Intrusive behavior by patients

[randomdoc1]

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Hello, just wanted to see how others handle these type of situations and of your own experiences. And looking for some support. I do plan to respond to other threads too! Busy week. So at this point in my career, I literally only have two med management patients. I'm otherwise a consultant were I see people to advise if they are candidates for TMS. They have a course of TMS and then return to their regular outpatient care. I've been encountering more often than typical, inappropriate intrusive behavior by patients where they try to insert themselves into my life. I'm quite busy single handedly managing a practice and single parenting. But recent events that have happened:

• a former patient who now sees a different psychiatrist in my office for years, found my gmail and emailed me saying he really needed my input on something
• after seeing one patient for a consult for TMS and sending an authorization request, the patient instead of contacting the clinic with a question found my gmail and starts trying to email my personal channel
• 1-2 patients were not candidates for TMS and showed up at the clinic with no appointment waiting for me in the waiting room wanting to talk to me. When told I was not in the office (I was) they insisted staff inform me they are doing very poorly and that I absolutely must know (and did continue to try to contact the clinic and called from different numbers)
• a current TMS patient has been somewhat hostile, severely resentful, and making techs uncomfortable because she said she was under the impression (despite much notice) that she would become my long term patient. She expected I would personally render all TMS sessions. When she enters the clinic she expects warm greetings from staff. I'm busy and running around in the clinic and she vented about how she felt I was insensitive and dismissive that "she's right there anyways" and I'm not warmly welcoming her and engaging with her 5 days a week during her TMS sessions. This is ridiculous! And sounds very personality disordered.

These are the following modalities the office has used so far.

• patients are informed on the website, in the consent signage emails and in person by me that I am not a regular psychiatrist and they are considered established with their current provider. I am only a consultant.
• I swept through any of my digital presence and tried to remove any trace of my personal emails as feasible
• patients who were not TMS candidates are informed so and it is communicated they are not considered to be established patients with the clinic, it is a consult only. Sometimes we have to remind them when they try to leave clinical messages with me, but even after that, they still try to communicate as if still established. They are already well established in a multidisciplinary team in a hospital system already. So access to care is not the issue. They are reminded multiple times that the message is to be relayed to their hospital system and I've had staff forward the message to their hospital system too. But some patients resorted to even calling from blocked numbers and continuing to try to contact.

Maybe there is not too much more that can be done, but I do find this environment to be helpful and supportive. I am thinking of adding another clause in the consents and/or a patient handout, outlining in painful (but professional) detail that
-no one is establishing longitudinal care with me
-under what conditions I do and do not respond to communications
-what the time limited relationship looks like
-the extremely important role of their ongoing providers
-so very specifically outlining the functions of myself and most importantly their main outpatient care team

Part of me here is maybe especially looking for emotional support. Googling me, trying to find my personal channels like email and phone number make me feel incredibly uncomfortable. Especially as a small framed relatively younger woman (younger by standards of a physician). Also, the not taking no for an answer and waiting for me at my workplace...

 

[comp1]

So, thankfully, I don't do any outpatient, but this all sounds like bog standard personality pathology. Whenever I read about TMS I always thought... regardless of any formal indication, this is going to practically be used mostly on people with severe personality disorders. The dependency involved with five days a week of attention and recognition of your suffering was going to be irresistible. Heck, the narcissistic stroking of needing advanced new technology to treat your specific illness was just be too much. Are you worried about some sort of medicolegal issue? Maybe abandonment, since all of your signage seems directed towards avoding that claim? If you are, you should be getting formal advice from your malpractice carrier. I don't know how your referrals work, but maybe you can educate your referral sources that primary personality pathology is not an indication for TMS and they may consider not referring such cases to you, even if the patient really, really wants it? Your written communication with patients seems very clear already. I seriously doubt having any additional professional language is going to dissuade anyone who already has bad boundaries from continuing to have bad boundaries. You and your staff are going to have to keep verbally redirecting patients with inappropriate behavior when on site. Have a very low threshold for contacting law enforcement when there are any threats. With your patient population, I'm fairly surprised you didn't describe any. I also think being aware of your own countertransference here is extremely important and hopefully will help you make even better clinical decisions too.

 

[randomdoc1]

So, thankfully, I don't do any outpatient, but this all sounds like bog standard personality pathology. Whenever I read about TMS I always thought... regardless of any formal indication, this is going to practically be used mostly on people with severe personality disorders. The dependency involved with five days a week of attention and recognition of your suffering was going to be irresistible. Heck, the narcissistic stroking of needing advanced new technology to treat your specific illness was just be too much. Are you worried about some sort of medicolegal issue? Maybe abandonment, since all of your signage seems directed towards avoding that claim? If you are, you should be getting formal advice from your malpractice carrier. I don't know how your referrals work, but maybe you can educate your referral sources that primary personality pathology is not an indication for TMS and they may consider not referring such cases to you, even if the patient really, really wants it? Your written communication with patients seems very clear already. I seriously doubt having any additional professional language is going to dissuade anyone who already has bad boundaries from continuing to have bad boundaries. You and your staff are going to have to keep verbally redirecting patients with inappropriate behavior when on site. Have a very low threshold for contacting law enforcement when there are any threats. With your patient population, I'm fairly surprised you didn't describe any. I also think being aware of your own countertransference here is extremely important and hopefully will help you make even better clinical decisions too.

You are correct that there is a super high co-occurrence with personality pathology. It's been such a mixed experience. Some cases are very rewarding where I take that opportunity to give psychoeducation and some chronic cases finally reach the acceptance stage of the personality disorder, pursue evidence based therapy and progress while having a healing experience with TMS for co-morbid MDD. I can recall some who after TMS, established with a practicum therapist and years later, they can do so well and the practicum gets a great education. There's also plenty of cases where no matter how much psychoeducation, they want the quick fix and to continue maladaptive behaviors including latching on to providers they fantasize about. It's been extremely fortunate that no claims on any provider here have ever been filed. We're really proud of the preventative risk mitigation. It's a good idea to discuss with referral sources and collab. Some of the prescribers I'm in very regular communication with, so I know for a fact that the established care is there and overall pretty good care and as a united front we direct that patient back to the main outpatient providers. Although as you alluded to, even in those cases...you hear the wishful thinking of patients asking if they can still have this, that, or the other reason to meet with me and we just do the broke record routine and repeat what we said many many times. lol, I considered law enforcement or even borrowing the building security guard for show here and there just to gently dissuade inappropriate behavior. I mean, is law enforcement ever necessary? Pretty rarely. The only time it happened is when a homeless guy refused to leave and ate the food from our fridge.

