Office Space, psychiatry edition

[lockian]

For those who have watched Office Space, you probably remember the was Peter Gibbons was able to leg to of all his worries, roll into work in flip flops, refuse to acquiesce to the BS of his workplace and told everybody exactly what they needed to be told?

I wish I could do the same, minus the flip flops. I wish I could follow my clinical instincts and not over-think or second guess. I wish I could tell patients what they need to be told, set the boundaries that need to be set, to cut through all the noise and have a no-BS approach.

One of my first mentors, before med school even, told me that I would make a good doctor because I could see what was truly important about a patient. Somewhere along the line, I must have lost that. Maybe I stopped trusting myself. Maybe mind is too much on improbable but catastrophic side effects, liability, patients disliking me and retaliating in someway. That isn't good for me or for the work.

Unlike with Peter Gibbons, you can't just flip a switch. However, has anyone succeeded in achieving the above, or at least approaching it? (lol, looking at you @randomdoc1 )

Edit: I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

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[Liquid8]

Great film. Sometimes I feel like Milton and burning the whole place down, but on reflection it's probably been a while since I've thought like that. I'd put the reason down to the autonomy of private practice and being self-employed, allowing me to ignore, or at least minimise non-clinical bureaucratic BS.

Gaining more trust in your own clinical decision making will usually come with more time and experience.

 

[dl2dp2]

There's what you say and then there's how you say it. I never lie to patients or throw meaningless platitudes. It doesn't mean that how I tell my patients what they needed to hear is not carefully strategic.

 

[Fan_of_Meehl]

For those who have watched Office Space, you probably remember the was Peter Gibbons was able to leg to of all his worries, roll into work in flip flops, refuse to acquiesce to the BS of his workplace and told everybody exactly what they needed to be told?

I wish I could do the same, minus the flip flops. I wish I could follow my clinical instincts and not over-think or second guess. I wish I could tell patients what they need to be told, set the boundaries that need to be set, to cut through all the noise and have a no-BS approach.

One of my first mentors, before med school even, told me that I would make a good doctor because I could see what was truly important about a patient. Somewhere along the line, I must have lost that. Maybe I stopped trusting myself. Maybe mind is too much on improbable but catastrophic side effects, liability, patients disliking me and retaliating in someway. That isn't good for me or for the work.

Unlike with Peter Gibbons, you can't just flip a switch. However, has anyone succeeded in achieving the above, or at least approaching it? (lol, looking at you @randomdoc1 )

Mental health / medicine has become more and more like Office Space over the course of my career (just check out 'Milton' in my profile pic, LOL).

The best I have done is try to practice 'radical acceptance' of it all (wish I didn't have to) and realizing that I don't need to 'set the building on fire' (as ole Milton did). The building is ALREADY on fire and will burn itself down soon enough (it isn't sustainable). It becomes more clownish and dysfunctional with each passing day. It will burn itself down in time.

 

[Liquid8]

Mental health / medicine has become more and more like Office Space over the course of my career (just check out 'Milton' in my profile pic, LOL).

The best I have done is try to practice 'radical acceptance' of it all (wish I didn't have to) and realizing that I don't need to 'set the building on fire' (as ole Milton did). The building is ALREADY on fire and will burn itself down soon enough (it isn't sustainable). It becomes more clownish and dysfunctional with each passing day. It will burn itself down in time.

Now I feel like the "This is Fine" dog!

 

[Fan_of_Meehl]

Now I feel like the "This is Fine" dog!

View attachment 357592

And you know what the real kick in the teeth is? It's not just healthcare. It's academia. It's business. It's the legal profession. It's law enforcement. It's {name the sub-section of our society}. They all seem to be headed in the same direction. Over-complicate the truly simple, over-simplify the truly complex. Derogate and tear down the highly trained, experienced specialist (make sure you strip them of all authority but load them up with all responsibility). Elevate the 'administrator/manager' self-appointed 'expert'-class who can parrot the 'newspeak' and publicly (and unthinkingly) wave the pom poms wearing a million dollar smile and three piece suit. Meanwhile, the quality of EVERYTHING is degrading over time. Systems are breaking down.

