/published-articles/139-splitting-at-work

Certainly, but in my limited experience people are usually referring to manipulation and not splitting. Your link is very different from the "therapist and psychiatrist aren't on the same page / patient says therapist told them x when talking to the psychiatrist." I've often heard people use it on the wards when a patient causes confusion by intentionally telling the nurse and the team different things. Overvalue/undervalue can definitely end up also causing similar situations, but I've found it more rare.

 

[Doctor Bagel]

Certainly, but in my limited experience people are usually referring to manipulation and not splitting. Your link is very different from the "therapist and psychiatrist aren't on the same page / patient says therapist told them x when talking to the psychiatrist." I've often heard people use it a lot on the wards when a patient causes confusion by intentionally telling the nurse and the team different things. Overvalue/undervalue can definitely end up also causing similar situations, but I've found it more rare.

Except the providers in question are also falling into this overvalution/undervaluation paradigm. This other provider is clearly an idiot and doesn't know what they're doing. Why is that doctor being so mean to that patient? Etc. etc. I will be the one provider who gets you and understands what is happening (playing into our needs to be idealized). As noted in the article above, also these patients aren't intentionally creating these conflicts, so I'm not sure manipulation is the right word.

 

[FlowRate]

Except the providers in question are also falling into this overvalution/undervaluation paradigm. This other provider is clearly an idiot and doesn't know what they're doing. Why is that doctor being so mean to that patient? Etc. etc. I will be the one provider who gets you and understands what is happening (playing into our needs to be idealized). As noted in the article above, also these patients aren't intentionally creating these conflicts, so I'm not sure manipulation is the right word.

Eh, re-reading the post I was sort-of replying to, I just realized splitting wasn't even being used in the defense mechanism sense (initially thought it was.)

Regardless, I'm not trying to imply that people who split are just being manipulative. I'm saying I've seen a lot of people use the word "splitting" when the patient is just being manipulative by playing team members against each other--the reason I don't think it's splitting is because (in the multiple cases I'm thinking about) there aren't extreme good/bad characterizations of the team members by the patient, the team members haven't developed discordant good/bad extreme views of the patient (or any other intra-team conflict), and there's often clear secondary gain.

 

[clausewitz2]

Eh, re-reading the post I was sort-of replying to, I just realized splitting wasn't even being used in the defense mechanism sense (initially thought it was.)

Regardless, I'm not trying to imply that people who split are just being manipulative. I'm saying I've seen a lot of people use the word "splitting" when the patient is just being manipulative by playing team members against each other--the reason I don't think it's splitting is because (in the multiple cases I'm thinking about) there aren't extreme good/bad characterizations of the team members by the patient, the team members haven't developed discordant good/bad extreme views of the patient (or any other intra-team conflict), and there's often clear secondary gain.

Then this is 'splitting' in the same sense people toss around "antisocial" to mean "patient behaves in an unpleasant fashion."

 

[deleted343839]

I also wouldn't automatically send a patient with a fear of flying to a therapist. The airlines have programs that nervous flyers can attend (for a fee), and for all I know they may be more effective than CBT, DBT, or any other BT. The last time I read about it, they go into the mechanics of flight and what makes it safe. Show me a therapist who can do that.

If it's really just an information deficit, there are books on the market that explain how flight works and why it's safe. But most people who fear flying are already aware that commercial aviation is exceptionally safe and reliable, which is why the airline programs not only educate about flight but also incorporate psychoeducation and anxiety management skills training. For example, British Airways' program is co-facilitated by psychologists. There is also a popular program called SOAR which was started by an airline pilot who went on to grad school to become an LCSW.

These programs are great examples of creative dissemination of behavioral treatment principles. They're not cheap but are probably more affordable than one-on-one exposure therapy (especially if you cap off the exposure hierarchy with an actual flight - and yes, I know a psychologist who has done that). Motivated patients who can already tolerate stepping onto a plane might be able to do all this with a self-help approach, though.

 

[nancysinatra]

That's the difference with giving 1/4mg to the tune of 10-15 tabs every 2-3 months compared to higher dosages scheduled.

Fair enough. Although 1/4mg is pretty low. I agree with the limited number of tabs. The problem patients are the 2mg QID people. I personally would never dose it like that but I inherited a caseload full of such patients and it is really hard to get those doses down. At least, if I don't want to spend all day every day being yelled and screamed at.

 

[nancysinatra]

I'm going back to my old job. But not until mid July. I'll have time to do some nothing.


Sent from my iPhone using Tapatalk

That's good - I hope you get a nice vacation in. The two months will be over before you know it. Your current job sounds awful. You are being way overworked. I'm glad you're getting out.

I know what it is like to be burned out. I like my current job ok, but I'm burned out too. Last week I agreed to sign a patient's therapy cat form, because I was just so sick and tired of fighting over things like that. I only have one more month to go and then I am on to new endeavors. Things I am not going to miss:

Xanax requests
Demands for Adderall
Insomnia complaints
Requests to fill out disability forms
Requests to fill out therapy pet forms
PHQ-9s
Credentialing paperwork
People who answer "yes" to my question about whether they exercise and then when I ask what it consists of, they say that they walk a couple blocks each day
People with obvious Axis II issues who have taken every medication (all prescribed by past providers) and complain in an angry tone of voice that "nothing works" but who also refuse to go to therapy or change anything about their lifestyle

 

[birchswing]

Regarding learning that airplanes are safe, I am reminded of a line from the Andy Griffith show:

Barney: All I'm saying is that there are some things beyond the ken of mortal man that shouldn't be tampered with. We don't know everything, Andy. There's plenty going on right now in the Twilight Zone that we don't know anything about and I think we aught to stay clear.
Andy: Wasn't it you that said we got nothing to fear but fear itself?
Barney: Well that's exactly what I've got - fear itself.