I was talking with staff and another interesting idea came a mind. Major hospitals and clinics do have rather large signs about patient conduct and I will be getting one for our office too. These incidences don't happen often but I'm hoping the signs will also dissuade contact from people who are not established. It would be a no loitering/trespassing/harassment sign just touching on statutes but also terms of conduct for anyone in this clinic. In other words, we won't tolerate harassment, verbal abuse, etc. etc.

 

[randomdoc1]

OR...since I'm such the entrepreneur, maybe I should monetize all this and lean into it. How about a reality show? LOL

 

[theduderino]

It sounds like you are doing what you can from an administrative point of view. The written consents are important esp if something like a board complaint for abandonment comes up. It obviously does not sound like you abandoning your patients, but patient's perception of being in a treatment relationship is what drives these complaints so the more written stuff you have them sign, the better. I'd also consider sending a discharge/disengagement letter if you feel they aren't good candidates for rTMS after your consult. Many patients don't understand the concept of a consult and I am starting to send certified letters to make things as clear as possible if I decline a patient after an initiation consultation. If this summarizes further treatment recommendations (e.g follow up with your outpatient team) that can be the basis for how all of your staff responds to outreach attempts in the future. The more consistently you and your staff communicate the same message, the better it is.

The patients who are giving you problems are not going to be reading the intake forms very carefully, haha. You're already repeating the highlights in person, which is important. You're going to continue to have personality disordered patients b/c you're offering a service that is often thought of as addressing treatment resistant depression (whatever the hell that is) and these patients are often psychologically complex. The more consistent you can enforce boundaries in an empathetic way, the better. Addtionally, the more you can coordinate w/ their other service providers the better the overall communication/boundaries will be.

• a former patient who now sees a different psychiatrist in my office for years, found my gmail and emailed me saying he really needed my input on something - I've had this happen before. I try not to give input as it re-establishes a patient relationship. I say something like your current psychiatrist is better placed to give you advice since I haven't seen you for x amount of time.

 

[shoomer]

I think you've taken the right steps. We all know being clear and firm in our boundaries is the solution, but the reason we know that is that psychiatrists face these challenges often. I would get security involved for anyone who refuses to leave.

An additional consent sheet is a good idea. Make it clear that only communication through the office is permitted.

It's uncomfortable overall, but you picked a consulting role to get away from this and now you're facing karma LOL. Seriously though, I would reassure you by saying these are not huge or out of the ordinary intrusions from patients. Good to learn from these rather than from something dangerous.

 

[Candidate2017]

Sounds like a day in the life of a psychiatrist. However, you're doing better than most since you have your own PP and dictating your practice terms.

It's probably best to not open any unrecognized emails. For hostile patients, there should be a discharge protocol. For randoms showing up, staff needs better training. They should never inform anyone whether you're in the office, just that, "Dr. R is not available, I can take a message if you are an established patient," or "Go to our website for info on how to establish care." This is a safety issue, as stalkers can lie in wait, and it's not unheard of for burglary rings to break into physicians' homes while they are in clinic or the OR.

I mean, is law enforcement ever necessary? Pretty rarely. The only time it happened is when a homeless guy refused to leave and ate the food from our fridge.

I was talking with staff and another interesting idea came a mind. Major hospitals and clinics do have rather large signs about patient conduct and I will be getting one for our office too. These incidences don't happen often but I'm hoping the signs will also dissuade contact from people who are not established. It would be a no loitering/trespassing/harassment sign just touching on statutes but also terms of conduct for anyone in this clinic. In other words, we won't tolerate harassment, verbal abuse, etc. etc.

All large organizations have security protocols (health emergencies CPR/AEDs, fire, active shooters, potentially violent patients, code words, etc.). Being a solo doesn't absolve you from that responsibility. And if a homeless guy (who mostly likely carries a shank, like most homeless guys) feels comfortable enough to trespass, disregard instructions to leave, enter private staff rooms, and steal your lunch, then you have to ask yourself how much more comfortable would an actual stalker or violent person feel.

Signage and consent forms are good for legal CYA, but that's about it.

 

[psydocc]

at this point in my career, I literally only have two med management patients. I'm otherwise a consultant were I see people to advise if they are candidates for TMS. They have a course of TMS and then return to their regular outpatient care.

So not even med management during their course of TMS? To be honest, I suspect part of the confusion (other than general personality disorder traits leading to boundary violations) is due to this TMS-only model being a less common set up... At my clinic and 99% of those around me that do TMS, we manage the medications and continue to see patients post-TMS. I'm not even sure how I would feel if I only did the TMS procedure and a psychiatrist (or more likely a midlevel) at another clinic was in charge of the patients medication regimen. Benzos, stimulants, AED mood stabilizers could all influence the TMS seizure risk. On the other hand, I could see how it could be financially enticing to just sit back and collect the money for TMS while not being responsible for the long term care or outcomes of the patients. Too ethically iffy for my tastes but I can understand the appeal of this model.

 

[Bartelby]

As an outpatient psychiatrist who does not own or operate a TMS machine, I actually appreciate having clinics that will just do a course of TMS while I continue to manage the overall care of the patient. I don't think transferring all care to the TMS clinic should really need to be a requirement for patients to get TMS.

 

[randomdoc1]

So not even med management during their course of TMS? To be honest, I suspect part of the confusion (other than general personality disorder traits leading to boundary violations) is due to this TMS-only model being a less common set up... At my clinic and 99% of those around me that do TMS, we manage the medications and continue to see patients post-TMS. I'm not even sure how I would feel if I only did the TMS procedure and a psychiatrist (or more likely a midlevel) at another clinic was in charge of the patients medication regimen. Benzos, stimulants, AED mood stabilizers could all influence the TMS seizure risk. On the other hand, I could see how it could be financially enticing to just sit back and collect the money for TMS while not being responsible for the long term care or outcomes of the patients. Too ethically iffy for my tastes but I can understand the appeal of this model.

