It is bad, and it is getting worse

[annoyedpsychiatrist]

I was trained that it was the clinician's job to engage patients. If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it. That's really our job. Of course one has to keep a frame as well, but some will go overboard and the frame ends up more about protecting themselves than providing treatment. It's a hard way to go about things, and some failures are inevitable, but I also think this makes the work more engaging and possibly more fun/interesting and you may end up feeling less burned out. I think many end up doing what they accuse patients of doing, i.e externalize and dump it all on something else.
If patients are not engaged in their treatment despite them showing up in your office, imo you have to figure out what you can do differently. Therapy training was extremely helpful for this. How to listen, connect, 'hold', 'validate'.. all of these can make a critical difference in patient engagement. Getting supervision can be extremely helpful as well.

Disagree. The patient is the one who typically has to fix their problems. We typically serve as a guide, providing medications when appropriate, supportive therapy/CBT interventions, etc. Obviously this is different for things like psychosis/mania. We can not force anyone to put in the work and they will not put in the effort until they are in the right stage of change.

The physician is fully capable of doing the wrong thing, sure, but psychiatry is not a spectator sport. The first requirement of change is a desire to change. I can offer words/advice/etc but desire comes from within, not from other people.

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[G Sheb]

Who "trained" you in that garbage? Don't work harder than your patient. You do not infantilize your patients.

lol. The people who trained me had incentives for good patient outcomes. Keeping patients engaged in therapy and treatment, or have them commit to treatment and improve; rather than having disasters on their watch with poor outcomes and hospitalizations.
I am definitely not surprised though by these responses.

 

[docksan]

I think it's case dependent. Some patients thrive from engagement and others are enabled by it.

You cannot force a horse to drink water, as they say. Engagement comes from giving that unconditional, non judgemental positive regard, not from constantly calling your patients, trying to get them to show up, refilling their meds all the time, and doing what they want.

You can very quickly enable maladaptive behaviors if you just do everything.

 

[erg923]

lol. The people who trained me had incentives for good patient outcomes. Keeping patients engaged in therapy and treatment, or have them commit to treatment and improve; rather than having disasters on their watch with poor outcomes and hospitalizations.
I am definitely not surprised though by these responses.

Something funny about what I said?

Your former statement is such backwards thinking to me if you understand behavioral principles/psychology.

And how do you reconcile those stated beliefs ("If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it.") with MI. MIs whole matra and approach is "no fixin, no fixin, no fixin."

 

[docksan]

You should know they're quite the doctorate of hot takes on this board.

I'm always willing to meet a patient where they're at in their story, but it's their story. The more of it I dictate the less of it they can own.

You can reassure and support patients without doing more work than them.

 

[G Sheb]

And how do you reconcile those stated beliefs ("If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it.") with MI. MIs whole matra and approach is "no fixin, no fixin, no fixin."

Alright this IS laughable, sorry.
There's no point of continuing this.
We just have to agree to disagree.

 

[erg923]

Alright this IS laughable, sorry.
There's no point of continuing this.
We just have to agree to disagree.

Ok. So what do think MIs underlying theme is? And what is your source?

 

[smalltownpsych]

Alright this IS laughable, sorry.
There's no point of continuing this.
We just have to agree to disagree.

I just wanted to add in that developing engagement with the patient is a clinical skill so I agree with you on that point. The nuances of how that works and the dialectic of accepting responsibility for that part of your job while recognizing that the patient has a role as well is a bit too complex for this medium of communication and that the other posters are sort of straw manning a bit. I personally get frustrated when I see the unhealthy dynamic of deflecting too much responsibility to the patient or even the system to avoid confronting our own discomfort/insecurities with extremely challenging or sometimes seemingly impossible tasks.

It’s like when we had a patient suicide and everyone at the treatment center kept emphasizing how it wasn’t anyones fault. I thought it was our job to help this patient so they don’t commit suicide so I think this would count as a fail. That was clearly not an acceptable perspective. Not our fault, patients fault was all I heard and I hear that in smaller ways every single day.

 

[G Sheb]

I just wanted to add in that developing engagement with the patient is a clinical skill so I agree with you on that point. The nuances of how that works and the dialectic of accepting responsibility for that part of your job while recognizing that the patient has a role as well is a bit too complex for this medium of communication and that the other posters are sort of straw manning a bit. I personally get frustrated when I see the unhealthy dynamic of deflecting too much responsibility to the patient or even the system to avoid confronting our own discomfort/insecurities with extremely challenging or sometimes seemingly impossible tasks.

It’s like when we had a patient suicide and everyone at the treatment center kept emphasizing how it wasn’t anyones fault. I thought it was our job to help this patient so they don’t commit suicide so I think this would count as a fail. That was clearly not an acceptable perspective. Not our fault, patients fault was all I heard and I hear that in smaller ways every single day.