Yeah. The building is on fire. But it's a slow burn. And we've handed the keys to the fire extinguishers to inept compensatory-narcissist control freaks who have been elevated far beyond their competence and given complete power/control over those who actually know how to get things done competently and who actually DO care (about patient outcomes, for example) all the while braying and preaching the loudest and most publicly they can about how much THEY care and about how ethical/moral THEY are because they scream it out loud in the public square while the actual providers are sitting in sessions with actual patients actually trying to address their problems and give them hope.

 

[lockian]

Mental health / medicine has become more and more like Office Space over the course of my career (just check out 'Milton' in my profile pic, LOL).

The best I have done is try to practice 'radical acceptance' of it all (wish I didn't have to) and realizing that I don't need to 'set the building on fire' (as ole Milton did). The building is ALREADY on fire and will burn itself down soon enough (it isn't sustainable). It becomes more clownish and dysfunctional with each passing day. It will burn itself down in time.

I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

 

[painballer27]

For those who have watched Office Space, you probably remember the was Peter Gibbons was able to leg to of all his worries, roll into work in flip flops, refuse to acquiesce to the BS of his workplace and told everybody exactly what they needed to be told?

I wish I could do the same, minus the flip flops. I wish I could follow my clinical instincts and not over-think or second guess. I wish I could tell patients what they need to be told, set the boundaries that need to be set, to cut through all the noise and have a no-BS approach.

One of my first mentors, before med school even, told me that I would make a good doctor because I could see what was truly important about a patient. Somewhere along the line, I must have lost that. Maybe I stopped trusting myself. Maybe mind is too much on improbable but catastrophic side effects, liability, patients disliking me and retaliating in someway. That isn't good for me or for the work.

Unlike with Peter Gibbons, you can't just flip a switch. However, has anyone succeeded in achieving the above, or at least approaching it? (lol, looking at you @randomdoc1 )

Edit: I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

What's wrong with flip flops?

 

[Fan_of_Meehl]

I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

When patients are lying, being gamey/manipulative, demanding the impossible, etc., I find the trick is to try to find a way to not worry about it or not let it be my problem. I let them do their thing, explain the facts of therapy (that it's about self-change, that it is work, etc.), let them emote (but not too much) and then just gently and robotically redirect to the task at hand. I feel that the worst thing I could do is let it 'get under my skin' or make it clear that they are upsetting me (even if they are). That would only reinforce their maladaptive behavior. It gets easier with practice to just shrug it off. If I am in a clinical role, then I don't really have to 'catch' them malingering or anything. I just take what they say at face value and offer the treatment recommendations. I think it's much more challenging for prescribing providers because of the medications (of abuse) issue, however.

 

[comp1]

I find that I can do this a lot more easily on an inpatient unit than in outpatient settings. It gives me time and ability to more appropriately and effectively set boundaries than in a 30 minute office visit.

 

[Stagg737]

I find that I can do this a lot more easily on an inpatient unit than in outpatient settings. It gives me time and ability to more appropriately and effectively set boundaries than in a 30 minute office visit.

Agree strongly with this. Boundaries are a lot easier to set when you can physically walk away from a situation. On the outpatient side, I've found it easiest to just turn the onus back on the patients; a nice side effect of "patient-centered care". Confirming that we don't have a magic pill to make them better, discussing the standards of care, laying out options, and re-affirming that their treatment is their responsibility is how I've been able to end the day without demanding and manipulative patients weighing on me.

I think this is something that any psychiatrist who isn't burnt out or a total narcissist (or who hasn't reached nirvana, lol) always deals with. I'm relatively inexperienced, but it's probably the most important wellness skill I developed during the later years of residency.

 

[erg923]

No one should aspire to be a Peter Gibbons, lest we want to live "off the grid" or some sort of other such thing... I don't think. While understandable, the approach is not reasonable or feasible....obviously.

