meow1985

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Sep 12, 2017
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Being on the bad side of the split sucks, y'all.

I'm currently in a situation where a longitudinal patient's behavior is dancing on the not-so-healed wounds of insecurity from being named in a lawsuit by a patient I took care of in early residency. I'm an easy target at baseline because I am quite insecure, and given recent events, whenever someone is unhappy with me I get horrified of complaints, HR, board and legal action, and wonder if I did in fact do something wrong and therefore should be punished. I stop wanting anything. I cancel plans and don't do nice things for myself because I feel I do not deserve them. It helps only a little to know that the patient's actions are out of proportion and driven by their own... well, stuff.

I need a better way to protect myself from all this, because what basically happens is that whenever something like this comes up, I struggle through my day and then go home and collapse face-first into bed. My limbs get heavy and I can barely do even basic self care, let alone behavioral activation. This goes on for several days until it's better, and then the next patient rejection comes along. This is, obviously, not optimal. And it's actually gotten worse in the last 2 years because before I was too mentally and physically exhausted from call to care and/or didn't appreciate that some of the **** that happens can also happen to me.

Also, I know I need to talk to my therapist about a different approach or a referral to someone else who might be able to do a different kind of therapy, but I have a hard time bringing it up, so we keep not getting to it at appointments.
 
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I’m so sorry you’re going through this. I think what you said makes sense. I’m not sure what kind of therapy (or clinical superverision) you’re receiving right now, but would maybe think about different types of therapy that could best address the issues you’re describing. We all think about transference in the clinical situation but I think less frequently discussed are the difficulties faced by the kinds of people who are drawn to at least a more psychodynamically oriented psychiatry—sensitive people who have often been very good at taking care of others from a young age but do not have much practice taking care of themselves or even knowing what that might mean. My bias is that a more analytic or dynamic approach could be more helpful in these situations.
 

TexasPhysician

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I have a low tolerance for drama in my practice. Any physically threatening, legal talk, or excessively severe language even left on company voicemail at 3am will quickly result in a termination letter from me.

You’ll become fairly good at recognizing when patients are unhappy with you. I sit them down and have a discussion. It goes something like: I feel like you are becoming frustrated with your care. I want you to receive the best care possible. Sometimes physicians and patients have differing opinions about that vision and what it entails. It doesn’t mean that I don’t understand. I deeply care and want all of my patients to improve including you. I feel that “x” is the best next course or alternatively “y”. It is your right to disagree or feel that other options are superior. I would be happy to assist you in transitioning to care elsewhere . I respect your opinion even though we disagree.

Typically this discussion is related to my unwillingness to escalate benzo doses or my advise to taper. It is more likely to result in clearing the air and improving rapport if benzos aren’t involved.

There are community clinics that focus on keeping patients engaged with them at almost any cost with the belief that they can improve mental health despite large obstacles (clinic related). That isn’t my clinic or my philosophy. I believe we all do our best work when our mind is clear to focus on the patient, not the drama.
 
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watto

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We had a resident process group that was particularly helpful for things like this. There's a validation / strength you build from hearing you are not the only one having these experiences.
 

PsyDr

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1) Some of these are not your feelings. They are your patient's feelings, manifesting in you. It's a difficult thing to recognize starting out.

a. Ever been fine at work, have a patient call, saying they urgently need you to fill out some form, and all the sudden you're anxious about this deadline? It's not your anxiety, it's theirs.

2) Some lines that may be useful to someone trying to work on this in therapy:

a. "I'm having a hard time separating my feelings from those of my patients'"
b. "I need to process my realistic fears from what's happened to me, and if such events will happen again"

3) Sometimes preparing for bad outcomes is highly comforting.

a. A useful exercise is to investigate the public data from your state's medical board and the DEA about who, what, and why people have gotten in trouble. It usually becomes very clear that the board acts on rather severe and clear cut things. Avoiding things associated with those areas may be something you want to do.

b. Another useful exercise is to look into how defensive people document their work. This is something you can act on.
 