Yes, there's a lot of allure to doing that, and it is a bit of a dance, and you need to set up a structure to protect yourself as well, but if there is a pattern of patients not engaging, then rather than throwing in the towel, blindly thinking "oh they do whatever they want" and externalizing things to cultural or whatever factors, it's time to check what YOU can do. As a skilled clinician, it is your job to do your best and find a way to motivate and engage patients and this is definitely not synonymous with 'infantilizing'. The treatment fails if patients drop out and decompensate. Sometimes failures are inevitable and we will have them, but it is a failure nonetheless. It is a tough job.

 

[clausewitz2]

Yes, there's a lot of allure to doing that, and it is a bit of a dance, and you need to set up a structure to protect yourself as well, but if there is a pattern of patients not engaging, then rather than throwing in the towel, blindly thinking "oh they do whatever they want" and externalizing things to cultural or whatever factors, it's time to check what YOU can do. As a skilled clinician, it is your job to do your best and find a way to motivate and engage patients and this is definitely not synonymous with 'infantilizing'. The treatment fails if patients drop out and decompensate. Sometimes failures are inevitable and we will have them, but it is a failure nonetheless. It is a tough job.

You're conflating "this particular patient doesn't seem to be getting anywhere and drops out of therapy" with "a whole bunch of my patients aren't getting anywhere and drop out of therapy." I agree 100% with you that you should always be looking for places to improve what you're doing and should be ready to make corrections if something seems to be going systematically wrong. This can be true while also being 100% compatible with the idea that at the end of the day patients do have to have some motivation for change of some kind and willingness to endure some degree of discomfort in order to experience any real gains.

 

[calvnandhobbs68]

It’s like when we had a patient suicide and everyone at the treatment center kept emphasizing how it wasn’t anyones fault. I thought it was our job to help this patient so they don’t commit suicide so I think this would count as a fail. That was clearly not an acceptable perspective. Not our fault, patients fault was all I heard and I hear that in smaller ways every single day.

Yeah sorry no it's pretty clear we do a terrible job of predicting who's at risk of suicide and preventing suicide at an individual (not population risk based) level. It's like blaming a primary care doctor for a patient death by MI because of his management of the patient's hypertension/DM/HLD. People die, we all die sometime.

I'd even count it as a win if somehow we could track that the patient committed suicide later than he/she otherwise would have due to your treatment....that's literally what all of our medical interventions do is delay the inevitable.

 

[Merovinge]

Yes, there's a lot of allure to doing that, and it is a bit of a dance, and you need to set up a structure to protect yourself as well, but if there is a pattern of patients not engaging, then rather than throwing in the towel, blindly thinking "oh they do whatever they want" and externalizing things to cultural or whatever factors, it's time to check what YOU can do. As a skilled clinician, it is your job to do your best and find a way to motivate and engage patients and this is definitely not synonymous with 'infantilizing'. The treatment fails if patients drop out and decompensate. Sometimes failures are inevitable and we will have them, but it is a failure nonetheless. It is a tough job.

I think this is a bit of a generational thing. I always heard "Don't work harder than your patient" from several of my attendings, but I do think that largely comes from an ego protection place (although certainly don't enable your patient is basically rule 101 of psychiatry).

Our newest doc recently responded to a therapist who said she is not working harder than the patient with, "it's our job to work harder than the patient to get them to the point that they can work harder than us". Guy was in his first 6 months out of fellowship and I loved his take on it.

 

[G Sheb]

You're conflating "this particular patient doesn't seem to be getting anywhere and drops out of therapy" with "a whole bunch of my patients aren't getting anywhere and drop out of therapy." I agree 100% with you that you should always be looking for places to improve what you're doing and should be ready to make corrections if something seems to be going systematically wrong. This can be true while also being 100% compatible with the idea that at the end of the day patients do have to have some motivation for change of some kind and willingness to endure some degree of discomfort in order to experience any real gains.

Yeah, there is always effort and discomfort, but part of the challenge is finding the 'hook' that will make the effort more tolerable for the patient.
You will not succeed in all cases, but if you take it that it is part of your job to try as hard as possible, I think the work will actually be more interesting, meaningful, and while of course keeping the necessary structure for you to protect yourself and function well.

I think this is a bit of a generational thing. I always heard "Don't work harder than your patient" from several of my attendings, but I do think that largely comes from an ego protection place (although certainly don't enable your patient is basically rule 101 of psychiatry).

Our newest doc recently responded to a therapist who said she is not working harder than the patient with, "it's our job to work harder than the patient to get them to the point that they can work harder than us". Guy was in his first 6 months out of fellowship and I loved his take on it.

It could be generational, but I also think it has to do with your approach.
If you take a more psychodynamic approach, 'patient doesn't want to do the effort' is not very meaningful, and you're looking to see what is happening that they don't want to do the effort, and try to address this. There is a reason they are in the office in the first place.

 

[SmallBird]

Yeah, there is always effort and discomfort, but part of the challenge is finding the 'hook' that will make the effort more tolerable for the patient.
You will not succeed in all cases, but if you take it that it is part of your job to try as hard as possible, I think the work will actually be more interesting, meaningful, and while of course keeping the necessary structure for you to protect yourself and function well.






