F0nzie

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Is there a reason why some patients choose to harass/abuse yet they don't want to leave the practice? Even after attempts to resolve the issue, offering a refund, and giving referrals to other psychiatrists they choose to stay, pay, and harass. What am I missing here? Is there a value add that I'm not seeing here?


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Is there a reason why some patients choose to harass/abuse yet they don't want to leave the practice? Even after attempts to resolve the issue, offering a refund, and giving referrals to other psychiatrists they choose to stay, pay, and harass. What am I missing here? Is there a value add that I'm not seeing here?


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Them staying should not be an option. Fire them.
 
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F0nzie

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Them staying should not be an option. Fire them.
Yea maybe I should stop wasting my time trying to understand. Feels like being trolled IRL.

Alright well let's talk about the psychology of trolling: Real world applications.


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F0nzie

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It may be they're not specifically harassing you, but they treat everyone like this, and you're the one person who has the patience to tolerate and handle them.
Definitely a pervasive issue that affects multiple domains (work, personal, family).


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Definitely a pervasive issue that affects multiple domains (work, personal, family).


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Confront the behavioral pattern directly. If they don't want to begin working on changing the behavior, then you can't help them. "When you said this. It made me feel this way and I thought this (usually a very honest exposure of some version of wanting to tell them to get f-ed). I didn't react though because I know that is how others in your life react and that is part of the pattern. We can work on this, but recognize that I will call it out when I see it." I have had some success with a variation of this approach. It really depends on how much sociopathy is there verses a problematic interpersonal pattern.
 

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I was just reading about eristic discourse, it is basically when a person argues only to refute the other person, rather than to search for truth. Basically arguing for the sake of conflict, which in this line of work is probably playing out some past conflict in the patient's lives. Here is some info about trolling, lifted from a completely unrelated site:


"Application of the term troll is subjective. Some readers may characterize a post as trolling, while others may regard the same post as a legitimate contribution to the discussion, even if controversial. Like any pejorative term, it can be used as an ad hominem attack, suggesting a negative motivation.

As noted in an OS News article titled "Why People Troll and How to Stop Them" (25 January 2012), "The traditional definition of trolling includes intent. That is, trolls purposely disrupt forums. This definition is too narrow. Whether someone intends to disrupt a thread or not, the results are the same if they do."[6][7]Others have addressed the same issue, e.g., Claire Hardaker, in her Ph.D. thesis[7] "Trolling in asynchronous computer-mediated communication: From user discussions to academic definitions."[8] Popular recognition of the existence (and prevalence) of non-deliberate, "accidental trolls", has been documented widely, in sources as diverse as Nicole Sullivan's keynote speech at the 2012 Fluent Conference, titled "Don't Feed the Trolls"[9] Gizmodo,[10]online opinions on the subject written by Silicon Valley executives[11] and comics.[12]

Regardless of the circumstances, controversial posts may attract a particularly strong response from those unfamiliar with the robust dialogue found in some online, rather than physical, communities. Experienced participants in online forums know that the most effective way to discourage a troll is usually to ignore it,[citation needed] because responding tends to encourage trolls to continue disruptive posts – hence the often-seen warning: "Please do not feed the trolls".

The "trollface" is an image occasionally used to indicate trolling in Internet culture.[13][14][15]

At times, the word can be abused to refer to anyone with controversial opinions they disagree with.[16] Such usages goes against the ordinary meaning of troll in multiple ways. While psychologists have determined that the dark triad traits are common among internet trolls, some observers claim trolls don't actually believe the controversial views they claim. Farhad Manjoo criticises this view, noting that if the person really is trolling, they are a lot more intelligent than their critics would believe.[16]"
 
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It's testing behavior. Much of the time they're really looking for you to set limits with them (professionally, respectfully). Giving into them actually is a form of failing the test (in control mastery terms). They keep testing hoping that you'll change and stand up to them.
 

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uhm, think about dialectic part of DBT or the title of the famous self help book about that population.
 

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Yea maybe I should stop wasting my time trying to understand. Feels like being trolled IRL.

Alright well let's talk about the psychology of trolling: Real world applications.


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Online? I think some Canadian researchers associated trolling behavior with significantly higher prevalence of "Dark Triad" traits.

If you can share some more specifics, what behaviors do the harassment and abuse by psych patients usually consist of?
 
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F0nzie

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Online? I think some Canadian researchers associated trolling behavior with significantly higher prevalence of "Dark Triad" traits.

If you can share some more specifics, what behaviors do the harassment and abuse by psych patients usually consist of?
The behaviors I am referring to are yelling, lying, call/email spamming, aggressive body language, verbal/physical threats, etc.