 

[thoffen]

Splitting is not conscious. It is not manipulation. It is a defensive mechanism. A patient splitting staff members is productive because it stabilizes the characters of others and the expectations of the patient. This person is bad and I can't trust them. This person is on my side and I can. Consciously manipulating staff to fight each other for gain is not splitting.

The split is often combined with other defenses, such as projective identification, and susceptible staff members will then be all the more willing to take on their new roles.

 

[thoffen]

I may regret saying this because I haven't finished reading the whole thread, but isn't Xanax actually indicated for specific phobias? Isn't that, like, it's only actual useful purpose? And isn't one of the most common, most discrete, and most debilitating specific phobias the fear of flying on an airplane? Has that condition been ruled out in this patient? Maybe the therapist was actually doing the appropriate thing by triaging the case to psychiatry. Maybe the guy has another flight coming up soon.

Fear of flying might be the one situation where I would actually want to use Xanax. Assuming the patient doesn't have the usual 4 or 5 other questionable diagnoses related to anxiety. The other good use for xanax is people with fear of MRIs, or needle sticks.

I also wouldn't automatically send a patient with a fear of flying to a therapist. The airlines have programs that nervous flyers can attend (for a fee), and for all I know they may be more effective than CBT, DBT, or any other BT. The last time I read about it, they go into the mechanics of flight and what makes it safe. Show me a therapist who can do that.

Combinations of imaginal, VR, and in vivo exposure therapies for phobias (such as flying) is more helpful in my eye. Almost impossible to compare with research. But helpful is somewhat subjective. Xanax certainly could help the acute situation, but will do nothing for the underlying disorder and may reinforce the disorder and also other anxieties. Exposure therapy, on the other hand, will address the underlying disorder and may benefit approach to other anxieties, and will have durable benefit after discontinuation of treatment.

 

[milesed]

I just give them specific instructions as to what they need to be doing with their therapy time.I go over basics of CBT and do some practice with them.

 

[deleted343839]

Exposure therapy, on the other hand, will address the underlying disorder and may benefit approach to other anxieties, and will have durable benefit after discontinuation of treatment.

Also true for panic disorder. PRN meds and even most therapy techniques reinforce safety behaviors. You're beating back extinction rather than facilitating it.

I once sat next to a lady on a plane who was pretty afraid of flying. As we taxied to the runway she took a tablet (probably Xanax or similar), and she closed her eyes, winced and white-knuckled it through takeoff. I didn't have the heart to tell her that whatever benefit she thought she got was a placebo effect.

 

[sunlioness]

That's good - I hope you get a nice vacation in. The two months will be over before you know it. Your current job sounds awful. You are being way overworked. I'm glad you're getting out.

I know what it is like to be burned out. I like my current job ok, but I'm burned out too. Last week I agreed to sign a patient's therapy cat form, because I was just so sick and tired of fighting over things like that. I only have one more month to go and then I am on to new endeavors. Things I am not going to miss:

Xanax requests
Demands for Adderall
Insomnia complaints
Requests to fill out disability forms
Requests to fill out therapy pet forms
PHQ-9s
Credentialing paperwork
People who answer "yes" to my question about whether they exercise and then when I ask what it consists of, they say that they walk a couple blocks each day
People with obvious Axis II issues who have taken every medication (all prescribed by past providers) and complain in an angry tone of voice that "nothing works" but who also refuse to go to therapy or change anything about their lifestyle

Thank you. I really hope things work out for you.

Today I am back and not a single person asked if I was feeling any better. They did tell me to be mindful of one patient on my schedule. Someone I've never seen before who was scheduled with me for fifteen minutes this afternoon after he and his spouse both were verbally aggressive with another doc here last week who refused to prescribe a benzo after it came to light through reliable sources that he was diverting.

So that will be fun. I'm looking forward to that. Thanks for the heads up.

(Seriously though, who does that?! If a patient is cut off from a bzd Rx because it's been established that he's selling it, why does he get to make a case with another doc? And if he and he family are being threatening, why do they even get to come here at all? And why is this now my problem and why do I only get fifteen minutes to sort it out? And why is there no panic button in my office?)

 

[Shikima]

Thank you. I really hope things work out for you.

Today I am back and not a single person asked if I was feeling any better. They did tell me to be mindful of one patient on my schedule. Someone I've never seen before who was scheduled with me for fifteen minutes this afternoon after he and his spouse both were verbally aggressive with another doc here last week who refused to prescribe a benzo after it came to light through reliable sources that he was diverting.

So that will be fun. I'm looking forward to that. Thanks for the heads up.

(Seriously though, who does that?! If a patient is cut off from a bzd Rx because it's been established that he's selling it, why does he get to make a case with another doc? And if he and he family are being threatening, why do they even get to come here at all? And why is this now my problem and why do I only get fifteen minutes to sort it out? And why is there no panic button in my office?)

Simple. You're a technician with Rx rights. Tech's don't get any respect.

 

[OldPsychDoc]

...
(Seriously though, who does that?! If a patient is cut off from a bzd Rx because it's been established that he's selling it, why does he get to make a case with another doc? And if he and he family are being threatening, why do they even get to come here at all? And why is this now my problem and why do I only get fifteen minutes to sort it out? And why is there no panic button in my office?)

Great questions to raise in your EXIT INTERVIEW in <60 days!

 

[DD214_DOC]

I really want my clinic to change the sign on my office door from, "Psychiatrist" to, "Alienist". Can we start a movement to bring this back?

 

[Shikima]

I really want my clinic to change the sign on my office door from, "Psychiatrist" to, "Alienist". Can we start a movement to bring this back?

Alienist?