It could be generational, but I also think it has to do with your approach.
If you take a more psychodynamic approach, 'patient doesn't want to do the effort' is not very meaningful, and you're looking to see what is happening that they don't want to do the effort, and try to address this. There is a reason they are in the office in the first place.

I feel the type of resistance dynamic therapists think about are much more subtle issues around disclosure, being late for appointments, some misdirected affect, an occasional raised voice. I don't believe the idea is to put up with people who are trying to meet unrelated needs by manipulating the system without any interest in engaging in recovery.

 

[Stagg737]

@Bartelby , I appreciate the thoughtful response, to address some of them:

1- It's kind of like working in a substance use disorder treatment center. At times you have to meet the patient where they are. You may work with harm reduction, engage them in motivational interviewing, celebrate small wins, and be available when they decide to take next steps. Some of those patients will keep using heavily, but I think you still do a service working with those who are (at least initially) not motivated. It's a long-term numbers game, and you are still doing good.

Yea, I don't enjoy SUD treatment at all. It's simultaneously one of the most rewarding experiences and awful experiences in our field imo. The cases where patients actually improve significantly and manage to obtain (near) sobriety and get functional and stay that way for a year or more were some of the most rewarding experiences, but the number of failures to get one success can be crushing. I just don't have the emotional/cognitive stamina for it (at least not right now).

2 - In a practical sense, it's hard to just tell a patient (in so many words) that they are wasting your time and then discharge them. And if you're not going to discharge them, finding the value in what you do and putting up appropriate emotional barriers (not feeling responsible for their choices) can help avoid burn out.

3 - If they genuinely don't have interest in treatment I would definitely have that conversation with them. They might choose to go and know that the door is open for re-intake if they change their mind. There's nothing wrong with that.

I wouldn't be that direct, but I have had the "what are we trying to do?" conversation many times and I actually don't think I struggle with discharging patients once I've made that decision. My distress comes from the number of outpatient appointments that occur and the effort put into those appointments by myself before we get to that realization. It just feels like with some patients they haven't made any improvements (and won't) because they aren't doing what they need to and it makes it feel like all the previous appointments with them were just wasted time. In residency I had a couple patients come back later who made great progress and I had some that dropped off and never came back. I'm fine with that either way. I struggle with the more dependent traits where the patients continually come back but nothing improves, nothing really changes, and they just seem to want to complain about how they're not better but simultaneously say they want to keep seeing psych. Think of those patients from residency who had been seen by the clinic for 5-10+ years and never seem to actually get better.

4 - This should not be most of your panel in the right outpatient setting. It's more a matter of dealing with a not insignificant subsection that you will get in most outpatient settings. The more motivated people racking up gains can help carry you through some of the more drudging encounters!

It's not the majority, but as you said it's a significant minority (probably about 20% in my current clinic). The issue I'm dealing with is that I'm a consult clinic, but the docs before me were treating this like a continuity clinic and had some patients they saw regularly for 2-3 years. It's a mix of me trying to educate those patients that I'm not their long-term psychiatrist and we need to work on cutting the cord and seeing new consults and 2-3 f/ups later when they should be returning to PCP having them say "but I'm not better yet!" while failing to do the things they need. We're trying to figure out what our best policies going forward will be, but it's been tiring.

5 - Sometimes I think we just don't have the tools to adequately help patients. That can easily stir up feelings of helplessness and frustration in us, when obviously we want our patients to get better. I know there is a big difference in those who simply choose not to (for instance) go to recommended therapy, take recommended medications, or make recommended lifestyle changes versus those who (for instance) have schizophrenia and do their best but still have a severe symptom burden. Still, I have to monitor myself for some of that helplessness and frustration when dealing with a patient who just doesn't get better. I try to find compassion for what they are going through, and acknowledge that sometimes we just reach the limits of what we will realistically accomplish. I hope I still make such patients' lives better in some way, and the fact they keep coming back (when I'm not writing controlled substances or offering other obvious secondary gain) suggests I may be.

I think this is a lot of what I'm struggling with. It's just not something that's been an issue for me in other settings, but with outpatient it just seems to hit harder. Maybe I just don't jive with outpatient, maybe it's just the clinics I've worked in. PGY-4 was better, but I still didn't love it. Idk, but either way I just feel tired of it.

 

[Stagg737]

I was trained that it was the clinician's job to engage patients. If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it. That's really our job.

If patients are not engaged in their treatment despite them showing up in your office, imo you have to figure out what you can do differently. Therapy training was extremely helpful for this. How to listen, connect, 'hold', 'validate'.. all of these can make a critical difference in patient engagement. Getting supervision can be extremely helpful as well.

Yes, but that's not really what I'm getting at. The patients I'm referring to ARE engaged...DURING the appointment, but then the next appointment comes along and they didn't follow through with what was discussed between appointments. So we try something else, and they don't follow through. I feel like a good number of patients need a life coach to constantly check in on them and cheer them on to force them to stay motivated.

lol. The people who trained me had incentives for good patient outcomes. Keeping patients engaged in therapy and treatment, or have them commit to treatment and improve; rather than having disasters on their watch with poor outcomes and hospitalizations.
I am definitely not surprised though by these responses.