I do think adopting the common-sense mentality of "patient-centered care" does not equal "patient-dictated care" is really the only way to fight back. I have never really had much problem doing this with my patients, but do realize it gets more harry when all the medications and medication expectations get involved. Personality factors and how much one actually enjoys confrontation/argument in the name of/in the face of quality clinical care and clinical science is another issue.

I never had much personal investment in direct clinical care until I had to do it (latter graduate school.... and a bit after)...so I think I just kept doing this and if people got mad...they got mad. I never wanted to get into a row about it with patients or anything....but it happens.

 

[Fan_of_Meehl]

No one should aspire to be a Peter Gibbons, lest we want to live "off the grid" or some sort of other such thing... I don't think. While understandable, the approach is not reasonable or feasible....obviously.

I do think adopting the common-sense mentality of "patient-centered care" does not equal "patient-dictated care" is really the only way to fight back. I have never really had much problem doing this with my patients, but do realize it gets more harry when all the medications and medication expectations get involved. Personality factors and how much one actually enjoys confrontation/argument in the name of/in the face of quality clinical care and clinical science is another issue.

I never had much personal investment in direct clinical care until I had to do it (latter graduate school.... and a bit after)...so I think I just kept doing this and if people got mad...they got mad. I never wanted to get into a row about it with patients or anything....but it happens.

Good points.

I think--despite what we sometimes tell ourselves (or our employer preaches)--EVERYTHING in therapy is actually a *negotiation* between therapist and client. It isn't a one-way street (nor should be). I can't force them to do anything, they can't take total control over the session and force me to do anything.

And I found that 9 times out of 10 the best way to deal with 'resistance' is less boxing and more judo or, as Mr. Miagi says in Karate Kid, something like:

"Danelsan...you no want get hit...you best defense? No be there."

 

[erg923]

Good points.

I think--despite what we sometimes tell ourselves (or our employer preaches)--EVERYTHING in therapy is actually a *negotiation* between therapist and client. It isn't a one-way street (nor should be). I can't force them to do anything, they can't take total control over the session and force me to do anything.

And I found that 9 times out of 10 the best way to deal with 'resistance' is less boxing and more judo or, as Mr. Miagi says in Karate Kid, something like:

"Danelsan...you no want get hit...you best defense? No be there."

I actually didn't do alot of this stuff when working in the VA system. It's just just a matter of your relationships, how much you really want to fight, etc. I think the VA is worse in this matter since 2017 though..... but in the mid ought's one could really just do whatever...and it was kind of....whatever. Boss doesn't have to "like me'...etc. We actually played a few CC golf scrambles together on the off.....but there was always some tension there.

 

[allantois]

I find that I can do this a lot more easily on an inpatient unit than in outpatient settings. It gives me time and ability to more appropriately and effectively set boundaries than in a 30 minute office visit.

Are you actually saying you are solving anyone’s issues inpatient?

 

[allantois]

“I understand you’ve been having these issues for many years and while I would like to help you resolve them, but it is going to take us time” - something along those lines. Patients come to us with a problem they’ve been having for years and expecting quick fixes when their problems may be characterlogical, environmental, etc

 

[smalltownpsych]

For those who have watched Office Space, you probably remember the was Peter Gibbons was able to leg to of all his worries, roll into work in flip flops, refuse to acquiesce to the BS of his workplace and told everybody exactly what they needed to be told?

I wish I could do the same, minus the flip flops. I wish I could follow my clinical instincts and not over-think or second guess. I wish I could tell patients what they need to be told, set the boundaries that need to be set, to cut through all the noise and have a no-BS approach.

One of my first mentors, before med school even, told me that I would make a good doctor because I could see what was truly important about a patient. Somewhere along the line, I must have lost that. Maybe I stopped trusting myself. Maybe mind is too much on improbable but catastrophic side effects, liability, patients disliking me and retaliating in someway. That isn't good for me or for the work.

