How not to get emotionally drained?

[contemplating2005]

---

Members don't see this ad.

Psychiatry can be emotionally draining for some. I am curious what techniques or personality types would do well in this profession. I have heard from others that it is hard at times not to bring work life to home. Others seem to not be affected by it at all.

 

[WisNeuro]

You have to be able to compartmentalize things. Also, try to hold on to the "wins" and be able to learn from and let go of the "losses."

 

[Monocles]

I really like OP's question and hope that some good discussion can come from it. I too, am interested in hearing from some of our more seasoned colleagues who have done this for decade+. Does it help to work with a population that you feel more passionate about?

 

[Stagg737]

Might sound odd, but I'm a bit of a nihilist and I think it helps me deal with the patients you can't help as much as you'd like. Obviously I'm always going to do my best, but even then there are those who can't be helped (or don't want to be) in a way you feel is adequate. Being able to walk out at the end of the day and know that even if your patient isn't improving that you're doing your best is a perspective that has helped me deal with the "losses" in every rotation I was on.

In contrast, if you're the type of person who takes cases personally or feels a real need to "save" people, psych may be a more difficult field. I'm just an intern, so very early on this path, but I've noticed that many of my attendings have been more laid-back/type B personalities and I think there's a reason for that. The few type A psychiatrists I've worked with either carried higher patient loads (forcing them to de-personalize and compartmentalize more) or were very good at compartmentalizing and not taking their work home (or at least this is how they came across).

I'd also be interested to hear about any other coping mechanisms from the more experienced members here other than compartmentalization and good life balance (healthy diet, exercise, socialization/family life, making time for hobbies, etc).

 

[WisNeuro]

I really like OP's question and hope that some good discussion can come from it. I too, am interested in hearing from some of our more seasoned colleagues who have done this for decade+. Does it help to work with a population that you feel more passionate about?

I'll say yes on this one. I had spent about 6 years in the VA system and was on the verge of being burnt out, mostly due to the rates of malingering/invalid assessments in my clinic. It honestly made me question if I was in the right field. After a job change, and drastic drop in PVT/SVT failures during my assessments, I am much happier and not really feeling burnt out at all. 35 hour weeks also help with that.

 

[contemplating2005]

Might sound odd, but I'm a bit of a nihilist and I think it helps me deal with the patients you can't help as much as you'd like. Obviously I'm always going to do my best, but even then there are those who can't be helped (or don't want to be) in a way you feel is adequate. Being able to walk out at the end of the day and know that even if your patient isn't improving that you're doing your best is a perspective that has helped me deal with the "losses" in every rotation I was on.

In contrast, if you're the type of person who takes cases personally or feels a real need to "save" people, psych may be a more difficult field. I'm just an intern, so very early on this path, but I've noticed that many of my attendings have been more laid-back/type B personalities and I think there's a reason for that. The few type A psychiatrists I've worked with either carried higher patient loads (forcing them to de-personalize and compartmentalize more) or were very good at compartmentalizing and not taking their work home (or at least this is how they came across).

I'd also be interested to hear about any other coping mechanisms from the more experienced members here other than compartmentalization and good life balance (healthy diet, exercise, socialization/family life, making time for hobbies, etc).

Would you say type B personalities are better suited for this? I am a bit of a nihilist as well.

 

[TexasPhysician]

Psychiatry is a diverse field, so it is VERY possible to find a niche that you find rewarding. It is different for everyone.

Some people love the challenge of county outpatient psych, but I don’t enjoy it. The high no shows, high % social issues + psychosis, and bureaucracy leave me feeling drained easily.

Others don’t enjoy addiction work, but I do. I also really enjoy cash pp in which patients really want advanced education. I don’t think I’ll ever fully retire.

 

[Candidate2017]

I try to be professional (detached, objective and adhering to professional standards of care). While I enjoy helping people get better, I don't pretend to be a superhero or have a savior complex. I understand my limitations and strongly believe my job is to point people in the right direction and that the heavy lifting is done by the patient and their family. Whether they choose to take the direction I'm pointing at is up to them.

