Losing your cool with a patient

[texanpsychdoc]

I am curious to see if there are folks here who have found themselves frustrated with the patients in which you lost their cool during the session. I will admit, that working with folks that have personality disorders is a challenge, and that is my weakness.

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[ThatPsyGuy]

During an internship at a SUD recovery center, I was working with a court-mandated client. They learned that they had to continue into a transitional/sober living home instead of being able to go home. This obviously didn't go over well with them and they started directing their aggression toward me by cursing, yelling, and tossing over some of my desk objects (not violently, but just being an ass).

Unfortunately, this day I didn't get much sleep, a few clients had left the facility, and I was juggling a lot of projects. I found myself getting caught up in their anger, getting curt and frustrated. Luckily I caught on that I was getting elevated after I started raising my voice. I hit them with the "I feel that we're not reaching each other at the moment and that we probably need a moment to process how we're feeling right now," then went to my supervisor to vent.

I admire the people who specialize in and work with SUD populations. Takes a lot of patience.

 

[smalltownpsych]

No. I have raised my voice intentionally at times when it is appropriate and sometimes with substance abusers it completely is. Got to be louder than the voice in your head that is trying to f’ing kill you. Now if I’m dealing with more antisocial types, I will intentionally stay even more cool. They want to get under your skin as a manipulation tactic, can’t let them win and so I give them nothing. Other patients will intentionally try to push your buttons, which is a typical game for 12 year olds as they test limits and build skills so that tells you where the patient is at. When I see that I tend to take a mental step back. I usually call attention to it and try to explore why. “It seems as though you are trying to upset me or get under my skin for some reason“. Their response to this will tell me a lot. The closest I do come to losing my cool is actually with parents, but have so far kept it in check.

Really the only person that can really get me to lose my cool is my wife and vice versa, but I am thinking that is pretty normal for being together since I was going to night classes to finish my general education requirements at the local community college with a crazy dream of being a psychologist one day. She actually believed it would happen. Not real rational on her part, and I would never advise a young person to believe a line of crap like that, but…😁

 

[BuckeyeLove]

Now if I’m dealing with more antisocial types, I will intentionally stay even more cool

This 100000000% You've gotta play chess.

 

[cara susanna]

I once "snapped" with a patient and said something very irreverent that led to the patient walking out and refusing to ever see me again. This was a patient who basically came in and vented about the same things over and over, but then refused to do any actual work. I do wish that I'd handled it differently.

 

[smalltownpsych]

I once "snapped" with a patient and said something very irreverent that led to the patient walking out and refusing to ever see me again. This was a patient who basically came in and vented about the same things over and over, but then refused to do any actual work. I do wish that I'd handled it differently.

I may have done this one a time or two. 😉 Just tells me I have to work at setting the limits earlier so that the patient realizes they don’t want to see me earlier in the process. Saves me a lot of frustration. I usually explain how venting doesn’t help the moment they start it. Just because no one else in your life will listen to your crap doesn’t mean I’m going to. if they want to change that pattern, great, if not, they will find a different therapist. Plenty of supportive therapists out there who will spend years supporting maladaptive patterns.

 

[cara susanna]

I may have done this one a time or two. 😉 Just tells me I have to work at setting the limits earlier so that the patient realizes they don’t want to see me earlier in the process. Saves me a lot of frustration. I usually explain how venting doesn’t help the moment they start it. Just because no one else in your life will listen to your crap doesn’t mean I’m going to. if they want to change that pattern, great, if not, they will find a different therapist. Plenty of supportive therapists out there who will spend years supporting maladaptive patterns.

Since I'm in the VA I felt like I had limited options with this patient, but I wish I'd talked to my supervisor/treatment team about the issue and basically had the "this isn't therapy and we have to be doing therapy, otherwise we have to discharge" talk.

That's why I say that legacy/supportive patients burn me out the most. Give me someone with BPD or tons of trauma, as long as they're actually doing some work, any day.

 

[smalltownpsych]

Since I'm in the VA I felt like I had limited options with this patient, but I wish I'd talked to my supervisor/treatment team about the issue and basically had the "this isn't therapy and we have to be doing therapy, otherwise we have to discharge" talk.

That's why I say that legacy/supportive patients burn me out the most. Give me someone with BPD or tons of trauma, as long as they're actually doing some work, any day.