Unlike with Peter Gibbons, you can't just flip a switch. However, has anyone succeeded in achieving the above, or at least approaching it? (lol, looking at you @randomdoc1 )

Edit: I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

I think I understand what you are saying and have felt much the same way. I was thinking just the other day that maybe I lost it and I was able to help and connect and say the right things better before. It is usually because I have a few patient interactions that don’t go well. I have been doing this for 20 years now and I have developed some incredible skills and abilities and yet almost every day I find moments of doubt or inadequacy. One of my greatest supervisors always said, “Can you tolerate the distress of uncertainty?” A very important point for me is to put my energy into the patients that I can help.

That being said, I approach every patient with the attitude that I can be of help and that this will be a positive relationship. That is what I bring to the table and then we see what they bring. In other words, the next step is the assessment and case formulation. In my mind, it Is almost like a interpersonal chess game where I am trying to see four or five moves ahead as I’m trying to figure out the whole dynamic of how to help this person improve their life. After all, that’s why they came to see me. Some patients we can do that collaboratively and comfortably. Others refuse to play or only want to keep doing what they’re doing and I’m just part of that game, and others I have to be patient as we build the trust and understanding.

 

[Fan_of_Meehl]

I think I understand what you are saying and have felt much the same way. I was thinking just the other day that maybe I lost it and I was able to help and connect and say the right things better before. It is usually because I have a few patient interactions that don’t go well. I have been doing this for 20 years now and I have developed some incredible skills and abilities and yet almost every day I find moments of doubt or inadequacy. One of my greatest supervisors always said, “Can you tolerate the distress of uncertainty?” A very important point for me is to put my energy into the patients that I can help.

That being said, I approach every patient with the attitude that I can be of help and that this will be a positive relationship. That is what I bring to the table and then we see what they bring. In other words, the next step is the assessment and case formulation. In my mind, it Is almost like a interpersonal chess game where I am trying to see four or five moves ahead as I’m trying to figure out the whole dynamic of how to help this person improve their life. After all, that’s why they came to see me. Some patients we can do that collaboratively and comfortably. Others refuse to play or only want to keep doing what they’re doing and I’m just part of that game, and others I have to be patient as we build the trust and understanding.

"I have been doing this for 20 years now and I have developed some incredible skills and abilities and yet almost every day I find moments of doubt or inadequacy."

This part of what you said really hits home.

I think this spirit is absolutely essential to being an effective therapist...I think the gnawing sense of doubt or inadequacy is our proper appreciation of the promise and peril of surfing that line between chaos and order in a very complex and often very unstable system. It's the price of actually being present in the real moment with the patient and actually paying attention (and actually caring about what happens next).

 

[Stagg737]

One of my greatest supervisors always said, “Can you tolerate the distress of uncertainty?” A very important point for me is to put my energy into the patients that I can help.

That's a great line, someone should put that in a movie or something.

"Danelsan...you no want get hit...you best defense? No be there."

"What do you mean I can't do whatever I want and not have anything bad happen? You're dumb, now give me my Xanax so I don't have to worry about bad things happening when I do that dumb thing!"

 

[Stagg737]

Edit: I guess people heard “Office Space” and instantly thought of the system, but what I really wish I could do is to set boundaries that need to be set with patients and not feel bad about it. Like, if patients are lying, being gamey/manipulative, demanding the impossible, etc I want to be able to say that I won’t stand for it. Everyone says it will come with time but geez, it is hard going. I wish I could fall asleep and wake up ten years later with the learning process already done.

I think another important point is to consciously remind yourself that you cannot help everyone and that you can only do so much. At the end of the day, think about the ways you were able to help people. Some people aren't ready to accept the help they need, and some people never will. Having the surgeon mentality of "I'm going to fix this" is unsustainable in psych, and it's important to remember this even for the small things we think we can or should be able to fix. Do what you can and what you know is right for the patient, give them options when possible, and remind yourself of what you actually did. Oftentimes the outcomes aren't reflective of our expectations or efforts, and dwelling on the outcome or what 'could have been' will only cause you more stress.