 

[futuredo32]

In contrast, if you're the type of person who takes cases personally or feels a real need to "save" people, psych may be a more difficult field. I'm just an intern, so very early on this path, but I've noticed that many of my attendings have been more laid-back/type B personalities and I think there's a reason for that. The few type A psychiatrists I've worked with either carried higher patient loads (forcing them to de-personalize and compartmentalize more) or were very good at compartmentalizing and not taking their work home (or at least this is how they came across).

One reason psych isn't for me. With other fields it's more objective, definite "Rights" and "Wrongs" . In psych the meds are trial and error and the long wait for them to start working. The one comment I got on every rotation as a med student was "very caring " or "extremely empathic" . I thought those were good traits for psychiatry. During residency the comments on my evals were "too caring, too empathic". One of my therapy patients at the VA where I was rotating during residency was in the hospital, had multiple serious medical issues and had mentioned that during his prior hospitalizations that none of his friends or family ever went to visit him when he was in the hospital and that was so hard. He went for medical treatment at a different VA and I could see his chart, he wasn't expected to live over 48 hours. I asked both my therapy supervisor and my regular supervisor (for med patients) if I could go visit him so he wouldn't be so lonely, they both said it was not required but was acceptable. My PD found out and I almost got kicked out of residency because of this. Amazingly, he lived. I just didn't want him to feel so lonely before death. I went on my own time and thought it WAS a gray area , but had permission from two supervisors. I'm glad I went. My patient was so grateful.

It's hard not to let the patients problems become yours, not to constantly worry if they are safe. One of my patients had an awful marriage, and finally found the courage to initiate divorce proceedings, one of her sons is quite ill and it would be a miracle if he lived. She finally had an opportunity for a new start but she is likely going to lose a child who she deeply loves and I am supposed to feel nothing?

 

[OldPsychDoc]

....
I'd also be interested to hear about any other coping mechanisms from the more experienced members here other than compartmentalization and good life balance (healthy diet, exercise, socialization/family life, making time for hobbies, etc).

There's a reason those inpatient units have locked doors. Much easier to leave it behind.

And yes--have a life you enjoy outside of medicine.
And a dog.

 

[Stagg737]

Would you say type B personalities are better suited for this? I am a bit of a nihilist as well.

Not necessarily type B, but the psychiatrists I've met who were older and still doing well all seemed to be very laid back while the more tightly wound or strongly type A people seemed to manage far more poorly and were trying to be on a fast-track to retirement. Not saying everyone fits those profiles, but psych seems to attract far more laid back individuals than many other fields, and I think there's a reason for that.

She finally had an opportunity for a new start but she is likely going to lose a child who she deeply loves and I am supposed to feel nothing?

Not saying you shouldn't feel anything, but imo you have to find a way to manage those situations without letting them affect you on too personal of a level. I've worked with patients who have similar or worse situations and if I tried to connect with them as if they were family I don't think I could sustain a career in this field. That doesn't mean you can't empathize or develop a relationship with your patients, it just means maintaining boundaries in regards to your own mental state as well as your patients'.

 

[contemplating2005]

Not necessarily type B, but the psychiatrists I've met who were older and still doing well all seemed to be very laid back while the more tightly wound or strongly type A people seemed to manage far more poorly and were trying to be on a fast-track to retirement. Not saying everyone fits those profiles, but psych seems to attract far more laid back individuals than many other fields, and I think there's a reason for that.



Not saying you shouldn't feel anything, but imo you have to find a way to manage those situations without letting them affect you on too personal of a level. I've worked with patients who have similar or worse situations and if I tried to connect with them as if they were family I don't think I could sustain a career in this field. That doesn't mean you can't empathize or develop a relationship with your patients, it just means maintaining boundaries in regards to your own mental state as well as your patients'.

can you go into more detail why laid back individuals tend to do better?