I think it's important to recognize that the dark triad is not unique to the psychiatric population-- it exists in every speciality and industry. There are probably a higher number of these individuals working as salesmen at car dealerships and corporate executives than at the average psych clinic.


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The behaviors I am referring to are yelling, lying, call/email spamming, aggressive body language, verbal/physical threats, etc.

I think it's important to recognize that the dark triad is not unique to the psychiatric population-- it exists in every speciality and industry. There are probably a higher number of these individuals working as salesmen at car dealerships and corporate executives than at the average psych clinic.


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Don't be afraid to fire those who are very aggressive.
 
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The behaviors I am referring to are yelling, lying, call/email spamming, aggressive body language, verbal/physical threats, etc.

I think it's important to recognize that the dark triad is not unique to the psychiatric population-- it exists in every speciality and industry. There are probably a higher number of these individuals working as salesmen at car dealerships and corporate executives than at the average psych clinic.


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Is this common in your practice or in general psychiatry practice?
 
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F0nzie

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For those that don't know of the dark triad it's: narcissism, psychopathy, and machiavellianism. We don't learn about machiavelliansim in residency, or at least I didn't...not sure why. These individuals have mastered the art of deception and use it to gain control and power. They are like magicians using smoke and mirrors to distract their targets before striking. I have only encountered one of these in clinical practice in the last 8 years-- it was a con artist couple.


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I fire one warning shot to those who are abusive to staff, inform them that they are free to leave the practice and referrals can be made. This usually solves it. If they don't shape up, they get the dreaded certified letter. There is a 4 month wait to get in, I am not risking my mental health for those whose axis 2 pathology prevents them from wellness.


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For those that don't know of the dark triad it's: narcissism, psychopathy, and machiavellianism. We don't learn about machiavelliansim in residency, or at least I didn't...not sure why. These individuals have mastered the art of deception and use it to gain control and power. They are like magicians using smoke and mirrors to distract their targets before striking. I have only encountered one of these in clinical practice in the last 8 years-- it was a con artist couple.


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Are people who express machiavellian behavior more intelligent, on average, than the general population? I seem to recall learning that they are not, but they're just prone to manipulation and deceit -- how well they actually pull it off being variable.
 
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F0nzie

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I fire one warning shot to those who are abusive to staff, inform them that they are free to leave the practice and referrals can be made. This usually solves it. If they don't shape up, they get the dreaded certified letter. There is a 4 month wait to get in, I am not risking my mental health for those whose axis 2 pathology prevents them from wellness.


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Not to get off track but is there a significant degree of additional liability protection if the letter is sent certified versus regular mail?


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Are people who express machiavellian behavior more intelligent, on average, than the general population? I seem to recall learning that they are not, but they're just prone to manipulation and deceit -- how well they actually pull it off being variable.
The dumb ones don't get any press unless it's embarrassing enough to post on Reddit.


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Maybe a UDS may help? Wouldn't be surprised if there was comorbid AODA, but breaching that topic would probably not get you anywhere. Seriously though, it's easier to just fire and fill up your practice with nice low risk clients, straight forward depression and anxiety. They have to be ready and invested on their own first and then we can move ahead.
 

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Is there a reason why some patients choose to harass/abuse yet they don't want to leave the practice? Even after attempts to resolve the issue, offering a refund, and giving referrals to other psychiatrists they choose to stay, pay, and harass. What am I missing here? Is there a value add that I'm not seeing here?


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is "You actually work at a VA" not an option?
 
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Not to get off track but is there a significant degree of additional liability protection if the letter is sent certified versus regular mail?


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I think the buzz word you're trying to avoid is abandonment. You want documentation the patient was discharged and provided appropriate referrals.
 

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"I hate you, don't leave me"
Yep, was thinking this exact quote as well. :nod:

If these are borderline pd patients you're dealing with, then consistency is key in my opinion. Whatever they do in terms of acting out, they get the same empathic, but firm/resolute emotional response each and every time.
 

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If you are able to draw their behaviour to their attention and get them to reflect on their pattern of interpersonal interactions, they may become less obnoxious over time and there may be an opportunity to model more acceptable social behaviour. If this doesn't occur or they aren't interested in making some changes, then it's probably time to question what they are actually hoping to achieve by seeing you and call an end to the therapeutic relationship. Perhaps they get some kind of buzz out of being a jerk and aren't aware of the problem, not unlike a drug user in the pre-contemplative stage of change.