So this is the interesting thing. When I had more time and energy, I made the TMS program here like an IOP model. I optimized the meds, met with the patient every 1-2 weeks, and we did a med check with add on psychotherapy. We dived deeply into how they even ended up in the TMS treatment arm and delicately broached co-occurring disorders and did a short term psychotherapy approach. I was passionate about helping patients get a better understanding of underlying causes. On the one hand, ethically it felt much better. The treatment felt much more complete. Patients really appreciated it and benefited from getting a preview of when I try to offer good evidence based psychiatry and I'm hoping to show them that it exists and they just need to find the right treatment environment AND engage in it themselves. The problem is that with the co-occurring personality pathology, some people would just not take no for answer and it got stressful when termination approached and happened. It left me feeling betrayed and as if people were trying to keep me hostage for their own selfish agendas by implying "abandonment." No psychiatrist has the capacity to take on every personality disordered case in the state for weekly or twice a week meetings. The expectations bordering on entitlement that came out was ridiculous sometimes. Pseudocrises would arise and other chaos, often feeling somewhat manipulative in nature. So that's when I started adopting TMS only (no therapy and definitely never having my name on another prescription bottle). Because too often, people were not respecting my boundaries. It was like "if I can't have you, I don't want anyone else." (feels like a break up LOL...). It gave me the major ick.

Some of the distress is a me thing. In the course of my career, I had two BPD patients stalk me over the course of years. One called every place I worked (met her in residency) and she'd pretend to be an established patient and try to sneak on my schedule. The other, her and I terminated when I left my job to start the practice. We had a formal termination session and she had an appointment with a new psychiatrist confirmed. Then 13 months into my practice, she calls my office, saying she's a current patient in need of a follow up. My staff said she has no chart here so she must have seen me elsewhere and my schedule is full. She went on a rampage, making various fake google accounts and facebook accounts trying to tank my listing. She was literally trying to get my business to die (she also owned her own company so she was extra aware of what she was trying to do). Both experiences were disturbing and frankly made me worried about if I'd find one of them waiting in the parking lot for me. It also opens another discussion. Healthcare providers are empathic and can be selfless and often times patient assault and harassment is under reported. It's for various reasons including we're not sure if it would lead to anything productive anyways and somewhat of a pass patients can get because "they're sick." I don't have a smart idea for how this culture/societal norm can be tweaked into something healthier though. I do have a kind demeanor, come across as very approachable and non-judgmental and take pride in my ability to interpret, do psychodynamic work, and pretty decent pharmacology. I also do a fair amount of my own digital marketing, blogging and have a sizable digital presence. That presence includes a picture of a young looking female physician with soft features. And...I dare say a level of physical attractiveness (although I'm definitely not smoking hot by any means) in the photos (professional of course). Some of these characteristics and likely others that don't come to mind right now may be drawing patients to me and make them extra reluctant to terminate with a provider of my profile and personality structure. But, I digress. So @comp1 you are completely right about the countertransferance matter.

Interesting geographic difference, in my area, the TMS only model is much more common than TMS being an entry point to establishing for care. So it does not feel foreign to me. However, I can see in a psychologically complex patient, if they interact with a provider they feel infatuated with (not necessarily sexually), regardless of the surrounding circumstances, they can find themselves trying to sink their claws into them.

I do feel validated in realizing this is not that uncommon an occurrence. My colleagues in IOP/PHP programs run into similar things. Where termination is obvious, they have appointments set up elsewhere and patients will still contact the hospital for refills and act as if an ongoing relationship is still there. As everyone said, it's the nature of the work we are in too.

As an outpatient psychiatrist who does not own or operate a TMS machine, I actually appreciate having clinics that will just do a course of TMS while I continue to manage the overall care of the patient. I don't think transferring all care to the TMS clinic should really need to be a requirement for patients to get TMS.

This is precisely the relationship I have with those referring. They treat the office here similar to a PHP/IOP model. I also do collab with the main provider and patients seem to appreciate that two prescribers weighed in on med recommendations. It seems to deepen the confidence they have in the prescription and willingness to give the meds a fair trial. With the collab patients also like the insights discussed on the ddx and formulation of ongoing treatment plan during and after TMS.

 

[psydocc]

As an outpatient psychiatrist who does not own or operate a TMS machine, I actually appreciate having clinics that will just do a course of TMS while I continue to manage the overall care of the patient. I don't think transferring all care to the TMS clinic should really need to be a requirement for patients to get TMS.

To be clear, most regular psych clinics with a TMS machine would certainly not be opposed to doing just the TMS part for patients that already have a psychiatrist. I've even done this myself for local colleagues without machines with the understanding that I would also handle the med regimen for a few weeks while TMS is done and then the patient can return to their regular psychiatrist. It's when a psychiatry clinic only wants to do the lucrative TMS treatments, has no patients of their own, doesn't want ownership of any patients overall care, and offers no option for any degree of med management for patients they are actively treating that I find ethically sus. **Not saying this is how OP is doing things, I'm more so commenting in general on TMS/ketamine mills that actively refuse real ownership of patient care and outcomes.

 

[Crayola227]

Everyone is right....

One thing I would add is don't expect medical language, even as basic as consult, primary team, follow up, etc, to be understood by lay people, you'd be surprised how what seems basic to us needs to be completely spelled out for patients. Obviously the personality disordered it may not matter, but I'm frequently surprised by what desperate patients don't understand. You don't want your paperwork to get too long or it defeats the purpose, but some more clear language can't otherwise hurt and might at least head off some of it. But I would be sure they understand exactly how limited your role is without using that language. Seriously, if I had a nickel every time I explained what consult or follow up meant and why that doctor that saw you isn't going to keep helping you... (which I could see why that is confusing)...

So your primary team is who sent you to me. They take care of all your mental health issues. They are consulting me, meaning they are just asking me if I think this one treatment is a good idea for you given everything about you and your medications and all that. I don't do anything but give the answer to that question, and if the treatment might be right for you, give you the treatment. All questions should go to them. I can't help you with anything except this one thing because I am a consultant, or someone who only does this one thing, and they are your mental health "home team."

You can talk more about what or when questions should be directed to you, but don't use the terms primary team or consultant without some 6th grade mini explanation attached.

 

[allantois]

I would concur that patients generally don’t have a good idea on how they are supposed to interact with the medical and mental health systems. I’m always surprised when people show up without an appointment to try to discuss something and it’s all too common of an occurrence. Or they walk in looking for psychotherapy - not sure at what place that would ever work? You just have to redirect and reremind them of the practice policies. Some people may have an expectation that you need to do their TMS (narcissistic personality?) and perhaps they are not the best candidates for TMS after all

 

[splik]

You are a victim of your own success! Patients are obviously getting attached to you. One thing I find helpful to remember is boundaries are for the psychiatrist to keep. If all patients could be expected to be well behaved, we wouldn't need the boundaries in the first place. From that vantage point, there is no issue if a patient emails your personal email, or tries to add you on social media, or turning up and insisting on talking with you. It is only a problem if it verges into harassment or threatening behavior.