 

[SourceOfDenial]

Work/life balance, being in a program that understands everyone has limits, being able to say no, individual therapy, (good) supervision that is self of the therapist work and not just 'what do I do with this patient' are where I would start. I disagree with compartmentalization, detachment...I do not strive for those things and I recognize that to be present I typically have to bring my full self. If I'm detached or compartmentalized it's a reason to pause and reflect on why.

Also, finding what you like and where you fit. For me it's using my psychiatry background in palliative and hospice medicine plus research + therapy. When I do do general inpatient moonlighting I feel like the psychiatry system is broken, people are suffering, and the drugs are useless. So, I try not to do too much of that.

 

[WisNeuro]

Work/life balance, being in a program that understands everyone has limits, being able to say no, individual therapy, (good) supervision that is self of the therapist work and not just 'what do I do with this patient' are where I would start. I disagree with compartmentalization, detachment...I do not strive for those things and I recognize that to be present I typically have to bring my full self. If I'm detached or compartmentalized it's a reason to pause and reflect on why.

Also, finding what you like and where you fit. For me it's using my psychiatry background in palliative and hospice medicine plus research + therapy. When I do do general inpatient moonlighting I feel like the psychiatry system is broken, people are suffering, and the drugs are useless. So, I try not to do too much of that.

Compartmentalization does not equal detachment when dealing with patients. It's possible to be fully engaged with patients at work, and being able to leave it at work and be fully engaged with family and friends at home.

 

[SourceOfDenial]

Compartmentalization does not equal detachment.

True(to some degree, although I'd probably argue they are somewhat similar) my putting them together was because they were both mentioned in the thread as ways to cope.

I don't leave my patients at work, and don't think that's the right idea for everyone either. We all(hopefully) care about our patients, we care about our families, the two aren't totally removed from one another. I think it's an unrealistic expectation to say trainees should leave their work at work-sure you shouldn't be constantly focused on patients 24/7, but similarly our work brains don't 'clock out' at 5pm.

 

[WisNeuro]

True(to some degree, although I'd probably argue they are somewhat similar) my putting them together was because they were both mentioned in the thread as ways to cope.

I don't leave my patients at work, and don't think that's the right idea for everyone either. We all(hopefully) care about our patients, we care about our families, the two aren't totally removed from one another. I think it's an unrealistic expectation to say trainees should leave their work at work-sure you shouldn't be constantly focused on patients 24/7, but similarly our work brains don't 'clock out' at 5pm.

My work brain has no problem clocking out at 2:30-3. It usually gets taken over by gym brain. Tonight, volleyball brain takes over. I think it's very realistic, and healthy, to work towards separating work and non-work. If you want to extend your work schedule beyond whatever it is and take it home with you, that's your choice. But, the people that I know that consistently talk about work and patient issues outside of work, tend to not be the happiest people I know.

 

[whopper]

If a patient is upsetting you have a fixer to come visit the patient to "fix" the situation.

I'm not being as sarcastic as you might think. In a hospital setting others such as nurses and social workers should take some of the heat off of you.

I've found my biggest frustrations in dealing with patients are ones where the patient needs to take some responsibility but aren't. E.g. a patient who shows up, doesn't want to be sober but his mother is forcing him to show up. Such a person will not get better by seeing me. I just tell it like it is. "You're only going to get better if you want to get better, put a lot of effort into it, so see me when that happens. Until then don't." Of course yes offer motivational therapy.

I used to work in a hospital where almost all the psychiatrists kept all of the malingerers there as long as they wanted. That really ticked me off. I tried to fight it but realized I wasn't going to win that one. I left that place. I offered to do lectures to teach how to detect it, deal with it, offered to teach the other psychiatrists how to do malingering screening....none of them were interested except for the ones where it wouldn't make much of a difference. E.g. the geriatric unit had no malingerers. What really bugged me is while at U of Cincinnati all the psychiatrists were all on board with dealing with this problem. The other place no.