100% agree with this sentiment. Even when long term supportive therapy is indicated for a stable patient with a chronic illness, it bores me. When it is part of a long-standing unhealthy pattern and they have no desire to change it and it’s been played out with other therapists, 🤮

 

[texanpsychdoc]

100% agree with this sentiment. Even when long term supportive therapy is indicated for a stable patient with a chronic illness, it bores me. When it is part of a long-standing unhealthy pattern and they have no desire to change it and it’s been played out with other therapists, 🤮

Yeah, in BHIP, I am working with everything, including a lot of co-morbid PD and SMI. It gets rough with a very select few patients I have. Not sure I want to continue doing therapy with PD folks or not. I find them intellectually intriguing, but just not sure if I want to spend my time treating them.

 

[Sanman]

100% agree with this sentiment. Even when long term supportive therapy is indicated for a stable patient with a chronic illness, it bores me. When it is part of a long-standing unhealthy pattern and they have no desire to change it and it’s been played out with other therapists, 🤮

I have a few of these and while the work can be frustrating, it is important to take a long term view. Without regular support, all these clients eventually backslid into SI or frequent crisis intervention. With regular treatment, I have helped them to maintain stability and slowly chiseled away at making gains. Over years of treatment, they have made progress, but it is slowwww.

 

[smalltownpsych]

I have a few of these and while the work can be frustrating, it is important to take a long term view. Without regular support, all these clients eventually backslid into SI or frequent crisis intervention. With regular treatment, I have helped them to maintain stability and slowly chiseled away at making gains. Over years of treatment, they have made progress, but it is slowwww.

I have worked with them as well and over time the progress is made and I can look back at them with some satisfaction. However, I still remember well how relieved I was to not have to see them anymore when I changed jobs. It just isn’t the kind of work I enjoy. I think other clinicians are better suited for that kind of work.

A similar example is a high functioning patient with relatively normal grief issues that I saw not too long ago. I don’t think I did a very good job because I was sort of like, “you’re fine, why are you here and I don’t know what to do or say other than provide standard emotional support that your supportive network is probably doing as well or better than me”. It wasn’t my intent, but it just isn’t my strong point. Meanwhile, chronic suicidality, self harm, turbulent interpersonal relationships and very few clinicians could help or would even want to and I’m like, “glad you’re here this will be hard but I can help. Let’s dig in.”

One challenge of providing psychotherapy is that it is hard to limit ourselves to clients that we are most effective with. Some of that is because even though I have a good idea of diagnoses that I tend to work well with, there are also personality traits or styles and many other variables at play so I can’t really predict what I can help with or not. I have had good success with some high functioning anxious types of patients and BPD patients where it just didn’t work. One thing I enjoyed about working in a residential program was the ability to mix and match therapist to client better and we even had a built in therapist change from one phase of program to another. That last part was brilliant although most people would meet that with initial resistance.

 

[PsychPhDone]

I am curious to see if there are folks here who have found themselves frustrated with the patients in which you lost their cool during the session. I will admit, that working with folks that have personality disorders is a challenge, and that is my weakness.

I raised my voice once when a patient started getting increasingly agitated and was on his way to saying things I'd have to report that I was pretty sure he didn't mean. I made the choice to shout so maybe it wasn't just out of frustration but it's the only time I've done that in session before. We discussed it later when he was calm and he agreed it was the right course of action given that he wasn't responding to anything else but I still dislike that it happened.

 

[texanpsychdoc]

I raised my voice once when a patient started getting increasingly agitated and was on his way to saying things I'd have to report that I was pretty sure he didn't mean. I made the choice to shout so maybe it wasn't just out of frustration but it's the only time I've done that in session before. We discussed it later when he was

I think comparatively, I probably have done worse. I got caught up in their crap and responded in a manner that just fed into their delusional thinking. In hindsight I know it was not the best approach and did not help. I wish I had that insight in the moment to help me make a better decision.

 

[smalltownpsych]

I think comparatively, I probably have done worse. I got caught up in their crap and responded in a manner that just fed into their delusional thinking. In hindsight I know it was not the best approach and did not help. I wish I had that insight in the moment to help me make a better decision.

its all a learning process. My biggest mistakes tend to come out of overconfidence or lack of preparation. I’m pretty good at winging it and coming up with the right plans on the fly so sometimes I’ll rely on that and at times it has gotten me into trouble. I always do better when i’m prepared, reviewed the record, spoke to collateral, came up with initial treatment plan, etc.

 

[PsychedOut2291]

I am curious to see if there are folks here who have found themselves frustrated with the patients in which you lost their cool during the session. I will admit, that working with folks that have personality disorders is a challenge, and that is my weakness.