It sounds like you have maintained the boundaries. This is part of their treatment whether they are getting psychotherapy or TMS.
If someone sends me an email that I don't think they should have (or calls and leaves a message or texts etc) I just delete it and consider it never received. I encourage others to do the same. It has never caused a problem for me yet. The exception to this is if you did receive harrassing, stalking, or threatening messages. Always keep those though I also would not typically respond to them. I was cyberstalked years ago briefly by a patient who become enamored with me. Freaked me out at the the time, but stopped soon after receiving no responses to multiple different forms of attempt to connect.

Also bear in mind, people often don't read the paperwork especially if it's too long. If there is an important point, you can have them specifically sign and initial that point. However don't have more than 1 or 2 things that have to be signed an initialed or they won't read or acknowledge it.

I always tell people at the beginning of a consult that this is a consultation and there is no ongoing care or treatment expected or guaranteed at this point. Some people will forget, and others will see themselves as "special" and fantasize about you bending the rules to see them. You become an extension of them and they need to see you as "special" too, to affirm their own entitlement and deserving of unparalleled care and unfettered access. You can see why they might be disappointed or act out when you don't enact these projections. And at the same time, that lack of enactment is part of the treatment they need and are receiving.

You could work on enhancing the institutional transference, so whatever positive attachment they have towards you extends to the clinic and all the support staff. This will also limit splitting. This can include introducing patients to the technicians and letting them know all care occurs under your supervision even if you are not directly there, and training the staff to enhance the positive expectancies of treatment and create a holding environment for patients.

 

[randomdoc1]

I would concur that patients generally don’t have a good idea on how they are supposed to interact with the medical and mental health systems. I’m always surprised when people show up without an appointment to try to discuss something and it’s all too common of an occurrence. Or they walk in looking for psychotherapy - not sure at what place that would ever work? You just have to redirect and reremind them of the practice policies. Some people may have an expectation that you need to do their TMS (narcissistic personality?) and perhaps they are not the best candidates for TMS after all

Agreed, would be nice is if there is some avenue to provide patient education. Of course, no expectation that everyone would just magically behave flawlessly but could be helpful for a portion of the population. There's fantasies of physicians being friends, family and unfettered selflessness. It's neither realistic nor healthy. Tons of colleagues talk about inbox burnout. I personally fantasize about the patient having self empowerment to carve out their outcomes, imho that's the dream. Don't know why, but the tones of your responses tend to make me want to chuckle. I wonder if in person you have a sense of humor. But then again, we can come across differently digitally. Someone here once told me they thought I was older white man who was balding which makes me crack up.

Seems to be multiple contributory factors
>>>how medical care and especially MH is marketed.
-We are not supposed to be your friend/SO/parent/etc. We are a professional resource aimed to help you get insights and create these outside the office. The office is not supposed to become your life.
>>>allowance of boundary crossing in medical systems.
-If certain behaviors are tolerated, patients expect that to be ok in other settings too. One pet peeve is not gently enforcing billing. In hospital systems you can have a massive balance and you can still make appointments with anyone and no one says anything about the financial issue, it usually sits as a piece of ignored mail or a unread chart message. There's also hardly a slap on the wrist for inappropriate behaviors too.
>>>entrenchment by healthcare providers themselves.
-Some gravitate to the savior role due to their own psychological processes. There's also a lot of bad therapy that want patients to stay in therapy forever so they enforce the dependent nature. Many therapists seem to have poor understanding of the role of medical care and embolden patients to "advocate" for unrealistic things.

One of the best no-nonsense psychotherapists in the practice sometimes runs into "side effects" of her own success. Sometimes her patients want more of her and express things like "I wish you were more concerned about me" or disappointment that their relationship is not deepening. In peer consult we discussed one case and I said it appears she's expecting more of the relationship than is appropriate. The patient may not like to hear that though. I wondered at times if psychoeducation before starting therapy would be helpful and how the goal is to get certain needs met outside your therapist. The MH clinic as the one stop shop for your life is unhealthy and just not sustainable.

Even before working in healthcare, I never thought it was ok to call a physician's personal phone or email their gmail even if I came across it. Let alone show up at their work and expect them to magically just have nothing better to do. So obviously, this is personality related too. I see this especially with profiles that seem to have experienced some level of privilege in their lives. Hope this does not make anyone too too mad, but the profile I've seen the most common offenses by a landslide (could be geographically different) are
-caucasian (almost never have seen individuals of color do this, but this is the experience of one provider)
-women
-tall
-light colored hair
-usually above average attractiveness
-does not seem to correlate with current income level
I think women may get a false sense of security of behaving certain ways towards providers. Men at least within this practice, are more careful, probably because of societal stereotypes. But women...it almost feels like "well it can't be sexual, I'm a woman so I won't be suspected." Inappropriate is inappropriate girlfriend!

If too much personality pathology does come out during TMS and typically it is within the first 2 weeks, I do stop TMS. Because it appears to be psychodynamically contraindicated. Interesting you mentioned candidacy. I tell them it can be re-explored at a different time but other things seem to be more pressing. Not surprisingly, you get a share of fury from the perceived injury....but seriously man...

Some people will forget, and others will see themselves as "special" and fantasize about you bending the rules to see them. You become an extension of them and they need to see you as "special" too, to affirm their own entitlement and deserving of unparalleled care and unfettered access. You can see why they might be disappointed or act out when you don't enact these projections. And at the same time, that lack of enactment is part of the treatment they need and are receiving.

You could work on enhancing the institutional transference, so whatever positive attachment they have towards you extends to the clinic and all the support staff. This will also limit splitting. This can include introducing patients to the technicians and letting them know all care occurs under your supervision even if you are not directly there, and training the staff to enhance the positive expectancies of treatment and create a holding environment for patients.

Your insights are always awesome! Fantasy is indeed what happens at times. You remind me of how this line of work brings out personality features in other staff. We once had a psychologist who would love to be part of the fantasy and she'd buckle under projection identification only to get frazzled when they went from being the best in the world to the worst person in the world. She no longer works here. Corrective experiences are indeed part of the treatment since entrenchment only promotes the behavior that is driving others away--entrenching further dependence on the clinic. The enhancing institutional transference is a great idea. Minimization of splitting and maintaining consistent experiences. I remember one of your older posts that made me laugh. Something comical about leaving bad yelp review(s) is more likely to get someone's attention than other means. It was a long thread and the yelp comment was funny.