 

[Fan_of_Meehl]

That's a great line, someone should put that in a movie or something.


"What do you mean I can't do whatever I want and not have anything bad happen? You're dumb, now give me my Xanax so I don't have to worry about bad things happening when I do that dumb thing!"

I hear ya. I think prescribing providers are in a tougher situation here with drug-seeking patients than psychotherapists are with their (ostensibly) therapy-seeking clients.

 

[TheRightMedication]

I hear ya. I think prescribing providers are in a tougher situation here with drug-seeking patients than psychotherapists are with their (ostensibly) therapy-seeking clients.

I am sympathetic to the way it feels when drug seekers, especially the sophisticated ones, are working us over.

However.

The correct course of action is not hard to ascertain. It's actually very, very easy - you know its right to say no and you say no. Use true words to describe why, once. Anything else is an illusion, born of some agent who is motivated to obfuscate. That agent could be the system you work in, the patient, or even (or most likely?) the people-pleasing part of yourself.

So. Don't let anyone make you feel like its a tough situation. That's a lie, and like any lie, letting go of it will make life much easier. And better. And you'll be surprised how many patients will respond with anger, initially, but will then reschedule with you.

 

[smalltownpsych]

I am sympathetic to the way it feels when drug seekers, especially the sophisticated ones, are working us over.

However.

The correct course of action is not hard to ascertain. It's actually very, very easy - you know its right to say no and you say no. Use true words to describe why, once. Anything else is an illusion, born of some agent who is motivated to obfuscate. That agent could be the system you work in, the patient, or even (or most likely?) the people-pleasing part of yourself.

So. Don't let anyone make you feel like its a tough situation. That's a lie, and like any lie, letting go of it will make life much easier. And better. And you'll be surprised how many patients will respond with anger, initially, but will then reschedule with you.

I find that the quicker I recognize the manipulation and tell someone that it won’t happen, then the quicker they drop it and then I can help or they leave pretty quickly. Either way is a win.

 

[TheRightMedication]

Consider also the patient's plight. There's nothing they need more than a boundary when they seek drugs inappropriately.

In saying no, you help them establish that most needed thing, the boundary.

Temporarily frustrating? Perhaps.

But it's a taste of freedom from the chaos and terror of life with a disordered self, and for this, many will return.

 

[lockian]

Consider also the patient's plight. There's nothing they need more than a boundary when they seek drugs inappropriately.

In saying no, you help them establish that most needed thing, the boundary.

Temporarily frustrating? Perhaps.

But it's a taste of freedom from the chaos and terror of life with a disordered self, and for this, many will return.

I do not know. This has not been my experience. Patients either leave and do not come back or come back and keep trying to push the boundary.

 

[TheRightMedication]

I do not know. This has not been my experience. Patients either leave and do not come back or come back and keep trying to push the boundary.

Psychodynamic talk is, famously, not falsifiable, so I can keep going on this. I think they come back to push the boundary again to have the experience of solid boundaries again. To test you, and the world, more.

 

[smalltownpsych]

I do not know. This has not been my experience. Patients either leave and do not come back or come back and keep trying to push the boundary.

When they don’t come back, that is a good thing. I know some may argue this but we can’t really help people in active addiction. We can help treat co-occurring patients in a structured setting but most people with addiction don’t need psychiatry or even psychotherapy early on in recovery, if they stop using they can get their lives back together and their mild to moderate symptoms will go away.

People who are in recovery know the difference between crazy and not crazy. They just don’t know how to help the addicts with mental illness and at times will give bad advice like stop taking your meds if you want to be sober. Most don’t want to give that kind of bad advice, but they also don’t trust us, mental health professionals, for a variety of reasons. See my dissertation research if you want to be bored to tears about that gulf between us and them. We see them as all the same and to be honest, early on it can be tough to tell the difference. One way to tell is that patients with “real” mental illness are usually not as effective with their manipulations.