 

[Crayola227]

It's also realistic and not un healthy that some of the time, it comes home with you. If I have a patient I'm close to and they kill themselves, I'm probably not going to have a good evening. Probably going to cancel my dinner date with my SO and stay in for the night. I don't know how much of a choice it is not ever be affected. FFS we read shyte in the news and have an emotional response.

 

[WisNeuro]

Y'all need to embrace your inner psychopathic personality traits. Life is soooo much easier. 😉

 

[cara susanna]

Realize that there's only so much you can do, and only so much that you have time for. Remember that this is a career, not a vocation. It's okay to take time off or call in sick or not fill an open slot or take breaks or do what you can to keep burnout low--this is a marathon, not a sprint. Know what your limits are. Set boundaries and hold firm to them. Don't work harder than your patient(s). Remind yourself that, in the end, they are responsible for their own lives and there is only so much you can do. In the end, it doesn't really affect you if they choose to do what you recommend or not, and it's their decision. They also do need to have some level of initiative and responsibility to engage in treatment (e.g., showing up to appointments on time).

I also like to remind myself of what expectations would be in healthcare settings other than mental health. For instance, could I show up to a primary care appointment an hour late and still get seen? Probably not.

 

[SourceOfDenial]

My work brain has no problem clocking out at 2:30-3.

You work at the VA?

 

[WisNeuro]

You work at the VA?

Nope. Used to, though. I made the decision to see more patients who actually needed my services, while also working fewer hours and making substantially more money. It's been a good transition.

 

[PsyDr]

1) I imagine outside of non-modifiable factors, the type of practice in which one on chooses to engage has a significant effect on coping. Some may do better with high volume, low emotional contact types of practice (e.g., med management in inpatient). Some may do much better low volume, high emotional contact (e.g., psychoanalysis). Some may do better with children, others adults, others brain injured, etc.

2) avoiding the classic factors associated with psychiatry/psychology boundary violations: lack of social support, substance abuse, etc. Weirdly, being board certified and being a DO is one for you guys.

3) The old old joke: A young, harried, psychiatrist shares a daily elevator ride every day at 6pm with another psychiatrist in his building. The older psychiatrist is tanned, in great shape, well dressed, smiling all the time. After a few years, the younger psychiatrist is burnt out has lost all his hair, put on 30lbs, can't keep a crease in his slacks. In desperation, he asks the older psychiatrist "What's your secret? Listening to other people's problems every day, all day long, for years on end, has made an old man of me.". The older psychiatrist replies, "You actually listen?!"

 

[NickNaylor]

Thurapy.

 

[WingedOx]

I'll say yes on this one. I had spent about 6 years in the VA system and was on the verge of being burnt out, mostly due to the rates of malingering/invalid assessments in my clinic. It honestly made me question if I was in the right field. After a job change, and drastic drop in PVT/SVT failures during my assessments, I am much happier and not really feeling burnt out at all. 35 hour weeks also help with that.

I'm 3 years in. I like my department and leadership, but I'm starting to feel like a cog in the machine. I started to dip my toes into the water of other options over the winter, but decided against it. The slow grind of outpatient work here isn't totally sustainable for me I've decided, but I'm ok giving it a couple more years since I'm not that unhappy with it to the point where I need to quit for my sanity (remember sunlioness?) But I have been perking my ears up for other opportunities.

 

[dl2dp2]

Speaking personal experience: I think experience makes you better. When I started my practice initially, a lot of drama gets internalized and one truly does feel "emotionally exhausted". But once you've encountered numerous examples of very similar situations that are precarious, it becomes not emotional but rather technical. What you say, what you do become kind of second nature and almost scripted in some way. Not to say that managing these cases isn't complex, but it certainly doesn't feel as emotionally involved once you do this a lot. It very much changes into more like a puzzle solving aspect.

