Talking about abuse

[OldPsychDoc]

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One of our colleagues on this forum asked me to discuss this anonymously. It's relevant, important, and unfortunately, timely.

I have a young patient that presented with multiple serious issues. i am a 4th. Yr student and have worked extensively with her. The patient responds well to me, so I have working with a few weeks. She has improved significantly. Today when I went to see her she disclosed a history of sexual abuse. I tried to fake my way through it, and I don't think that I said anything wrong. However, I know that I was not helpful. For the rest of the day, I have been useless. I don't know how to deal with this better. I did report back to my attending to let her know about the patients disclosure, as well as my inability to respond properly . This was very uncomfortable. Again, I really do love psychiatry and I know that if I can overcome this weakness I will be a very good psychiatrist. Is this problem one that can be overcome? To be clear, this question is General. This specific situation will be followed up on by my attending.

I think there are three separate issues raised by this question--1) the general issue of the prevalence of physical and sexual abuse in our patient population and needing to assess it in our evaluations of patients; 2) what can and should we do about it once we find it; and 3) our own personal reactions to those aspects of patients' stories.

I'll let you all discuss 1 & 2 as you see fit, but from this post I'm most concerned about #3, based on the terms the OP uses and how it seems to have affected them. Just a couple of general principles--these folks will frequently spark some fairly intense counter-transference in even the most experienced clinicians. You did right in discussing it with your attending. I'm not sure what you expected "responding properly" would be in this situation, and what you did that you considered "useless" or unhelpful. There shouldn't be any pressure on you to "be helpful" with this, especially as an MS4. The "proper response" is empathetic listening. Now if you feel that you can't learn to do that without needing to "fix" the situation--you might indeed find that you have problems in psychiatry. We have to listen to a lot of uncomfortable stories, some of which have a tendency to hit close to home. (I was DONE with Peds the night I watched an unsuccessful resuscitation of a 10-month old...) Good training will help you see what you CAN do to move that patient along to the next step in dealing with their past trauma without your becoming a secondary victim.

 

[clausewitz2]

I think one thing that some people struggle with is if someone does report a trauma history, don't start trying to excavate all of the painful details unless you are this person's established therapist and you have the training and supervision necessary to do trauma narratives properly. If you are evaluating someone in the ED or working with them on an acute inpatient unit, sure it is relevant that they have a history of, say, sexual abuse. If they tell you this, ask about immediate safety, ask whatever questions your state requires in the situation for possible mandatory reporting purposes, ask about PTSD symptomatology but you really do NOT need to push on the details. Some people are going to be very prepared to discuss this and may volunteer quite a lot, but lots of folks who are abuse victims do not want to talk about it under circumstances where they don't feel like they are choosing to discuss it, and forcing the issue is probably actively harmful.

@OldPsychDoc is right on about getting better at tolerating people telling you about awful things in their lives that you are not going to fix.

 

[wolfvgang22]

In practical terms, how do you deal with the pressure and expectation to "do something" from patients, families of patients, and hospital administration?

 

[FlowRate]

Basically what clausewitz said, with some additions (aimed at a MS4/PGY-1 level):

Your job (as a MS4/PGY-1) is usually to address their current or immediate future circumstances (ED disposition or acute phase of inpatient treatment.) In most cases, you should not be bringing up trauma or encouraging them to bring up trauma except as a screening question. You won't be helping them work through any trauma. If the patient is becoming ruminative, emotionally disregulated, or giving large amounts of graphic detail, often the right thing to do is to find a way to empathically change the subject.

You will not be able to fix any part of their experience and neither will they (unless it's ongoing.) Validate that it was an emotionally traumatic time, but do not dwell on that. This is similar to the approach during acute DBT, where your goal is to form an attachment and help them change current behaviors while reducing disregulating behavior (like bringing up trauma) e.g. "yes, you had a traumatic experience AND you are able to change behaviors related to that experience."

 

[DisorderedDoc417]

This is interesting. Unfortunately I find the opposite problem an equal struggle. That is to say that when inundated with revolving door patients suffering from borderline personality disorder who all ruminate on the numerous abusive relationships they seem to frequently partake in, it is hard to be empathetic... or offer helpful advice.