Oct 13, 2008
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You already have some insight into how much of this relates to your own psychology. It sounds like you need to find a way to give yourself a sense of purpose, mastery, worth, and/or happiness that's not work.

If you want to do some cognitive interventions on yourself, it might be worth challenging the implicit assumption that bad outcomes or patient behaviors are due to you. Unless you're a really egregiously bad doctor, they almost certainly are not primarily due to you. One theoretical might be "if X colleague were this patient's doctor, would the patient behave essentially the same way?" Only you can know whether you're able to suspend your harsh self-judgement enough to avoid devaluing yourself/idealizing other docs and engage in that in a realistic way.
 

birchswing

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I have a low tolerance for drama in my practice. Any physically threatening, legal talk, or excessively severe language even left on company voicemail at 3am will quickly result in a termination letter from me.

You’ll become fairly good at recognizing when patients are unhappy with you. I sit them down and have a discussion. It goes something like: I feel like you are becoming frustrated with your care. I want you to receive the best care possible. Sometimes physicians and patients have differing opinions about that vision and what it entails. It doesn’t mean that I don’t understand. I deeply care and want all of my patients to improve including you. I feel that “x” is the best next course or alternatively “y”. It is your right to disagree or feel that other options are superior. I would be happy to assist you in transitioning to care elsewhere . I respect your opinion even though we disagree.

Typically this discussion is related to my unwillingness to escalate benzo doses or my advise to taper. It is more likely to result in clearing the air and improving rapport if benzos aren’t involved.

There are community clinics that focus on keeping patients engaged with them at almost any cost with the belief that they can improve mental health despite large obstacles (clinic related). That isn’t my clinic or my philosophy. I believe we all do our best work when our mind is clear to focus on the patient, not the drama.
I am not personally confused by this, but I could see how this approach would be confusing to patients for the reason that in psychodynamic-oriented treatment the whole point is the therapeutic relationship itself and dealing with what it brings up (the drama). In such a relationship, a patient would be encouraged to express upset at a practitioner (assuming they are upset), both for the sake of realizing it's safe to do so but also to then examine the upset. This is why I think it's tricky business with psychiatrists tacking on therapy to sessions. But from the outside it seems like psychiatrists scoff at the idea of medication management and want something more than that. I might be naive to what that is, but to me that would be therapy. And in therapy, you don't generally fire people for drama, whereas I could see why you would if it's a more transactional relationship with medications.

Having said that, I have mixed feelings about the "screen" in therapy and the idea that all of the patient's feelings are actually feelings about something else or toward someone else. Part of me thinks it's a useful heuristic for the patient. Part of me thinks it's a defense mechanism for the practitioner.

I have never abused a doctor. But I have told psychologists things that normal social boundaries would not allow for (at least for me). But with medication visit appointment providers, it's like seeing a dentist where you have that polite small talk for the most part. I don't know how you go halfway in on that. If you're really doing therapy and your therapist is pissing you off, then you generally say something. I've had times I thought I was going to quit therapy and went in to talk about that and left feeling better. Granted I'm not abusive, but I also tend to use the screen metaphor. If I had just focused on the content rather than on the process the content led to, I would have had an untherapeutic outcome.
 

TexasPhysician

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I am not personally confused by this, but I could see how this approach would be confusing to patients for the reason that in psychodynamic-oriented treatment the whole point is the therapeutic relationship itself and dealing with what it brings up (the drama). In such a relationship, a patient would be encouraged to express upset at a practitioner (assuming they are upset), both for the sake of realizing it's safe to do so but also to then examine the upset. This is why I think it's tricky business with psychiatrists tacking on therapy to sessions. But from the outside it seems like psychiatrists scoff at the idea of medication management and want something more than that. I might be naive to what that is, but to me that would be therapy. And in therapy, you don't generally fire people for drama, whereas I could see why you would if it's a more transactional relationship with medications.

Having said that, I have mixed feelings about the "screen" in therapy and the idea that all of the patient's feelings are actually feelings about something else or toward someone else. Part of me thinks it's a useful heuristic for the patient. Part of me thinks it's a defense mechanism for the practitioner.