Legitimate question: Have you ever worked in the VA system?

It’s like when we had a patient suicide and everyone at the treatment center kept emphasizing how it wasn’t anyones fault. I thought it was our job to help this patient so they don’t commit suicide so I think this would count as a fail. That was clearly not an acceptable perspective. Not our fault, patients fault was all I heard and I hear that in smaller ways every single day.

It's not that black and white though. If a patient really wants to kill themselves, they're going to do it and you're not going to stop them short of locking them away under constant observation until they die a "natural" death. Sure, there's plenty of times when the system, which we are a part of, could have done more or flat out fails. However, there are certain patients that either don't want or won't accept our help while simultaneously saying they want help to our faces, that's more of the population I'm referring to.

I think this is a bit of a generational thing. I always heard "Don't work harder than your patient" from several of my attendings, but I do think that largely comes from an ego protection place (although certainly don't enable your patient is basically rule 101 of psychiatry).

Our newest doc recently responded to a therapist who said she is not working harder than the patient with, "it's our job to work harder than the patient to get them to the point that they can work harder than us". Guy was in his first 6 months out of fellowship and I loved his take on it.

Eh, I'm 50/50 with you there. Depends on how much you're already working and also on the patient. I'm willing to go the extra 100 miles for the patient who is legitimately sick, wants to get better, and puts in what effort they can to get there. But again, those aren't the patients I'm referring to here. Some patients just don't want to work or are so averse to discomfort that they just won't. That's more of where I'm coming from and how the "don't work harder than your patient" was framed for me.

 

[G Sheb]

I feel the type of resistance dynamic therapists think about are much more subtle issues around disclosure, being late for appointments, some misdirected affect, an occasional raised voice. I don't believe the idea is to put up with people who are trying to meet unrelated needs by manipulating the system without any interest in engaging in recovery.

This is not the patient population I was referring to. Those who are consciously gaming the system need strong limit setting. Needless to say, you shouldn’t be doing anything to harm the patient. I’d argue it’s still worthwhile to try to connect with them and find a hook to steer the treatment in a proper direction. No one will blame you if you fail though.

I’m sorry you’re struggling so much with your career that you feel you’re ready to jump ship. One thing I will say is that your posting history in this thread and elsewhere reflects a pattern of extreme valuation and devaluation. I don’t think this is an accurate reflection of the field. I encourage you to look at factors outside your career before making a drastic decision.

 

[G Sheb]

Yes, but that's not really what I'm getting at. The patients I'm referring to ARE engaged...DURING the appointment, but then the next appointment comes along and they didn't follow through with what was discussed between appointments. So we try something else, and they don't follow through. I feel like a good number of patients need a life coach to constantly check in on them and cheer them on to force them to stay motivated.


Legitimate question: Have you ever worked in the VA system?


It's not that black and white though. If a patient really wants to kill themselves, they're going to do it and you're not going to stop them short of locking them away under constant observation until they die a "natural" death. Sure, there's plenty of times when the system, which we are a part of, could have done more or flat out fails. However, there are certain patients that either don't want or won't accept our help while simultaneously saying they want help to our faces, that's more of the population I'm referring to.


Eh, I'm 50/50 with you there. Depends on how much you're already working and also on the patient. I'm willing to go the extra 100 miles for the patient who is legitimately sick, wants to get better, and puts in what effort they can to get there. But again, those aren't the patients I'm referring to here. Some patients just don't want to work or are so averse to discomfort that they just won't. That's more of where I'm coming from and how the "don't work harder than your patient" was framed for me.

This is exactly the patient population I’m referring to. Patients who show up but display resistance to intervention. It’s very interesting from a psychodynamic perspective. Clearly they are looking to get something.

When you’re saying they’re not doing what we discussed, what do you mean? If you’re referring to CBT, CBT is not for everyone. Not everyone wants to do homework. It’s still worthwhile to explore what’s holding them and what you can do differently. If it’s a pattern, then I think supervision can be extremely helpful. When I made that comment I knew you wouldn’t take it personally (unlike the few who got clearly triggered).

I did work at a VA. Though I’m curious what lead you to that question.

 

[tr]

Yeah, there is always effort and discomfort, but part of the challenge is finding the 'hook' that will make the effort more tolerable for the patient.
You will not succeed in all cases, but if you take it that it is part of your job to try as hard as possible, I think the work will actually be more interesting, meaningful, and while of course keeping the necessary structure for you to protect yourself and function well.






It could be generational, but I also think it has to do with your approach.
If you take a more psychodynamic approach, 'patient doesn't want to do the effort' is not very meaningful, and you're looking to see what is happening that they don't want to do the effort, and try to address this. There is a reason they are in the office in the first place.

I come from a more MI perspective and I would say that in general, when a patient "doesn't want to put in the effort," the unstated subtext is "to achieve the goals that are important to the *clinician*."

Most people are more than willing to put in the effort to achieve their own goals that are actually important to them.