 

[comp1]

It is an absolute fantasy to think more documentation will in any way reduce personality disordered behavior. Maybe it has some magical medicolegal benefit (still doubtful), but definitely no effect on actual behavior. None of what the OP describes comes from ignorance of policies, at all. It comes from not viewing policies in general or any limitations as applying to them personally. I do agree that physician harassment and abuse is under reported in general which is unfortunate and actively harmful because consequences for a given behavior are often the only therapeutic option available to a patient.

 

[TexasPhysician]

It is an absolute fantasy to think more documentation will in any way reduce personality disordered behavior. Maybe it has some magical medicolegal benefit (still doubtful), but definitely no effect on actual behavior. None of what the OP describes comes from ignorance of policies, at all. It comes from not viewing policies in general or any limitations as applying to them personally. I do agree that physician harassment and abuse is under reported in general which is unfortunate and actively harmful because consequences for a given behavior are often the only therapeutic option available to a patient.

Agreed.

No sign or additional documentation will help.

A personal discussion at the beginning of treatment may provide some benefit, but even that is unlikely to change much behavior.

These behaviors are all aspects of being involved in the life of people with personality disorders. Becoming a consultant doesn’t mean the patients with personality disorders will treat you differently. If anything, it translates to you being the elusive expert that they are missing.

A good option here, which will significantly reduce profit, is to screen out everyone with a personality disorder. Inform every referring physician that you don’t accept any patients with a personality disorder or anyone considered a “difficult” patient. Maybe even require a MMPI before patients get to you. Alternatively 100% lean into personality disorders and establish mandatory inclusion into your advanced DBT PHP program with a complement of therapists that are also on-call for “issues”.

 

[Ceke2002]

I agree with what Splik said about boundaries being for the Psychiatrist to keep, but I also think a PD patient who repeatedly pushes or crosses boundaries, despite psychoeducation and being told 'no', is a sign of someone who is either ambivalent about genuine improvement/recovery, or is outright rejecting the idea. Unless they're a complete idiot I'd a hazard a guess that most patient's with personality disorders are still aware that constantly trying to push the boundaries of their own fantasies into reality will most likely result in their therapy being terminated. If you're treating that person as a therapist maybe that's something to explore within the therapeutic frame. If you're not a therapist for the patient, I'd strongly consider nuking them from orbit.

 

[splik]

I agree with what Splik said about boundaries being for the Psychiatrist to keep, but I also think a PD patient who repeatedly pushes or crosses boundaries, despite psychoeducation and being told 'no', is a sign of someone who is either ambivalent about genuine improvement/recovery, or is outright rejecting the idea. Unless they're a complete idiot I'd a hazard a guess that most patient's with personality disorders are still aware that constantly trying to push the boundaries of their own fantasies into reality will most likely result in their therapy being terminated. If you're treating that person as a therapist maybe that's something to explore within the therapeutic frame. If you're not a therapist for the patient, I'd strongly consider nuking them from orbit.

You might think so, but this isn't the case at all, nor the remedy. Many patients with severe personality pathology push boundaries repeatedly and it is par course (unless as discussed above if it is threatening or harassing). Most of these patients are ambivalent about recovery (as it might mean abandonment or that they weren't that sick in the first place) but a lot of patients really are just clueless about what is acceptable. It's quasi psychotic in some cases. You tell them something and they think you mean that applies to other people not them. Almost as if you were saying it with a wink and a nod.

In general, it is when you terminate such a patient that the real headaches begin. For borderline patients, it triggers abandonment schemas and attachment anxiety and for narcissistic patients it triggers narcissistic injury and righteous indignation. They can always hurt you more. I have found that patients vote with their feet and thankfully 95% of the time, they will either get with the program or self-terminate. It is much, much better and less drama all round if such patients terminate themselves (i.e. better to be fired by such patients).

 

[Ceke2002]

You might think so, but this isn't the case at all, nor the remedy. Many patients with severe personality pathology push boundaries repeatedly and it is par course (unless as discussed above if it is threatening or harassing). Most of these patients are ambivalent about recovery (as it might mean abandonment or that they weren't that sick in the first place) but a lot of patients really are just clueless about what is acceptable. It's quasi psychotic in some cases. You tell them something and they think you mean that applies to other people not them. Almost as if you were saying it with a wink and a nod.

In general, it is when you terminate such a patient that the real headaches begin. For borderline patients, it triggers abandonment schemas and attachment anxiety and for narcissistic patients it triggers narcissistic injury and righteous indignation. They can always hurt you more. I have found that patients vote with their feet and thankfully 95% of the time, they will either get with the program or self-terminate. It is much, much better and less drama all round if such patients terminate themselves (i.e. better to be fired by such patients).

I will admit I tend to get a bit twitchy on the subject of boundaries in a medical Psychiatric setting, and don't think it's acceptable short of someone having lost complete touch with all reality. Obviously I don't think a patient should be terminated over a simple misunderstanding, or a more simple boundary crossing that could be rectified with some gentle reminders and resetting of therapeutic frames and boundaries. I probably should have been a bit more clear about that.

And this is probably why I might not have made a very good Doctor after all. Somehow I don't think the urge to fully arc up and start throwing hands at patients for not showing proper respect to another physician would've earnt me too much respect, or a passing grade.

Interesting discussion though, and I hope OP is safe and has gotten some good advice.

 

[comp1]

Oh no...these patients do not have any insight into their behaviors or their consequences. They just don't and a TMS clinic is not going to be the magical place they get them. It has nothing to do with IQ. It is about what they have experienced previously in life and how they coped with it. I concur with heavy screening before referral.

 

[PsyDr]

1) Consider altering your marketing to your SERVICES rather than your SELF. That might create some differentiation between your personal life and your professional life. There is a difference between, “I get health services from this person” compared to “this person heals me”.

2) It’s safe to assume that you get many emails from unknown people. It’s also likely that you don’t read those emails. Why are you reading stuff that upsets you?

 

[allantois]

Agreed, would be nice is if there is some avenue to provide patient education. Of course, no expectation that everyone would just magically behave flawlessly but could be helpful for a portion of the population. There's fantasies of physicians being friends, family and unfettered selflessness. It's neither realistic nor healthy. Tons of colleagues talk about inbox burnout. I personally fantasize about the patient having self empowerment to carve out their outcomes, imho that's the dream. Don't know why, but the tones of your responses tend to make me want to chuckle. I wonder if in person you have a sense of humor. But then again, we can come across differently digitally. Someone here once told me they thought I was older white man who was balding which makes me crack up.

I'm glad you find my responses humorous - at the end of the day I think we shouldn't be so serious about life.