I don’t think I’ve necessarily lost my cool with patients but rather lost my energy due to the high level of attention that some needed. In most cases, patients with personality disorders tend to be very emotionally demanding and often require a great deal of investment. Nonetheless, such patients have provided some of the most rewarding clinical experiences throughout my career. So, I’ve never really lost my cool with any patient but at times, lost some of myself as a result of the intensive nature of the therapeutic relationship with personality disordered patients. To be honest, I would totally go through the experience with each of these challenging and rewarding cases again in a heartbeat!

 

[Mojito_15]

Itty bitties who cannot be reasoned with, with parents/teachers who don't want to follow through on ABA or even just consistent expectations, are by far my biggest weakness. I have 0 interest in working with that population ever again.

 

[texanpsychdoc]

Itty bitties who cannot be reasoned with, with parents/teachers who don't want to follow through on ABA or even just consistent expectations, are by far my biggest weakness. I have 0 interest in working with that population ever again.

Indeed - that is why the very brief child/teen stuff I did in my one of my first practica, I was like "nope, never again - aint nobody want to deal with Karens all day "

 

[cara susanna]

I have a few of these and while the work can be frustrating, it is important to take a long term view. Without regular support, all these clients eventually backslid into SI or frequent crisis intervention. With regular treatment, I have helped them to maintain stability and slowly chiseled away at making gains. Over years of treatment, they have made progress, but it is slowwww.

For sure, the problem is that the VA expects us to be doing active treatment with patients and discharging them at some point, including always taking new patients, while not actually giving us clear ways of cutting off treatment. Either the VA needs to have something in place where we can do supportive therapy (or designate providers who can), or let us unilaterally discontinue therapy.

 

[PikminOC]

For sure, the problem is that the VA expects us to be doing active treatment with patients and discharging them at some point, including always taking new patients, while not actually giving us clear ways of cutting off treatment. Either the VA needs to have something in place where we can do supportive therapy (or designate providers who can), or let us unilaterally discontinue therapy.

It's the government. That's never going to happen

 

[PsychedOut2291]

It's the government. That's never going to happen

It seems that the VA is really encouraging short-term, evidence-based psychotherapy. I completed my internship at a small VA hospital with very few mental health providers and a large demand for services. Everyone was really clear about conducting short-term therapy and supporting the patient’s independence and autonomy. That being said, I was able to provide long-term psychotherapy for some patients who needed it.

Some of the best clinical experiences that I have had were long-term therapy cases. However, they were both intensive and emotionally demanding. Termination of therapy after several months was extremely hard. I sense maybe some providers don’t want to offer that due to the amount of time and energy.

I recognize both views. On one end, it’s just not feasible to provide long-term psychotherapy given the dearth of providers and increased need for services. There’s also concern about fostering dependence, whereby a client uses the therapeutic relationship to meet a social need. On the other end, there are some people who struggle with several chronic mental health issues such as personality disorders, which can interfere with responsiveness to intervention efforts. As such, long-term therapy is needed in order to address issues such as interpersonal problems, mood disturbances, and trauma, among others. Of course, the patient preferences need to be considered. I wish there were some sort of happy medium but unfortunately, it doesn’t seem like that’s the case right now.

 

[borne_before]

I once dropped the F-bomb when a very coddled ten year old with a barf phobia wouldn't even say the word during an exposure. I said "c'mon dude, it's just freaking word." Two days later mom sent me an email admonishing me for that.

 

[MiniLop]

I once dropped the F-bomb when a very coddled ten year old with a barf phobia wouldn't even say the word during an exposure. I said "c'mon dude, it's just freaking word." Two days later mom sent me an email admonishing me for that.

Yeah, I think the closest I've come to losing my cool with a patient was actually with the overaccomodating parents of a yeen anxiety case who were trying to micromanage therapy. I basically suggested that they fire me. And they did!

 

[borne_before]

Yeah, I think the closest I've come to losing my cool with a patient was actually with the overaccomodating parents of a yeen anxiety case who were trying to micromanage therapy. I basically suggested that they fire me. And they did!

I mean, I tell parents and patients when I'm frustrated like all the time. Usually they are too.

"I'm feeling stuck and frustrated because of (lack of follow through/engagement/this ain't jiffy lube for kids/too much accomodaiton even though we have talked about that)."

 

[throwaway_psychdr]

I somewhat recently lost my cool with a patient who was being rather unreasonable. On any other day, i would have let it roll off my back, but it got to me that day. It was a signal to how high my burnout had gotten and sort of represented a parallel process to something going on in my personal life that I needed to deal with. As others have stated, it's a learning experience. We’re human and our jobs are interpersonal in nature- we’re not going to handle every interaction perfectly. Important to do some good self-reflection if you experience something like this.
(Edited to remove unnecessary detail)

For sure, the problem is that the VA expects us to be doing active treatment with patients and discharging them at some point, including always taking new patients, while not actually giving us clear ways of cutting off treatment. Either the VA needs to have something in place where we can do supportive therapy (or designate providers who can), or let us unilaterally discontinue therapy.