The key to moving forward is to figure out what those goals actually are, and whether as the clinician you can find common ground with the patient on a set of goals you are willing to help them achieve.

 

[Stagg737]

This is exactly the patient population I’m referring to. Patients who show up but display resistance to intervention. It’s very interesting from a psychodynamic perspective. Clearly they are looking to get something.

When you’re saying they’re not doing what we discussed, what do you mean? If you’re referring to CBT, CBT is not for everyone. Not everyone wants to do homework. It’s still worthwhile to explore what’s holding them and what you can do differently. If it’s a pattern, then I think supervision can be extremely helpful. When I made that comment I knew you wouldn’t take it personally (unlike the few who got clearly triggered).

I did work at a VA. Though I’m curious what lead you to that question.

I'm not referring to patients showing direct resistance, I'm talking more about those who would likely have been classified as passive-dependent traits or what some may see as cluster C traits or even "laziness" or "apathy". I try and discuss goals of care openly and directly ask everyone what their specific goals of treatment are at every appointment and when discussing our plan I ask if they agree with the approach we're taking. My psychotherapy supervisors in residency all noted that I take a pretty Rogerian approach early on for patients with even decent insight as I agree that patients are going to buy into the methods far more when they believe they're working toward their own goals. I also try and get a strong sense of their level of insight early on so I know what they may actually be capable of doing. I get dismayed by the patients who appear to have decent insight, are agreeable with the plan they directed but then just don't follow through because...they forgot...or they got uncomfortable...or they wanted to do X/Y/Z instead and then continue to complain that nothing is changing.

I do utilize CBT, but mostly in the sense of exploring and understanding cognitive distortions and understanding why they are having automatic thoughts/feelings. Other than CBT-I, I only provide CBT-based homework to patients who say they want to be able to actively explore and PRACTICE their thought processes and reactions. I agree that assigning homework that a patient won't be engaged in or even do isn't helpful and I probably utilize basic behavioral activation more than true CBT.

The patients I'm referring to typically require quite a bit of holding, but never seem to move to the next phases of therapy, usually d/t lack of wanting to face discomfort and using avoidance or repression. As I mentioned, I feel like a lot of these patients have what would fall into Cluster C traits for most people who require a lot of encouragement and supportive therapy, but can be difficult to discern when you're providing support vs enabling dependency or reliance. Part of my current frustrations come from being in a consult clinic where my number of appointments with patients is more limited and realizing patients fall into this category where they need longer term therapy that I just don't have the time to do with them. But I also felt this way during residency with many patients (my panel at our academic clinic was somewhat notorious) who "wanted" treatment but were never seemed fully engaged.

 

[Stagg737]

I did work at a VA. Though I’m curious what lead you to that question.

Your comment earlier "The people who trained me had incentives for good patient outcomes. Keeping patients engaged in therapy and treatment, or have them commit to treatment and improve; rather than having disasters on their watch with poor outcomes and hospitalizations."

Sounds exactly like things I heard over and over from our VA in residency whenever they'd try and implement new policies that would inevitably lead to more work for us with minimal or no change in outcomes or patient status. For patients who are truly sick those programs can be great and there's a lot of CMHCs with ACT teams who do a lot of good. However, if there's a large percent of the group with personality issues then it can be a disaster. The VA I was at was like that and we saw a lot more abuse of the system by cluster B patients by trying to "keep them engaged". Ie, more frequent visits to the ER demanding a bed and certain classes of medications, behavioral outbursts on the unit and in clinic d/t knowing admins would force them to be allowed back, etc. Again, walking the line between support and enabling, which frankly shouldn't be difficult in those cases, but we all know many admin policies are either so general that they're problematic or so bureaucratic as to be useless (or both in the case of some VAs).

 

[PsyDr]

to the original question:

If cannabis is supposed to fix everything, then it’s all getting better.

 

[G Sheb]

Your comment earlier "The people who trained me had incentives for good patient outcomes. Keeping patients engaged in therapy and treatment, or have them commit to treatment and improve; rather than having disasters on their watch with poor outcomes and hospitalizations."

Sounds exactly like things I heard over and over from our VA in residency whenever they'd try and implement new policies that would inevitably lead to more work for us with minimal or no change in outcomes or patient status. For patients who are truly sick those programs can be great and there's a lot of CMHCs with ACT teams who do a lot of good. However, if there's a large percent of the group with personality issues then it can be a disaster. The VA I was at was like that and we saw a lot more abuse of the system by cluster B patients by trying to "keep them engaged". Ie, more frequent visits to the ER demanding a bed and certain classes of medications, behavioral outbursts on the unit and in clinic d/t knowing admins would force them to be allowed back, etc. Again, walking the line between support and enabling, which frankly shouldn't be difficult in those cases, but we all know many admin policies are either so general that they're problematic or so bureaucratic as to be useless (or both in the case of some VAs).