I worked briefly in an integrated primary care clinic and I was shocked with the behaviors that were tolerated from patients - stuff that would have gotten them discharged from any psych place right away. Not only that, I found that medical providers would routinely compromise mental health care treatment - they would often disagree with recommendations and openly undermine psychiatric as well as therapist recommendations. The medical director would particularly engage in rescue fantasies with patients, as well as engage in patient splitting. I quit after getting into an argument with the medical director about not prescribing meth and cocaine addicts amphetamines for non-existent ADHD (they did not want to cut it off due to a harm prevention model where the patients would stop coming altogether for general medical care.. in his opinion). I believe that a lot of the issues we see in the mental health world are a result of the way patients are allowed to interact in medical settings. Unfortunately, I do not see many medical trainees being interested in learning more about basic therapeutic dynamics so I do not see the situation changing for the better.

 

[randomdoc1]

You guys are such an awesome group. The insights here are fantastic. Especially with what the role I created, the two ways it can be interpreted. "elusive expert." And Ceke's presence here also adds a good insight too : ). As we are discussing, I've been working with an interesting case which makes interesting timing. Gero patient who qualified for ECT. Still could have been a reasonable ECT candidate but had some post ECT delirium. Not contraindicated to continue ECT but she pursued TMS in hopes of a treatment that is better tolerated. I've been collaborating with her PCP and psychiatrist. We all weighed in that it is in her best interest to
-really really work on reducing that polypharm which contributed to the delirium
-I especially talked about the benzo. I reinforced that her psychiatrist's recommendations are right, we need to minimize it for various reasons and she's slowly coming around and been more willing to decrease it
-do less telehealth and start coming in person to appts to promote behavior activation

The TMS started and a lot of cluster C personality traits surfaced. Hx of somatic preoccupation and various pain syndromes prior to TMS/ECT. Similar to her experience with ECT, she became concerned that TMS was causing physical or psychiatric side effects. We were only about 5 sessions in and still sub-therapeutic due to challenges with tolerating the sensation of the treatment. My techs are rather young and can be impressionable so when they are working with an elderly patient complaining of pain and asking for reassurance from the doctor, easy to fall into reinforcing the seeking behavior because they start to feel a sense of urgency off the patient. I provided psychoeducation to the staff to not feed into the behavior which some staff have a harder time understanding than others, but again, gently delivering a consistent message. For a little bit, patient did try to send emails/messages daily asking for immediate feedback from me and the message we sent back was
-regular business turnaround time
-if patient is feeling very uncomfortable, it is ok to pause it
-it's psychodynamically contraindicated to expect any staff member including the physician to be immediately available to ameliorate distress

I do know the TMS was going uneventfully, there were no adverse events noted in the sessions. PCP, family, and psychiatrist agreed these symptoms have been chronic. So there is not much the team in this practice can do to further to help. I think patient contacted the PCP office for prns and some substance use relatively recently emerged too. So the avoidant and dependent traits are really showing themselves. Collaborated with her treatment team that
-sobriety is required
-can reassess if/when she feels comfortable enough to explore it again
-but ultimately, this office has TMS as an option and her primary medical team as someone said is her "home" team. If running into matters, best to make an informed decision as our role in this office is limited but we are available to collab. Defining and laying out the roles really seemed to help.

Really liked everyone's ideas about screening options as well as having a robust treatment support team outside the office (and available)--to make roles clear and establish healthy boundaries. Also allowing all the healthcare providers to deliver a consistent message. I think this opens an opportunity to explore the psychological defenses and how avoidance and dependence is working as a barrier to progress in treatment.

 

[mistafab]

I think your instinct to add a palpable, single sheet of paper at initial consent that outlines "Role of TMS consultants: limitations of treatment and communication" that outlines out of office communications, turnaround time, consultant role is a good move.

Simple signage in the office, in large letters, may also help.

Email signatures within the organization can provide a quick blurb about the 'TMS consultants' role as a reinforcer and not there to respond to emergencies, as well as advice that primary provider is the contact for any concerns - that TMS specific concerns will be managed at regular business blah blah.

Inundate patients with clear boundaries, then as staff be pretty uniform in holding them. Don't respond to any personal emails at all. I think you're doing a good job, just some more frequency in your clinic's messaging to patients might help bolster your employee's confidence in how to address the concerns in the moment, and set a clear business culture for your employees to easily follow.

 

[randomdoc1]

I think your instinct to add a palpable, single sheet of paper at initial consent that outlines "Role of TMS consultants: limitations of treatment and communication"
Inundate patients with clear boundaries, then as staff be pretty uniform in holding them. Don't respond to any personal emails at all. I think you're doing a good job, just some more frequency in your clinic's messaging to patients might help bolster your employee's confidence in how to address the concerns in the moment, and set a clear business culture for your employees to easily follow.

This is actually gonna be kinda fun. Useful and at the same time entertaining for me. I already implemented some of your advice!

I see no harm as well in having one more sheet, that I will be delivering by hand to the patient during the visit. It now states in painful detail what the involvement is of Dr. R. And has a warm message something along the lines of
"your entire treatment with or without TMS is important. A robust team and comprehensive plan is a priority. We highly value the input and involvement of your main care providers who have much more extensive knowledge of the clinical history to deliver the best insights in the planning process. Therefore their ongoing role is critical for best outcomes!"

 

[PsyDr]

Some things I've been thinking about:

1) I am highly concerned about the liability of receiving portal messages from patients. I don't want to get a portal message at 3AM that says "I'm gonna kill myself right now", not read it until business hours, and have to face that in court. I also think it can devolve into unbilled time. I wonder if altering the fees for those types of messages would affect people's behaviors. Lawyers charge per email, and it affects how people contact them. I wonder if patient's seeking ad hoc contact can be altered by the same structure.

2) I wonder if plastics and derm could give some insight in how to handle this type of behavior. They seem to approach patients in a different fashion than most of healthcare.

 

[randomdoc1]

Some things I've been thinking about:

1) I am highly concerned about the liability of receiving portal messages from patients. I don't want to get a portal message at 3AM that says "I'm gonna kill myself right now", not read it until business hours, and have to face that in court. I also think it can devolve into unbilled time. I wonder if altering the fees for those types of messages would affect people's behaviors. Lawyers charge per email, and it affects how people contact them. I wonder if patient's seeking ad hoc contact can be altered by the same structure.

2) I wonder if plastics and derm could give some insight in how to handle this type of behavior. They seem to approach patients in a different fashion than most of healthcare.