I have never abused a doctor. But I have told psychologists things that normal social boundaries would not allow for (at least for me). But with medication visit appointment providers, it's like seeing a dentist where you have that polite small talk for the most part. I don't know how you go halfway in on that. If you're really doing therapy and your therapist is pissing you off, then you generally say something. I've had times I thought I was going to quit therapy and went in to talk about that and left feeling better. Granted I'm not abusive, but I also tend to use the screen metaphor. If I had just focused on the content rather than on the process the content led to, I would have had an untherapeutic outcome.
You are misunderstanding. I have no problem with a patient calmly expressing dissatisfaction with an element of treatment and working through it. It’s quite different when a straight medication patient calls you names for not upping benzos or threatening to sue you for not refilling a med within 4 hours on a Saturday because they missed their appointment. Physicians should recognize when they are being emotionally abused and terminate care.
 
OP
meow1985

meow1985

Wounded Healer
2+ Year Member
Sep 12, 2017
137
117
I am not personally confused by this, but I could see how this approach would be confusing to patients for the reason that in psychodynamic-oriented treatment the whole point is the therapeutic relationship itself and dealing with what it brings up (the drama). In such a relationship, a patient would be encouraged to express upset at a practitioner (assuming they are upset), both for the sake of realizing it's safe to do so but also to then examine the upset. This is why I think it's tricky business with psychiatrists tacking on therapy to sessions. But from the outside it seems like psychiatrists scoff at the idea of medication management and want something more than that. I might be naive to what that is, but to me that would be therapy. And in therapy, you don't generally fire people for drama, whereas I could see why you would if it's a more transactional relationship with medications.

Having said that, I have mixed feelings about the "screen" in therapy and the idea that all of the patient's feelings are actually feelings about something else or toward someone else. Part of me thinks it's a useful heuristic for the patient. Part of me thinks it's a defense mechanism for the practitioner.

I have never abused a doctor. But I have told psychologists things that normal social boundaries would not allow for (at least for me). But with medication visit appointment providers, it's like seeing a dentist where you have that polite small talk for the most part. I don't know how you go halfway in on that. If you're really doing therapy and your therapist is pissing you off, then you generally say something. I've had times I thought I was going to quit therapy and went in to talk about that and left feeling better. Granted I'm not abusive, but I also tend to use the screen metaphor. If I had just focused on the content rather than on the process the content led to, I would have had an untherapeutic outcome.
I hear what you're saying, but you may be overthinking this.

It is hard to truly separate medication management and psychotherapy, and seeing a psychiatrist is not like seeing a dentist because you basically have to tell the MD about your feelings, insecurities, and behavior patterns, and it's their job to figure out if these things are expected human reactions vs pathological.

However, quite apart from the "screen" metaphor, certain patients have certain patterns of interacting with the world, and you as their MD and yet another person in their life are swept up in it. You can choose not to engage like Texas, or you could try to use it as an opportunity to point out and advise on addressing the pattern. But that's assuming your own trauma response is not triggered by the patient's actions.

One of my issues is that I am actually relatively good already at picking up when people are unhappy or frustrated. But it triggers a trauma response in me so that it's hard to even think straight - at least these days. It wasn't always like this. So a script is helpful.
 

birchswing

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I hear what you're saying, but you may be overthinking this.

It is hard to truly separate medication management and psychotherapy, and seeing a psychiatrist is not like seeing a dentist because you basically have to tell the MD about your feelings, insecurities, and behavior patterns, and it's their job to figure out if these things are expected human reactions vs pathological.

However, quite apart from the "screen" metaphor, certain patients have certain patterns of interacting with the world, and you as their MD and yet another person in their life are swept up in it. You can choose not to engage like Texas, or you could try to use it as an opportunity to point out and advise on addressing the pattern. But that's assuming your own trauma response is not triggered by the patient's actions.