I think that's a weird take on engagement.
Engaging someone in treatment does not mean encouraging maladaptive or harmful behavior. That nonsense would not fly where I worked. It was a VA linked to a top 5 academic institution. You want to engage to steer them in what is actual treatment.
I definitely did have a roster of very high risk patients, usually with trauma history, a SMI, substance use and a hx of violence and SA. If I came in with the sort of attitude "I am only going to work as hard as they do", it would have meant patients hospitalized left and right, and likely multiple deaths. I had to work VERY hard for sure, and it was fulfilling work, and a good thing to know I did my best. The 'work hard as they do' thing has its place, and depends on the specific dynamic and case, but as a generalized mantra to apply to everyone? I think that's just bad care.

Regarding your difficulties with patients, I do think you could reconsider your approach. Some of this is frankly very common. Some patients like to relate like this; they complain, but it doesn't mean they are actually doing worse. Paradoxically, sometimes staying with them works, though certainly the countertransference can be strong and they come across as 'annoying'. I do think spelling out explicit goals isn't what everyone is looking for. This is where you could work around a bit with unconscious dynamics.

 

[smalltownpsych]

About the suicide thing, I’m talking about a patient who is engaged in treatment with me. Not the random patient that I would encounter in the ED or even on a short term inpatient unit. Sure I will try to do what I can but if patient does not engage in treatment, then I will still do what I can and I focus on my part in that. I fail at that one all the time and I continue to try to improve. I could easily focus on why the patient doesn’t follow through, but that is only useful in how it guides me to improve my treatment. I also look at increasing motivation for treatment as part of the treatment.

 

[Stagg737]

I definitely did have a roster of very high risk patients, usually with trauma history, a SMI, substance use and a hx of violence and SA. If I came in with the sort of attitude "I am only going to work as hard as they do", it would have meant patients hospitalized left and right, and likely multiple deaths. I had to work VERY hard for sure, and it was fulfilling work, and a good thing to know I did my best. The 'work hard as they do' thing has its place, and depends on the specific dynamic and case, but as a generalized mantra to apply to everyone? I think that's just bad care.

I mentioned excluding the group you're referring to from the "don't work harder than the patient" idea in a previous comment. For true SMI you often do have to work harder than them initially, especially if they're in a place where they lack the ability to develop insight at the time. Imo the "don't work harder than them" applies in more of a longer term relationship where they have or are very capable of developing insight but aren't doing their share of the work. As I said, my frustrations come from the amount of time it takes to realize the patient fits into that group and the subsequent distress from that realization.

 

[G Sheb]

I mentioned excluding the group you're referring to from the "don't work harder than the patient" idea in a previous comment. For true SMI you often do have to work harder than them initially, especially if they're in a place where they lack the ability to develop insight at the time. Imo the "don't work harder than them" applies in more of a longer term relationship where they have or are very capable of developing insight but aren't doing their share of the work. As I said, my frustrations come from the amount of time it takes to realize the patient fits into that group and the subsequent distress from that realization.

I agree in general. But a couple of points, when you get into these situations then I think it’s time to try something else. It means there is some kind of misalignment happening. Someone mentioned it means that goals are not aligned. That’s definitely true but sometimes goals are unstated and unconscious and some things can be missed from both the provider and patient side. Interpersonal stuff can be huge as well. I mean this is resistance and the challenge is to find why it’s happening and how you could address it. “Don’t work harder than them” does not mean drop the ball and let them go. If they are showing up to the appointments it certainly means they are getting something. You have to try to figure out what is the dynamic that is happening and that is impeding more progress. Problem solving and some of it is trial and error.

 

[randomdoc1]

Many people won't admit it, but they actually want a doctor who doesn't care and just prescribes them what they ask for.

Omg, same for therapy too! I know some find my approach tough. But sometimes I talk to psychologists about the infrequent case of a patient behaving inappropriately with staff and they kiss up to their psychologist—I’m like hey, looks like they just want a validation party and I don’t think they are a fit here or for therapy (at least at this time). They are clearly not executing changes. In those cases, I’m talking about people being verbally abusive, refusing to ever pay their copay/deductible rate. Some even flat out lied to their provider saying they paid or resorted to lying to staff to try to get back on the schedule despite multiple documented electronic threads of the conversations.

 

[smalltownpsych]

Omg, same for therapy too! I know some find my approach tough. But sometimes I talk to psychologists about the infrequent case of a patient behaving inappropriately with staff and they kiss up to their psychologist—I’m like hey, looks like they just want a validation party and I don’t think they are a fit here or for therapy (at least at this time). They are clearly not executing changes. In those cases, I’m talking about people being verbally abusive, refusing to ever pay their copay/deductible rate. Some even flat out lied to their provider saying they paid or resorted to lying to staff to try to get back on the schedule despite multiple documented electronic threads of the conversations.

The worst is when the toxic patient actually has the therapist feeling sorry for them because of how these people don’t understand them. Usually replicating unhealthy family dynamics from the patient and the therapist. Getting along with other people is one of my primary outcome measures so if they can’t then that is the patient’s problem, not the other people.