 

[nitemagi]

Great responses so far. The first step is to remove the need to "do something," or to fix it. Just be a person with them. Acknowledge that that is terrible, and that they have pain. Doing deeper trauma work, dealing with abreactions, reframing experiences, etc., is meant for your work as a therapist. I actually think this is a vital skill for a psychiatrist who wants to do therapy, but cut yourself a break -- you're a med student. I'm teaching 3rd and 4th year residents who are just learning to do this.

Speaking to OPD's other Topics --
1. It's everywhere, and it's not our job to ferret out the factual basis of what happened, IMO. It's more important to deal with the emotional impact of it, the narrative they have, and helping them connect with skills (internal) to be able move past it.
2. Good therapy. There's a host of approaches. I'm kinda meh about CBT in this, though it has some utility in terms of gaining some perspective on the cognitive distortions that arise from it. Psychodynamic can also be useful, while recognizing "understanding" the problem doesn't usually help the person feel like they've bypassed it. Psychodynamic can also be useful in the enacting of roles in the therapy relationship and using that to help it. Experiential and somatic therapies I believe have much more utility in addressing trauma, including Gestalt and appropriate use of hypnosis (while minding the risk of suggestibility).

 

[Ceke2002]

As a patient who has been in long term therapy for trauma issues, among other things, I will say that the main things I want from a therapist in terms of disclosing abuse is a) to be heard, b) to be believed, and c) not to have my therapist turn into a rescuer. That's not to say I won't my therapist to show no emotional response whatsoever, it's just that it's not like you can go back in time and change what's happened to someone, and more often that not if you get this idea of fixing someone it becomes part of a bigger narrative of therapist and saviour, and if the patient doesn't live up to the therapist's own rescuer expectations then that can end up being disasterous in terms of what the patient actually needs, because there's a tendency for the rescuer type therapist to withdraw when things don't go the way they thought it would with them riding in on a white horse and just making everything better. You're never going to make everything better, but you can help the patient along the path to a better understanding of themselves and the circumstances that have shaped certain traits over the years, and help them to navigate towards positive changes in their lives.

 

[Ceke2002]

...

 

[WisNeuro]

2. Good therapy. There's a host of approaches. I'm kinda meh about CBT in this, though it has some utility in terms of gaining some perspective on the cognitive distortions that arise from it. Psychodynamic can also be useful, while recognizing "understanding" the problem doesn't usually help the person feel like they've bypassed it. Psychodynamic can also be useful in the enacting of roles in the therapy relationship and using that to help it. Experiential and somatic therapies I believe have much more utility in addressing trauma, including Gestalt and appropriate use of hypnosis (while minding the risk of suggestibility).

As someone who had done hundreds of hours of trauma work utilizing PE and CBT, I'd have to argue that CBT is a bit better than meh. I've seen complete transformations in some patients using these techniques. They're not for everyone, but you can see huge gains in a 8-12 week time frame that persist. I generally ran a 8-12 week course with checkups every month or so over the next 6-12 months.

 

[splik]

Taking a step back - what do you consider "responding appropriately." The fact that most of us don't like hearing horrible things (or at the very least have conflicted feelings about it). To hear patients describe the absolutely awful atrocities they have experienced takes its toll. Even forensic psychiatrists have developed PTSD and from having to hear sex offenders go into great detail of the horrible crimes they have perpetrated or watch videos of abuse etc.