One of my issues is that I am actually relatively good already at picking up when people are unhappy or frustrated. But it triggers a trauma response in me so that it's hard to even think straight - at least these days. It wasn't always like this. So a script is helpful.
You might like the work of Byron Katie. I think for most people who use her materials, it's one of those take what you like and leave the rest type thing. In a way what she teaches is a bit like CBT (the very first question of her work is to ask if your stressful thought is true), but it sort of extends it to an extreme merging it with the Eckhart Tolle new age thinking. Sometimes it can be easier to picture an idea though when it's taken to its extreme, even if you wouldn't personally use it that way.
 

Candidate2017

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I think part of what you're feeling is due to the nature of being in a terrible clinic, and all resident clinics are inherently terrible. But it's an important aspect of training: seeing how the terrible stuff unfolds and gaining experience with how to deal with the sh*tstorm, just like residents in other specialties. In addition to helping us recognize and come up with solutions for the finite flavors of difficult patients, I'd like to believe this valuable experience helps us identify what work conditions and patient behaviors we will accept post-training, i.e., establish boundaries.

Some days and some difficult patients are still dreadful to deal with. But its an opportunity to practice what we preach to our patients when we help them on the road to some mastery of their obstacles, defenses, fears and anxieties.
 

FatherPsychiatry

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Would getting therapy for yourself help?
Agreed. All the advice given above is great, but between this and OP's other posts, it seems like there are some pretty deep-seated issues here that warrant exploration. OP did say s/he is seeing a therapist (last paragraph of the post), but mentions they have a hard time bringing these issues up, so maybe referral for a therapist that can develop a better alliance with OP would work.
 
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meow1985

meow1985

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Good idea. How about DBT?
Or just a different practice.

I tried two different therapists at the group private practice where I get my care, and they were both ultimately one-trick ponies where they just said the same things over and over. My prior one liked opposite action (which is part of DBT), and my current one likes to think of emotional distress as noise that will eventually grow less bothersome if you don't give it the time of day. With both, we just ended up having the same conversation over and over without getting at the real issues. I had a therapist I meshed well with in med school, but she only worked with med students, and is now retired. Surprisingly, she just let me talk about current and past struggles as they felt like coming, and offered really wise, perspective altering feedback. I dunno what it even was - psychoanalysis +/- supportive maybe?

I guess I get what my patients may have to go through. It's hard to find a therapist, and hard to keep starting over. The latter is really the biggest barrier. I have to start all over telling my sh!tty life story.
 

Mindfulpsych22

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Perhaps look for a highly-skilled DBT therapist? Even if you don’t need comprehensive DBT therapy, DBT therapists are trained to be very skilled in noticing and helping their clients with therapy interfering behaviors, including avoidance of bringing up relevant topics. A practitioner like this may be able to help you not only cope with your stressful situation but also make better use of your therapy sessions by helping to solve therapy-interfering behaviors.
 

SourceOfDenial

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My prior one liked opposite action (which is part of DBT), and my current one likes to think of emotional distress as noise that will eventually grow less bothersome if you don't give it the time of day.
So your therapist tells you if you worry less you’ll feel better?

Part of therapy being relational is you get to tell them when you don’t feel like it’s helping, and can process why you have been hesitant to bring it up. But if my therapist called my emotional distress noise I’d run, not walk for the exit. It’s how you feel and it’s your experience, which hardly seems like noise.
 

thepoopologist

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Therapy is not just about getting to know yourself, it's accepting yourself and only then being practiced enough to deal with what is hurled your way. Also I don't think retreating and isolating after a stressful day or week or month is necessarily bad, unless someone remains in that state several months later.

Honestly, some patients are frankly awful people and even though getting them "better" is supposed to be the goal, at a certain point its better to terminate care or limit contact as much as possible.
 

Jules A

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Honestly, some patients are frankly awful people and even though getting them "better" is supposed to be the goal, at a certain point its better to terminate care or limit contact as much as possible.
Might want to duck, someone called a patient a deluxe borderline recently and was descended upon like locusts.

I have to wonder if this field is necessarily a good fit for delicate souls. Maybe it is just my unique experience but I have had to set firm, repeated boundaries, have been threatened and am privy to things that are extremely disturbing. Having thick skin has served me well.
 
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