So much this. Sure maybe after 2 years hearing a patient vent you can find some in-roads, but is it really the therapy that's helping them get there or is it just time? Is this a good use of limited, skilled resources? When there are people who are ready to change and are having to wait because therapists are backlogged with a bunch supportive therapy cases, maybe it's time to draw some clear boundaries.

It seems that the VA is really encouraging short-term, evidence-based psychotherapy. I completed my internship at a small VA hospital with very few mental health providers and a large demand for services. Everyone was really clear about conducting short-term therapy and supporting the patient’s independence and autonomy. That being said, I was able to provide long-term psychotherapy for some patients who needed it.

I mean the VA says a lot of things, but then there's political/social pressure to bend the boundaries- that's the problem. Good that your VA was able to stick to short-term therapy but I think a lot of systems struggle to do that. Also depends on what clinic/area you work in.

 

[MiniLop]

I mean, I tell parents and patients when I'm frustrated like all the time. Usually they are too.

"I'm feeling stuck and frustrated because of (lack of follow through/engagement/this ain't jiffy lube for kids/too much accomodaiton even though we have talked about that)."

That's more or less what I said. They didn't like it. I said something to the extent of "I am treating your kid with a treatment approach consistent with the current body of research on interventions for anxiety. If you are unsatisfied, I am happy to provide you with referrals." And that's what happened.

 

[Sanman]

For sure, the problem is that the VA expects us to be doing active treatment with patients and discharging them at some point, including always taking new patients, while not actually giving us clear ways of cutting off treatment. Either the VA needs to have something in place where we can do supportive therapy (or designate providers who can), or let us unilaterally discontinue therapy.

It seems that the VA is really encouraging short-term, evidence-based psychotherapy. I completed my internship at a small VA hospital with very few mental health providers and a large demand for services. Everyone was really clear about conducting short-term therapy and supporting the patient’s independence and autonomy. That being said, I was able to provide long-term psychotherapy for some patients who needed it.

Some of the best clinical experiences that I have had were long-term therapy cases. However, they were both intensive and emotionally demanding. Termination of therapy after several months was extremely hard. I sense maybe some providers don’t want to offer that due to the amount of time and energy.

I recognize both views. On one end, it’s just not feasible to provide long-term psychotherapy given the dearth of providers and increased need for services. There’s also concern about fostering dependence, whereby a client uses the therapeutic relationship to meet a social need. On the other end, there are some people who struggle with several chronic mental health issues such as personality disorders, which can interfere with responsiveness to intervention efforts. As such, long-term therapy is needed in order to address issues such as interpersonal problems, mood disturbances, and trauma, among others. Of course, the patient preferences need to be considered. I wish there were some sort of happy medium but unfortunately, it doesn’t seem like that’s the case right now.

Well yes and no about the VA encouraging short-term evidence based therapy. They talk a good game. The reality is not so. In reality, PC-MHI, HBPC, etc folks are supposed to provide short-term EBPs and transfer veterans to other services for more severe long-term in depth services. However, they have no plan for when these services become full, when they are not available in a geographic area, or when veterans refuse these more comprehensive services. As a member of a primary care team for these people, I end up doing a lot of supportive therapy with them to keep them out of crisis because it is my liability if anything happens to them if they have no other place to go. This impacts other folks ability to receive short-term services and so we go round and round. I am lucky enough that I service a low census rural area so I can keep these people on my roster and it keeps my numbers full. Those with high volume clinics are stuck between a rock and a hard place. If you treated them, you are responsible for follow-up until someone else takes over. That may not happen for months to years in some cases. This is how you lose your cool with the VA (and hopefully not a patient).

 

[PsychedOut2291]

Well yes and no about the VA encouraging short-term evidence based therapy. They talk a good game. The reality is not so. In reality, PC-MHI, HBPC, etc folks are supposed to provide short-term EBPs and transfer veterans to other services for more severe long-term in depth services. However, they have no plan for when these services become full, when they are not available in a geographic area, or when veterans refuse these more comprehensive services. As a member of a primary care team for these people, I end up doing a lot of supportive therapy with them to keep them out of crisis because it is my liability if anything happens to them if they have no other place to go. This impacts other folks ability to receive short-term services and so we go round and round. I am lucky enough that I service a low census rural area so I can keep these people on my roster and it keeps my numbers full. Those with high volume clinics are stuck between a rock and a hard place. If you treated them, you are responsible for follow-up until someone else takes over. That may not happen for months to years in some cases. This is how you lose your cool with the VA (and hopefully not a patient).