Hospital systems face this in the biggest volume and my colleagues complain about this all the time. There likely is some convoluted disclaimer in their super long patient consent forms. However, I've told colleagues, they really should explore CPT codes for this and bring it up their revenue cycle team and coders. It's massive revenue the hospital is missing out on. But hospital coding in my personal experience is shat anyways. And like you said, it could be a beneficial psychotherapeutic intervention to be mindful of others and not treat providers as if they have infinite time and energy because no one does.

The personal experience that comes to mind is last month went to a PCP to do an annual physical. It was coded as a 99213 and went to deductible. Called hospital system back and said to bill as a preventative annual visit because
1.deductible exempt and they get the full payment automatically
2.better RVUs for the physician
3.better rate than a 99213
Shuddering at thinking of the sheer volume of the miscoding of that alone. O__O

 

[comp1]

I know liability is the non-stop focus on the forum here, but pretty much every hospital system in the country has some sort of portal system and they seem to keep having it with a standard "not for emergencies disclaimer" and I haven't seen a case report of legal liability for messages sent through that. I absolutely believe personality disordered patients will inappropriately use a portal system regardless of any disclaimers, as they will with office staff, voicemail and heck postal mail, but that doesn't create liability. In terms of increased workload, yes, it's definitely possible and the billing available for handling inbox messages is quite limited in my experience. We are most assuredly not lawyers.

 

[Ceke2002]

And Ceke's presence here also adds a good insight too : )

Thank you, I do try to be as constructive as I can so your kind words are appreciated. 😊 It seems like you've got a lot of good advice from fellow professionals as well, so that's great. 🙂

 

[randomdoc1]

I know liability is the non-stop focus on the forum here, but pretty much every hospital system in the country has some sort of portal system and they seem to keep having it with a standard "not for emergencies disclaimer" and I haven't seen a case report of legal liability for messages sent through that. I absolutely believe personality disordered patients will inappropriately use a portal system regardless of any disclaimers, as they will with office staff, voicemail and heck postal mail, but that doesn't create liability. In terms of increased workload, yes, it's definitely possible and the billing available for handling inbox messages is quite limited in my experience. We are most assuredly not lawyers.

You reminded me of a case of a patient who was upset about a bill. It was billed correctly, she just happened to have a deductible. And had to go out of her way to make a handwritten letter of how upset she was. All I can do is laugh. There was something just entertaining about it. She did terminate with the clinic, but I mean, what can ya do ya know? lol

Would these codes for inboxing work?
99421 5-10 min
99422 11-20 min
99423 21+ min

Getting paid for online digital E/M services

To get paid for patient messaging and online digital E/M services, report codes 99421-99423 when five criteria are true of the service.

www.aafp.org

personal experience, billing for it dramatically reduced the messaging and there did not seem to be a compromise in patient outcomes.

 

[sloh]

Hospital systems face this in the biggest volume and my colleagues complain about this all the time. There likely is some convoluted disclaimer in their super long patient consent forms. However, I've told colleagues, they really should explore CPT codes for this and bring it up their revenue cycle team and coders. It's massive revenue the hospital is missing out on. But hospital coding in my personal experience is shat anyways. And like you said, it could be a beneficial psychotherapeutic intervention to be mindful of others and not treat providers as if they have infinite time and energy because no one does.

The personal experience that comes to mind is last month went to a PCP to do an annual physical. It was coded as a 99213 and went to deductible. Called hospital system back and said to bill as a preventative annual visit because
1.deductible exempt and they get the full payment automatically
2.better RVUs for the physician
3.better rate than a 99213
Shuddering at thinking of the sheer volume of the miscoding of that alone. O__O

Read of an FM doc in Ohio on another forum who capitalized on converting all inbox message responses to televisits. He had to convince his employer to allow this in his contract. He was compensated by productivity/wRVU’s and was making around 800k per year

 

[Stagg737]

Read of an FM doc in Ohio on another forum who capitalized on converting all inbox message responses to televisits. He had to convince his employer to allow this in his contract. He was compensated by productivity/wRVU’s and was making around 800k per year

This is the correct way to "stick it to the man". Only problem is when stuff like this catches on and becomes common they make amendments to the billing codes to prevent this. See 90785 and translation services for an example.

 

[romanticscience]

for narcissistic patients it triggers narcissistic injury and righteous indignation.

Curious about your opinion. Someone like this self-terminates by ghosting. Do I formally discharge? A part of me says, yes--it mitigates risk by formally ending the pt-dr relationship. However, doing so has also triggered this sentiment, "Oh, you want to discharge me!? I discharge you! AND I'll make a complaint about you/leave a bad review!" I'm sure my medical malpractice insurance would say, "Send the notification." However, the dynamic psychiatrist in me says it's risk v. risk.

 

[randomdoc1]

Curious about your opinion. Someone like this self-terminates by ghosting. Do I formally discharge? A part of me says, yes--it mitigates risk by formally ending the pt-dr relationship. However, doing so has also triggered this sentiment, "Oh, you want to discharge me!? I discharge you! AND I'll make a complaint about you/leave a bad review!" I'm sure my medical malpractice insurance would say, "Send the notification." However, the dynamic psychiatrist in me says it's risk v. risk.

Others may have better ideas but what I've done to also minimize damage to the business is:
-sometimes I can see pharm data if rx coming from elsewhere and I can be relieved they already terminated
-write a letter saying something like "we have not connected in some time. Per standard clinic policies for all patients and state statutes, if we do not hear within ___ time, we will presume patient is currently not interested in continuing care and conclude this episode of care and are no longer in a patient physician relationship. This means we will be unable to issue further refills, schedule appts, or answer messages and care will need to be re-established first. I hope you are doing well and you may have found a new provider. If the need arises to re-establish, contact the office and we will look into what availability we have or provide contacts of offices we know that are in network and open to new patients. It has been a great pleasure to work together."