I definitely think this has made me a better psychiatrist. In fact, I would say whenever I get emotionally involved on a personal level for some reason (typically because the patient isn't doing well, and I instinctually start to try to push harder) I start to make technical errors, such as inappropriate (in hindsight) disclosures, various "wrong" thing to say, etc. To a certain extent this is the "surgical" aspect of psychiatry--how do you manage a very complex case on various fronts in sort of an elegant way without feeling like you are disorganized or "emotionally drained/overwhelmed".

There's something to be said about that elevator vignette--there's a facet of that that's very true. I think more senior people here can also attest to my experience.

 

[WisNeuro]

I'm 3 years in. I like my department and leadership, but I'm starting to feel like a cog in the machine. I started to dip my toes into the water of other options over the winter, but decided against it. The slow grind of outpatient work here isn't totally sustainable for me I've decided, but I'm ok giving it a couple more years since I'm not that unhappy with it to the point where I need to quit for my sanity (remember sunlioness?) But I have been perking my ears up for other opportunities.

I really hope your VA experience is better than mine. I love the mission of the VA, and I come from a military family, so the population (in general) is one that I love. But, it's so hard to be a provider there. Also, I have zero confidence that the pension remains where it is. They've taken baby steps to erode it in recent years, and I imagine that trend will only continue. Hard to keep people there when they can make significantly more money elsewhere, with shorter hours and less red tape.

 

[DD214_DOC]

If a patient is upsetting you have a fixer to come visit the patient to "fix" the situation.

I'm not being as sarcastic as you might think. In a hospital setting others such as nurses and social workers should take some of the heat off of you.

I've found my biggest frustrations in dealing with patients are ones where the patient needs to take some responsibility but aren't. E.g. a patient who shows up, doesn't want to be sober but his mother is forcing him to show up. Such a person will not get better by seeing me. I just tell it like it is. "You're only going to get better if you want to get better, put a lot of effort into it, so see me when that happens. Until then don't." Of course yes offer motivational therapy.

I used to work in a hospital where almost all the psychiatrists kept all of the malingerers there as long as they wanted. That really ticked me off. I tried to fight it but realized I wasn't going to win that one. I left that place. I offered to do lectures to teach how to detect it, deal with it, offered to teach the other psychiatrists how to do malingering screening....none of them were interested except for the ones where it wouldn't make much of a difference. E.g. the geriatric unit had no malingerers. What really bugged me is while at U of Cincinnati all the psychiatrists were all on board with dealing with this problem. The other place no.

Where's a good place to start? I have the same mindset, but increasing my knowledge on how to screen and identify this more reliably is always welcome. I hate the patient, "merry go 'round", and have no problem booting patients who are noncompliant and demonstrate no motivation to get better.

Malingering in kids/teens is even more challenging.

 

[Attending1985]

Where's a good place to start? I have the same mindset, but increasing my knowledge on how to screen and identify this more reliably is always welcome. I hate the patient, "merry go 'round", and have no problem booting patients who are noncompliant and demonstrate no motivation to get better.

Malingering in kids/teens is even more challenging.

This. What will sustain you is seeing people get better. People who stop drinking, leave an abusive partner, take a positive risk, stay out of the hospital, do better with less meds, start seeing a therapist, ect. If your panel is full of people who are just taking up space it will be no fun at all. The system is full of people who are happy to take up space but is also full of people who want help. Make room for those people.

 

[DD214_DOC]

This. What will sustain you is seeing people get better. People who stop drinking, leave an abusive partner, take a positive risk, stay out of the hospital, do better with less meds, start seeing a therapist, ect. If your panel is full of people who are just taking up space it will be no fun at all. The system is full of people who are happy to take up space but is also full of people who want help. Make room for those people.

Definitely agree. My most professionally-satisfying cases have been the ones in which I inherited a patient with an inexplicable pharmacological Hindenburg, and managed to get them down to just one or two meds or even none at all in several cases. These cases are are ones with kids who have been on multiple atypicals for years without any clear rationale, who had put on 40, 50, or more pounds, with nobody ever bothering to assess the need to continue.