1. When patients are talking about abuse, don't use a lot of silence. Don't let the patient dwell or becoming preoccupied by it. Keep talking to them to prevent dissociation or rumination on this.
2. Thank the patient for their disclosure and being comfortable enough to disclose this with you.
3. Acknowledge that the setting is probably not appropriate for a full exploration of all of this. TBH most pts dont want to go into great detail about this and it's pretty diagnostic if they do want to talk of sexual abuse from the get go. The question then becomes, "what aren't they talking about?"
4. Much more relevant than "what happened?" is "how has this affected you?" It is usually much easier for patient to talk about this and gives you more useful information to formulate the patient's problems.
5. Make it clear how much time you have with the patient. We should always be doing this as it gives the patient a frame to know how much time you have with them and how much detail they can go into with you.
6. Respond empathically to the patient if you feel moved to do so. If you don't feel empathic with the patient then figure out what it is about the patient that I'm not feeling so terrible. And pay attention to whether or not you are dissociating because of how hard it is to hear what the patient is saying or if you fall asleep (bored countertransference may indicate narcissistic or psychopathic pathology). If you don't know what to say, then say that "I don't really know what to say right now."
7. Don't try to shut the patient down or show discomfort to what they are saying. One of the problems with trauma is we can excessively fear re-traumatizing the patient or don't want to hear about it because it's too overwhelming for us. This can send very damaging messages to patients, e.g. "talking about it will make things worse" or "even my doctor doesn't want to hear about this" or "no one can even bear to listen to this" etc. Instead, if it feels unhelpful for the patient to be describing things in the moment, acknowledge "I'm not sure how necessary it is to discuss this further right now. Is it okay if I ask you some questions about some other things?"
8. The problem with medical training (which is why it is the worst possible preparation for psychotherapy training) is that it focuses too much on "doing" things. You don't have to do anything, and the problem with our culture is people are no longer able to tolerate emotions, believe that "something must be done" immediately, and we seek technical solutions to non-technical problems. I usually acknowledge with patients "there is nothing that can take away what happened to you, what we need to focus on is how this affecting you now, and how we can help you heal."
9. As a medical student no one is expecting you to be an expert at navigating these challenging situations. It takes years of experience and supervision to develop these skills. The fact that you are willing to recognize how this encounter affected you, solicit feedback on it, and look for ways to improve are all excellent signs and exactly the kinds of attributes we are looking for in prospective residents.

 

[Erratafromthetext]

And pay attention to whether or not you are dissociating because of how hard it is to hear what the patient is saying or if you fall asleep (bored countertransference may indicate narcissistic or psychopathic pathology). If you don't know what to say, then say that "I don't really know what to say right now."

This is such a tremendous post, I look forward to reading it again and again.

Do you mind expanding upon what you mean here as I was confused - is it if you're falling asleep that it can mean narcissistic or psychopaths pathology in the patient? I think I'm having trouble understanding "bored countertransferrance"

 

[valid username]

@splik , seriously? I'm trying to imagine being relaxed enough to fall asleep while alone in a room with a serial rapist. That could end poorly.

You should expand on and publish your answer. Or at least sticky it. It is so difficult to find written instructions on how to deal with abuse when it appears before the trainee is skilled. You just summed up all the interim informatiin we could possibly need. I especially appreciate that you suggest not too much silence, as my instinct would have been the opposite.

So many thanks!

 

[hamstergang]

If you fall asleep (which happens often to me lol) or start yawning or zoning off, it could well indicate narcissistic pathology in the patient.

I'm curious to know if there's actually research into this, but I would think that falling asleep during a patient interview mostly means that you are in need of sleep more than meaning anything about the patient.

 

[smalltownpsych]

I would just add that responding empathically and appropriately is doing something. Also, I find that it is important to help patient reconsolidate their defenses and explain that to them before sending them out the door. If they can't reconsolidate and they have a history of suicidality, then we will talk about admission. Also, there is a tendency to miss the next appointment so I will often broach that and also explain that next session we won't talk directly about the abuse so much as the effects of the disclosure and strategize for treatment. I find that shifting into psychoeducational mode is very important and many clinicians spend too much time with patient opened up and don't help put them back together. Keep in mind that my thinking on this is as the primary psychotherapist who will be treating the patient for the trauma.

 

[thoffen]

There's a lot to be said here, but there is no template for these situations. So I'll focus on two general points which might be highly relevant to the story.

1. There is first the self-perception that the student has faked their way through it and been unhelpful. This belief implies that there was a more "genuine" and "helpful" way to have handled the encounter. These are good virtues, but nonetheless a logical fallacy to think that a feeling matching these virtues is possible or even desirable for every situation. And this led to a globalized feeling that perhaps the student is unable to handle this in the general case or inappropriate for psychiatry. Quite a harsh judgment from a single encounter.

2. And thus we must consider that this feeling in the student was actually an important part of the interaction. For example that the student was in fact experiencing empathy and allowing through appropriate therapeutic structure for the patient to appropriately demonstrate her internal feelings.

In particular, the student deserves great kudos for recognizing a difference in their usual response to patients and asking for supervision.