I also think offering a refund is problematic and probably reinforces the bad behaviour due to the lack of any consequences. It may also suggest to them that you don't value the time or service being provided, so they don't have to either. I think that offering a discount to be treated badly is just inviting further trouble and if someone really doesn't want to pay for your service, then I put the onus back on then and refuse to allow them to rebook unless the account is settled, knowing that if they refuse to settle I am still able to claim a portion back from Medicare. Can recall discussing this with a senior psychiatrist who commented that if a patient is unhappy and you offer to only take the medicare benefits (in our system this would leave the patient with no out-of-pocket expenses), they often would argue that that you don't deserve to get that either - a case of if you give them an inch they will take a mile.
 
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Just wanted to add that if a patient is being physically threatening to you or your staff. Document it and then terminate them. If they are psychotic and agitated, that is one thing and being good at deescalating can help, but if they are a substance abuser with axis two pathology, the penal system is where the treatment they need is. From what I recollect from my ethics class from the Menendez case, the courts ruled that once a patient threatens you physically, that severs the therapeutic relationship on their part so it's not like it is patient abandonment. The main duty would be to notify police if the person is threatening harm to anyone.
 

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Not to get off track but is there a significant degree of additional liability protection if the letter is sent certified versus regular mail?
Only that they can't deny that they received, the return receipt is also placed in their file
actually it's more than that, it is now considered the standard of care to send a letter of termination by certified mail (I believe the AMA's ethics guidelines make reference to this). You should call them to terminate as well, offer to provide info or communicate with their new psychiatrist, and help them establish care with a new provider. A list or the link to the website of the local state psychiatric association or residency clinic is sufficient. The general rule of thumb is to provide a month supply of meds/refill, but you can provide nothing (if clinically indicated), or less or more as you feel comfortable with.
 
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The behaviors I am referring to are yelling, lying, call/email spamming, aggressive body language, verbal/physical threats, etc.
Fonzie, can you be specific about the verbal/physical threats? I haven't encountered this (still just a resident) but I am all ears, want to know more about it.
 

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Fonzie, can you be specific about the verbal/physical threats? I haven't encountered this (still just a resident) but I am all ears, want to know more about it.
You must not work with a VA or in a big city. I think I got my first death threat within the first few months of training...
 
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actually it's more than that, it is now considered the standard of care to send a letter of termination by certified mail (I believe the AMA's ethics guidelines make reference to this). You should call them to terminate as well, offer to provide info or communicate with their new psychiatrist, and help them establish care with a new provider. A list or the link to the website of the local state psychiatric association or residency clinic is sufficient. The general rule of thumb is to provide a month supply of meds/refill, but you can provide nothing (if clinically indicated), or less or more as you feel comfortable with.
That's good to know although I am not looking forward to making a trip to the post office for every closure.

What if we send a letter via certified mail and there is no receipt because the patient didn't pick it up? Is there an acceptable length of time to close due to lack of contact?


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Not trying to derail the convo, but I recently had a woman get loud/yelling/vaguely belligerent (though not specifically threatening physical harm), told she had to leave for the day, faked a panic attack in the parking lot and then proceeded to pelt me with mini-oreos. Not sure where that falls in the scheme of physically threatening, haha, but it did make me laugh. I appreciate the above conversation about sending certified mail for situations when that becomes relevant- thanks for sharing your wisdom, folks!
 
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Shikima

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That's good to know although I am not looking forward to making a trip to the post office for every closure.

What if we send a letter via certified mail and there is no receipt because the patient didn't pick it up? Is there an acceptable length of time to close due to lack of contact?


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It's documented that it wasn't picked up and would suffice. You made the attempt. The delivery notice would indicate that it wasn't picked up or rejected.
 
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You must not work with a VA or in a big city. I think I got my first death threat within the first few months of training...
I held out for about 9 months into my VA internship before getting my first.
I made it through my entire practicum without getting a death threat. Since that was half-time, I guess that is only equivalent to about 6 months. I did get to see a threat made to one of the staff psychologists though. Does that count? :)
 

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Yes, we went through all of the channels, training director and all. In my case, I still saw the person, but they were searched and escorted by police to and from each appointment. I've worked with individuals with Borderline PD quite a bit before, so it didn't bother me much. More attention-seeking behavior than an actual threat.
 
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F0nzie

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Not trying to derail the convo, but I recently had a woman get loud/yelling/vaguely belligerent (though not specifically threatening physical harm), told she had to leave for the day, faked a panic attack in the parking lot and then proceeded to pelt me with mini-oreos. Not sure where that falls in the scheme of physically threatening, haha, but it did make me laugh. I appreciate the above conversation about sending certified mail for situations when that becomes relevant- thanks for sharing your wisdom, folks!
Milk is the best defense for those mini-oreos.


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I had a patient (an accomplished computer hacker) threaten to put child porn on my computer. Coincidently, he did have a previous psychiatrist who was arrested for child pornography and he used this as a convenient threat against his involuntary hospitalization.
 
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