I agree with what you are saying. In VA hospitals within rural areas, they have been encouraging short-term EBPs as this approach ensures that they are being more efficient with their services and providing adequate care to the veterans.

 

[Mojito_15]

Indeed - that is why the very brief child/teen stuff I did in my one of my first practica, I was like "nope, never again - aint nobody want to deal with Karens all day "

I actually work almost exclusively with teens in my current job, once the kid can be reasoned with, we're good to go. Much like with adults, either they're going to change their behaviors, or they quit showing up. But I do not enjoy the under 12 crowd.

 

[texanpsychdoc]

Yeah, I think the closest I've come to losing my cool with a patient was actually with the overaccomodating parents of a yeen anxiety case who were trying to micromanage therapy. I basically suggested that they fire me. And they did!

I actually told my patient the other day that I was referencing in my original post, "you can't bully your way through therapy."

 

[Dr.Snowyplover601]

This 100000000% You've gotta play chess.

Second this. It's the way. Particularly when you get that sideways glance after an outburst like " oooh am I gonna get a reaction?"

 

[deuce22]

I am curious to see if there are folks here who have found themselves frustrated with the patients in which you lost their cool during the session. I will admit, that working with folks that have personality disorders is a challenge, and that is my weakness.

I have nothing to add that has not been already stated. But - and don't know if it is just me having this reaction - ever since this thread started, the discomfort I feel when scanning the forum and then reading 'you' instead of 'your' in the thread title is palpable. I want to make a formal plug for the simple edit to stop this madness once and for all.

Please. I'm begging you. I just want to resume lurking without my eyeballs feeling assaulted every time I log in (half serious).

 

[WisNeuro]

I have nothing to add that has not been already stated. But - and don't know if it is just me having this reaction - ever since this thread started, the discomfort I feel when scanning the forum and then reading 'you' instead of 'your' in the thread title is palpable. I want to make a formal plug for the simple edit to stop this madness once and for all.

Please. I'm begging you. I just want to resume lurking without my eyeballs feeling assaulted every time I log in (half serious).

I thought that I was the only one this bothered to an almost irrational degree.

 

[texanpsychdoc]

I have nothing to add that has not been already stated. But - and don't know if it is just me having this reaction - ever since this thread started, the discomfort I feel when scanning the forum and then reading 'you' instead of 'your' in the thread title is palpable. I want to make a formal plug for the simple edit to stop this madness once and for all.

Please. I'm begging you. I just want to resume lurking without my eyeballs feeling assaulted every time I log in (half serious).

LOL Oh my goodness...complete lapse of attention to detail on my end. You are so right. Darn, that is annoying isn't it? I just edited it! Thanks for the heads up.

 

[PsyDr]

I don’t think I’ve ever lost my cool with a patient. The neat thing about personality is that it is an enduring pattern. They are who they are, and they are going to behave in a certain way. Once those conversational parameters are established, the interview is pretty nice.

But I do pretend to be playfully frustrated with some patients, when appropriate. Because the longest longitudinal study of defense mechanisms said that humor is one of the most mature defense mechanisms. And they measured a president’s testicles, so you know it’s funny.

 

[smalltownpsych]

I thought that I was the only one this bothered to an almost irrational degree.

No it bothered me too. I have to fight the urge to correct others grammar and editing mistakes. The only thing worse for me than seeing another’s error is when I see one of my own as I reread a post. I get more these days than I did back in the day because most of the time now I’m using thumbs on an iPad.

 

[deuce22]

LOL Oh my goodness...complete lapse of attention to detail on my end. You are so right. Darn, that is annoying isn't it? I just edited it! Thanks for the heads up.

There is an argument to be made that you've just reinforced avoidance behavior but I'm really glad you did.

 

[texanpsychdoc]

There is an argument to be made that you've just reinforced avoidance behavior but I'm really glad you did.

Perhaps right...I resolved the angst by correcting my error. But did I do so because I have a pathological inclination in struggling with angst and personal "defects?" A good question indeed

 

[MiniLop]

There is an argument to be made that you've just reinforced avoidance behavior but I'm really glad you did.

Every time I see a therapist make a typo here or on one of the various professional FB groups I'm in, I assume they're doing it as a perfectionism and/or social anxiety exposure.

 

[smalltownpsych]

Every time I see a therapist make a typo here or on one of the various professional FB groups I'm in, I assume they're doing it as a perfectionism and/or social anxiety exposure.

That’s what I tell my patients when I screw up too! 😆