That way it leaves it for the patient to make the call but we are gently trying to say that there's regulations we are required to follow. However, it is most certainly not abandonment or a rejection. Never was. End of the day, on their end to interpret. lol

 

[smalltownpsych]

You guys are such an awesome group. The insights here are fantastic. Especially with what the role I created, the two ways it can be interpreted. "elusive expert." And Ceke's presence here also adds a good insight too : ). As we are discussing, I've been working with an interesting case which makes interesting timing. Gero patient who qualified for ECT. Still could have been a reasonable ECT candidate but had some post ECT delirium. Not contraindicated to continue ECT but she pursued TMS in hopes of a treatment that is better tolerated. I've been collaborating with her PCP and psychiatrist. We all weighed in that it is in her best interest to
-really really work on reducing that polypharm which contributed to the delirium
-I especially talked about the benzo. I reinforced that her psychiatrist's recommendations are right, we need to minimize it for various reasons and she's slowly coming around and been more willing to decrease it
-do less telehealth and start coming in person to appts to promote behavior activation

The TMS started and a lot of cluster C personality traits surfaced. Hx of somatic preoccupation and various pain syndromes prior to TMS/ECT. Similar to her experience with ECT, she became concerned that TMS was causing physical or psychiatric side effects. We were only about 5 sessions in and still sub-therapeutic due to challenges with tolerating the sensation of the treatment. My techs are rather young and can be impressionable so when they are working with an elderly patient complaining of pain and asking for reassurance from the doctor, easy to fall into reinforcing the seeking behavior because they start to feel a sense of urgency off the patient. I provided psychoeducation to the staff to not feed into the behavior which some staff have a harder time understanding than others, but again, gently delivering a consistent message. For a little bit, patient did try to send emails/messages daily asking for immediate feedback from me and the message we sent back was
-regular business turnaround time
-if patient is feeling very uncomfortable, it is ok to pause it
-it's psychodynamically contraindicated to expect any staff member including the physician to be immediately available to ameliorate distress

I do know the TMS was going uneventfully, there were no adverse events noted in the sessions. PCP, family, and psychiatrist agreed these symptoms have been chronic. So there is not much the team in this practice can do to further to help. I think patient contacted the PCP office for prns and some substance use relatively recently emerged too. So the avoidant and dependent traits are really showing themselves. Collaborated with her treatment team that
-sobriety is required
-can reassess if/when she feels comfortable enough to explore it again
-but ultimately, this office has TMS as an option and her primary medical team as someone said is her "home" team. If running into matters, best to make an informed decision as our role in this office is limited but we are available to collab. Defining and laying out the roles really seemed to help.

Really liked everyone's ideas about screening options as well as having a robust treatment support team outside the office (and available)--to make roles clear and establish healthy boundaries. Also allowing all the healthcare providers to deliver a consistent message. I think this opens an opportunity to explore the psychological defenses and how avoidance and dependence is working as a barrier to progress in treatment.

I hire people who are nice, friendly, and helpful. With certain personality types this doesn’t work well and as you mentioned it can reinforce some negative patterns of behavior. I also specialize in working with some of these “treatment resistant” types. We emphasize the importance of not feeling the need to be helpful and what it means to practice neutrality and boundaries. Also, boundaries. I personally work with the staff on this because if they get it, then it helps all of us and if they don’t, then I need to know because either they won’t work out or a different role would be more useful. Also, I would agree with what was said by splik and others about finding ways to help them to choose to leave if it is not a good fit as opposed to trying to make them.
One final thought, our nice staff are not good at being clear and direct and saying no. This gives patients a mixed message and creates problems down the road. For us, we don’t take insurance or do forensic evaluations. Both of these need to be stated clearly and directly up front and then repeated and receive clear acknowledgement from patients. They sometimes give lip service to these uncomfortable concverstaions and the. Sage isn’t clear enough. For your practice it sounds like patients would like a new psychiatrist/relationship and you to be that person and don’t like to hear that is not possible and that notion needs to be shut down early and often and clearly with little explanation or justification as to why from staff.

 

[randomdoc1]

I hire people who are nice, friendly, and helpful. With certain personality types this doesn’t work well and as you mentioned it can reinforce some negative patterns of behavior. I also specialize in working with some of these “treatment resistant” types. We emphasize the importance of not feeling the need to be helpful and what it means to practice neutrality and boundaries. Also, boundaries. I personally work with the staff on this because if they get it, then it helps all of us and if they don’t, then I need to know because either they won’t work out or a different role would be more useful. Also, I would agree with what was said by splik and others about finding ways to help them to choose to leave if it is not a good fit as opposed to trying to make them.
One final thought, our nice staff are not good at being clear and direct and saying no. This gives patients a mixed message and creates problems down the road. For us, we don’t take insurance or do forensic evaluations. Both of these need to be stated clearly and directly up front and then repeated and receive clear acknowledgement from patients. They sometimes give lip service to these uncomfortable concverstaions and the. Sage isn’t clear enough. For your practice it sounds like patients would like a new psychiatrist/relationship and you to be that person and don’t like to hear that is not possible and that notion needs to be shut down early and often and clearly with little explanation or justification as to why from staff.

Thank you. All of you guys give very informative feedback, including splik who discusses the subconscious wish to be special and somehow a magical exception will be made for them. Oh my goodness, I wish they could just see how many people think that way. One of my fave quotes is "I don't see why she can't just add one more patient in her work." You and 1000+ other people sister. No one is more special than anyone else. The past couple of years I've been trying to make my digital presence smaller by not marketing services by me and trying to upsell the clinic, the providers here and what the clinic as a whole offers. Although some of the effect is contagious, especially if there is a young pretty psychologist who is good at what they do, they become the next "Dr. R". Then I move their profile to the bottom of the website (and remove words form the bio since google is driven by content) because they get plenty of traffic as it is. There are definitely patient fantasies...especially of attractive young women with advanced degrees rendering care and maybe filling that spot of being the SO/mother they wish they had.

A source of mixed feelings is working with young and impressionable staff. To a naive person, it comes across as insensitive and uncaring. Why won't Dr. R come rushing to this poor old woman who's crying of pain during TMS? When in reality there's AODA and subconscious manipulation. Why won't Dr. R just go back to being a regular psychiatrist and give these poor people the love and attention they so desperately want? They look so happy when they talk to her? When in the longterm it is contratherapeutic. It reminds me of Kung Fu Panda. There is no dragon scroll. None of us here hold any magic we can dole out to patients. The magic is themselves, much like how the dragon scroll is only a mirror. LOL. As you can imagine, as clinic founders, we have to be very careful to minimize the staff splitting that so easily erupts. But it's also fulfilling to see when staff learn for themselves. When they do get a little involved with the patient until one day they set their own boundary (or cannot fulfill some ridiculous expectation the patient had) and suddenly the patient reacts to them in a scathing way and they're like "....oh, i see what you were worried about now." I do try to find staff personalities that have strong social skills, feel secure about themselves but are also not afraid to lay boundaries. They are hard to find, but it helps the work environment immensely.

Btw, does anyone know of good articles or reads for hires on boundaries and why it's critical in the MH office? I'm wondering if this is good to have for staff. As splik said, the consistency all around is a part of their treatment.