 

[randomdoc1]

The worst is when the toxic patient actually has the therapist feeling sorry for them because of how these people don’t understand them. Usually replicating unhealthy family dynamics from the patient and the therapist. Getting along with other people is one of my primary outcome measures so if they can’t then that is the patient’s problem, not the other people.

totally! Such a delicate line to walk as an employer. Because occasionally the staff splitting happens and sometimes the provider approaches me seeking disciplinary action on a staff member during incidences of manipulative behavior. So far, an effective middle ground I found was--why not cut out the middle man then? If you would like to continue to work with this patient then have the communication be clearly between just two parties so the transparency is completely there:
-provider manages the collection piece
-provider does the logistical communication of scheduling and cancellations

No more he said she said. I've done that with my own patients as well. One of two things always happens:
1.Patient owns up and changes
2.Patient or provider terminates.

I must say though, in my own experience of cases like these. The provider sees the behavior for what it is, and loses their overwhelming sympathy very fast because commonly patients try to repeat the same dynamic and come up with excuses and/or get evasive.
Problem solved LOL.

 

[romanticscience]

Omg, same for therapy too! I know some find my approach tough. But sometimes I talk to psychologists about the infrequent case of a patient behaving inappropriately with staff and they kiss up to their psychologist—I’m like hey, looks like they just want a validation party and I don’t think they are a fit here or for therapy (at least at this time). They are clearly not executing changes. In those cases, I’m talking about people being verbally abusive, refusing to ever pay their copay/deductible rate. Some even flat out lied to their provider saying they paid or resorted to lying to staff to try to get back on the schedule despite multiple documented electronic threads of the conversations.

I've found a pragmatic way of dealing with this is to use a therapeutic double bind. The term was used in the hypnosis literature by Milton Erickson, though I've seen a similar strategy used by Gunderson in his GPM model.

In GPM, you first start out by saying, "We'll continue this treatment as long as you're changing for the better; you wouldn't want to be seeing a provider and not getting better, amirte?"

Erickson would sometimes give his patients ordeals which essentially amounted to a task that he knew was impossible (e.g., how about you go climb to the top of that mountain before your next appointment?) and therefore allowed the patient to save face. There is very interesting literature on how hypnosis has been applied to factitious disorders to "resolve" the conflict. Another example, off the top of my head, was a case of factitious paralysis. The doctors told the person that they would apply electricity to the arm in a graded/increasing fashion week to week to "re-grow the nerves." They reassured the patient that since the arm was paralyzed, they wouldn't feel it. I think every patient re-gained their sensation after 1-day!

These take some creativity to create, but it is doable. I remember another study; patients with a supposed conversion weakness were told to do a 1-month of physical therapy. They were then told that if the symptoms persisted after 1-month, then the diagnosis was psychosomatic; however, if they got better, the symptoms most certainly were due to organic causes

This is why I like being a generalist (and also why I don't like doing TFP anymore). I have this built-in out for these kinds of patients. I can just shrug and be like, "Well, I think we need to refer you to see a specialist for K/TMS/ECT/TFP/DBT." It's another reason why I'm hesitant to get into ketamine; if you look at the practice patterns, these patients have been in treatment for like 10 years and have like 6 diagnoses.

 

[Stagg737]

Erickson would give his patients ordeals which essentially amounted to a task that he knew was impossible (e.g., how about you go climb to the top of that mountain before your next appointment?) and therefore allowed the patient to save face

Can you elaborate on that? I'm not sure what you mean by giving them an impossible task would help them save face.

 

[romanticscience]

Can you elaborate on that? I'm not sure what you mean by giving them an impossible task would help them save face.

For people who consciously don't want to get better (factitious?) or are malingering, you avoid that conversation and make it about their ambivalence about climbing, not calling them out on their dishonesty.

Usually, ordeals are meant to be therapeutically meaningful; in this case, you'd find an ordeal that was a little too hard as a way to end the relationship or pause the therapy. Ethics are dicey, I know, lol. Some of the guy's ideas are contentious!

 

[randomdoc1]

For people who consciously don't want to get better or are malingering, you avoid that conversation and make it about their ambivalence about climbing, not calling them out on their dishonesty.

Usually, ordeals are meant to be therapeutically meaningful; in this case, you'd find an ordeal that was a little too hard as a way to end the relationship or pause the therapy. Ethics are dicey, I know, lol

I love to have fun. Makes me think of House MD.

 

[tr]

For people who consciously don't want to get better (factitious?) or are malingering, you avoid that conversation and make it about their ambivalence about climbing, not calling them out on their dishonesty.

Usually, ordeals are meant to be therapeutically meaningful; in this case, you'd find an ordeal that was a little too hard as a way to end the relationship or pause the therapy. Ethics are dicey, I know, lol. Some of the guy's ideas are contentious!

Why would you *not* want to have that conversation? I would think that would be the only way to identify a productive path forward.

Otherwise, if there is an underlying motivation for the patient not to get better that you never address directly, you can keep meeting with them forever and make not an iota of progress.

 

[romanticscience]

I should clarify that I'd use this strategy (avoiding the conversation) only in the rare instances of malingering or factitious disorder. I don't expect the treatment to continue, and this would be an out for both of us.