 

[sunlioness]

I'm 3 years in. I like my department and leadership, but I'm starting to feel like a cog in the machine. I started to dip my toes into the water of other options over the winter, but decided against it. The slow grind of outpatient work here isn't totally sustainable for me I've decided, but I'm ok giving it a couple more years since I'm not that unhappy with it to the point where I need to quit for my sanity (remember sunlioness?) But I have been perking my ears up for other opportunities.

Hey what?

I quit a job for my sanity.

I didn’t quit Psychiatry or medicine.

Maybe that’s what you meant though.

Yeah that place had me seeing 20-30 unknown to me chronically mentally ill folks living in poverty daily for 15 minute med checks. When I told them I was burning out, my boss showed me my productivity numbers and said they didn’t justify my feeling that way. She added that maybe if I cared about my patients a bit more, I’d find it more sustainable. So I quit and returned to my previous job. “That’s dumb,” my boss said. “You’ll regret doing that”. I’m two years out from that and haven’t yet. Still love my vacays. 🙂

 

[WingedOx]

Maybe that’s what you meant though.

it was. 👍

 

[WingedOx]

When I rotated at the VA some of my supervisors said working here is especially hard because "there's no financial incentive for patients to improve". I think what she meant was in the civilian world patients have to pay out of pocket or co-pays, whereas MH visits in the VA are "free" (or at least patients don't see the bill). So for a lot of veterans they just come to appointments as more of a social visit because it breaks up the monotony of their day.

This depends on the patient, actually.

And in truth the q3-4 months well checkup is the least of my issues in my clinic. I'd prefer more of them to another trainwreck intake.

 

[WisNeuro]

When I rotated at the VA some of my supervisors said working here is especially hard because "there's no financial incentive for patients to improve". I think what she meant was in the civilian world patients have to pay out of pocket or co-pays, whereas MH visits in the VA are "free" (or at least patients don't see the bill). So for a lot of veterans they just come to appointments as more of a social visit because it breaks up the monotony of their day.

Actually, the incentive is for them to either maintain their level of illness, or get worse. It's not about the co-pays, it's about the SC.

 

[WingedOx]

On a somewhat related note, I found out this weekend that one of my former co-residents spent 2+ years dealing with a lawsuit for "false imprisonment" after admitting a suicidal patient during a moonlighting gig that I was part of as well. Hospital tried to settle initially despite my colleague demanding they don't, though the patient then rejected the settlement and took it to trial. Colleague was found not at fault but somehow the jury found in favor the plaintiff against the hospital. Completely f-cking insane.

It's also nice to remember that at least at the VA no one gives a crap about my Press Ganey scores. I take enough abuse as it is for trying to do the right thing.

 

[WisNeuro]

It's also nice to remember that at least at the VA no one gives a crap about my Press Ganey scores. I take enough abuse as it is for trying to do the right thing.

Probably different for providers with high volume, but no one has even mentioned my Press Ganey scores in the year plus that I have been here. They also don't care about the two patient advocate complaints (both patients who were below chance performance on PVTs looking to backdoor a disability or IME case).

 

[whopper]

Where's a good place to start? I have the same mindset, but increasing my knowledge on how to screen and identify this more reliably is always welcome. I hate the patient, "merry go 'round", and have no problem booting patients who are noncompliant and demonstrate no motivation to get better.

Phil Resnick does an outstanding lecture on it at various avenues such as the AAPL conference or APA conference.
Current Psychiatry has a few articles on it but they are too superficial and will leave most clinicians wanting more.
There are books on it.
https://www.google.com/search?rlz=1.......1..gws-wiz.......0i71j0i22i30.SPFz7x7vO5A

The Rogers book is considered the most comprehensive but it's not an easy to go to guide for a clinician. That's the book I've used and read. I haven't tried the others cause I figured my forensic psych fellowship already taught me what those other books would've taught me.