This is really cool paper describing the use of hypnosis in (what seems to be) factitious disorder. The guy was videotaped using his hand outside of therapy and was confronted; it didn't go well.


Because of the compensation issues involved, the patient had been secretly filmed, and evidence was cited in the psychiatric records of his apparently making some use of the left hand. One psychiatrist, having viewed the film, told the patient he was a malingerer. This enraged the patient, who considered the accusation an attack on his integrity.

Maybe Kernberg would go down that road of negative transference, but I've become too chicken! Analyzing this stuff sounds cool in theory but doesn't fit well with a high-volume solo private practice.

 

[G Sheb]

I should clarify that I'd use this strategy (avoiding the conversation) only in the rare instances of malingering or factitious disorder. I don't expect the treatment to continue, and this would be an out for both of us.

This is really cool paper describing the use of hypnosis in (what seems to be) factitious disorder. The guy was videotaped using his hand outside of therapy and was confronted; it didn't go well.


Because of the compensation issues involved, the patient had been secretly filmed, and evidence was cited in the psychiatric records of his apparently making some use of the left hand. One psychiatrist, having viewed the film, told the patient he was a malingerer. This enraged the patient, who considered the accusation an attack on his integrity.

Maybe Kernberg would go down that road of negative transference, but I've become too chicken! Analyzing this stuff sounds cool in theory but doesn't fit well with a high-volume solo private practice.

You could technically set 'gentle' limits without confronting them. I'm not sure if that is different from the 'ordeal' you described. I'd be curious if you have any particular example.
Certainly in the ER, I've found that a mixture of validation, while setting some limits ("I'm not sure inpatent is the right setting, I think outpatient is where the care can be best delivered.etc") seems to disarm some of the malingerers, and they 'reluctantly' give up and agree. Yes, even those malingering benefit from some validation and compassion. (I could still see the hint of resentment, but hey you're out, and I'm moving on).
I agree in general, confrontation does not work, and this is where most of the disasters with malingerers happen.
I'm not a huge fan of the Kernberg approach. It's certainly useful in some instances ('neutrality', calling it like you see it..etc with personality disorder) but imo that group takes it ideologically to the extreme. Kernberg is rooted in the classical, Freudian psychoanalysis. Relationists would take an entirely different twist on it.

 

[Attending1985]

This post hit home with me today. My first day back after a two week vacation and I’m feeling gloomy. Maybe a sleep medicine fellowship. That area seems so easy and stress free and the pay is good.

 

[Sushirolls]

This post hit home with me today. My first day back after a two week vacation and I’m feeling gloomy. Maybe a sleep medicine fellowship. That area seems so easy and stress free and the pay is good.

Except **Sleep Studies**
Reading those squiggly lines is so dang boring.
People don't prioritize Sleep. They won't follow up often.
Insurance auths are a pain, but you get into system with that and PA submissions by an MA.
Insomnia "I can't sleep!!!" and will you just shell out ambien, or actually do your own CBTi?
I know one sleep doc who got laid off during Covid, and then got replaced by mid-level.
The structure really is turning into 1 Doc to over see the midlevels.
PCPs and Psych are horrible are referring to Sleep Medicine. No amount of education or lunch chats will fix that.
Dentists are spamming the air waves with Oral Appliance and practically toting themselves as sleep doctors... They will use these third party Sleep Study for hire guns, who read studies from home for pennies on the dollar.
Everything isn't rosy in Sleep Medicine.
BUT if you like OSA, and like reading sleep studies, make that leap. If I did, I would have.

 

[Attending1985]

Except **Sleep Studies**
Reading those squiggly lines is so dang boring.
People don't prioritize Sleep. They won't follow up often.
Insurance auths are a pain, but you get into system with that and PA submissions by an MA.
Insomnia "I can't sleep!!!" and will you just shell out ambien, or actually do your own CBTi?
I know one sleep doc who got laid off during Covid, and then got replaced by mid-level.
The structure really is turning into 1 Doc to over see the midlevels.
PCPs and Psych are horrible are referring to Sleep Medicine. No amount of education or lunch chats will fix that.
Dentists are spamming the air waves with Oral Appliance and practically toting themselves as sleep doctors... They will use these third party Sleep Study for hire guns, who read studies from home for pennies on the dollar.
Everything isn't rosy in Sleep Medicine.
BUT if you like OSA, and like reading sleep studies, make that leap. If I did, I would have.

I’m not sure I like either. It’s just appealing to think about a low liability, low stress specialty that pays well. Although from an outsiders view it seems sleep could just be performed by RNs using a checklist.

 

[Sushirolls]

I’m not sure I like either. It’s just appealing to think about a low liability, low stress specialty that pays well. Although from an outsiders view it seems sleep could just be performed by RNs using a checklist.

Dig into the specialty more. Same as most, there is a reason why it's a one year fellowship.

 

[Coupd'Cat]

I have now had two pseudo seizure patients be intubated because the hospital has liability concerns when they have more dramatic presentations and are unwilling to get behind the idea that the patients symptoms are psychogenic.

What the hell!!!!