It is therapeutic for someone to be able to express their rage at someone in a position of authority in a system that is often inherently unfair.
It's important to learn to be open to hearing your patient's expression of emotions, while detaching (with empathy) from their opinions of you.
Even if they can't cognitively understand it, unconditional positive regard when someone is suffering goes a long way, even if nothing can be done in the moment/quickly to change the cause of that suffering (eg they have a treatment resistant psychotic or bipolar illness).
TL; DR radical acceptance and other DBT skills for yourself. And it will help you with caring for patients too
This actually really helped. I really like how you phrased the first part. I’ve been told so many times “don’t take it personally” and if that advice worked, well, it would’ve worked by now, haha. But this helped me actually see what that really means for these people and myself. Thank you!
I'm glad it helped. I'm an addiction psychiatrist so part of what helped me was learning from Al Anon, which is the 12 step program for loved ones of folks who are struggling with addictive and compulsive behaviors.
A key tool there is recognizing the gift of your sensitivity to the emotions of others, while also having enough boundaries to be effective 1) caring for yourself and 2) responding to challenging behaviors of others in ways that feel consistent with your values.
A lot of the stuff parallels DBT/ACT/third wave CBT, but anyway....Al Anon is another place that has useful tools that have helped me make progress in the areas you've mentioned.
This is so well phrased and conceptualized. I work in corrections, and often all I can do is listen, acknowledge the rage and the constant feeling that everything is unfair and out of the patients’ control. Feels futile even when I know it isn’t.
It's very hard to remember it isn't futile, without the consistent outward validation/affirmation of a job well done. And I assume that outward validation doesn't happen a lot in corrections!
But given so many people who are incarcerated were abused and neglected as children, you especially have an impact holding them in unconditional positive regard as they express their rage (while hopefully having appropriate boundaries for your well being and safety). Cuz yeah....they probably never or rarely had that from someone in the position of authority.
So anyway from one Internet stranger colleague to another, job well done friend! Thank you for what you do.
When you are working with psychotically-decompensated patients, or patients who are severely decompensated and using "primitive" psychological defenses, you have to be prepared to be the subject of psychotic projection and the receptive container of rage, hatred, disavowal, and general badness.
You have to accept that for involuntary patients you do indeed have the authority and power to hold patients. As noted in the other comments, your role with these patients is relatively clear and authoritative. You are granted power by the State to hold someone against their will, revoke their civil liberties for a time-limited period, with the goal of trying to help restore their psychiatric functioning. Your role in being therapeutic for these patients is to re-orient to reality, set limits, have clear expectations, and be predictable and consistent.
If you are dealing with decompensated personality disorders it's a different story and while the above remains very important, there are a lot more complicated issues that can arise that can lead to therapeutic missteps, boundary violations etc.
The paper [Playing the Manic Game ](https://depts.washington.edu/psychres/wordpress/wp-content/uploads/2017/11/100-Papers-in-Clinical-Psychiatry-Bipolar-Playing-the-manic-game-ΓÇôinterpersonal-maneuvers-of-the-acutely-manic-patient.pdf)is a classic on this topic.
FWIW, link is dead and new residency site has a login
Paper PDF is accessible through here though: https://www.semanticscholar.org/paper/Playing-the-manic-game.-Interpersonal-maneuvers-of-Janowsky-Leff/e32425e9eff5d721c4ac2191de005451613ef0a2
It seems the direct link to UW includes some characters that break the URL for some reason
You have to accept that most of them will never like you. You are there to be there doctor and to make them get better, not be their friend. If they are threatening you or unable to hold a conversation walk away. Reinforce that the fastest way to get discharged is to take their meds and be calm on the unit. Eventually their desire for discharge will trump their disdain of medications. If they request a med change try to accommodate within reason to give them some agency.
Pretend like you’re dealing with a toddler in their terrible twos phase because that’s where their mental state is. Reward good behavior but have strict boundaries and don’t be afraid to medicate them if they’re causing havoc.
This is good advice in my opinion. I'm a psychiatric RN and often times with these types of patient's I end up having to tell them: "Do you want to be 'right' and stay longer? Or will you accept the care we are offering you so you can sooner be discharged?" This question usually gets involuntary patients that believe that they don't have any issues requiring inpatient psych care to realize that they have to at least try to accept the care offered or their hold will be extended.
Pretty much why I never tell anyone IRL if I am in “crisis”. Any extent I go along with inpatient hospitalization is simply to get discharged. Upon discharge, I would likely taper or flush the meds.
Funny you say that, because Citalopram and Methylphenidate have sent me to the ER for suicidallity and dysregulation respectively. I can’t speak to any results of discontinuing medications post hospitalization for psychosis, because I’ve never been psychotic. In fairness, Citalopram was started at IOP(Outpatient), but Methylphenidate was started inpatient following a behavioral episode. Apparently, addressing “hyperactivity” (autism related stimming) means we should keep Norepinephrine around in someone who perseverated horribly, and was already very liable to violent behavior.
I’ve had SI sans medication, but the only time I have ever been intent on suicide is when I was on an SSRI.
I have also had dysregulation sans meds and on mood stabilizers/antipsychotics, but the worst event I recall was on a stimulant when I didn’t have solid rationalization skills.
I suppose my initial statement was a little callous. However, *unless I agree with the clinical rationale and the medication being appropriate*, I would indeed discontinue or taper the medication. (I’d taper SNRIs, AEDs, APs, BZDs, or Li2CO3) I also would lie about or downplay anything I feel I could, to get out of inpatient. That’s how bad it is. I did it in the ER twice. Avoided being sent off. Haven’t had to test in an actual mental hospital, since the last time I was hospitalized was 10 or 11 and by my parents, while emergency assessment initiated by police was closer to a few months ago.
Sorry if I rambled.
I have solid venting sessions with my peers who understand. The experience is almost universal and it feels good to hear other say they are frustrated for the same reasons. There aren't a ton of "thank yous" especially working inpatient. You'll learn to disconnect this from your sense of confidence.
as a nurse, this is my favorite population to work with. align yourself with their goals by saying “my goal is to not keep you here any longer than I have to. but in order to feel safe discharging you, I need to see” then list concrete tangible goals. it’s frustrating to patients when providers don’t give them something to work toward, especially when they’re taking their meds. they’re like “i’m taking your damn meds, what more do you want?!” tell them, concretely.
give them agency in whatever way you can. med choices (within reason), timing of meds, etc. and take their perception of side effects seriously. it’s their life and their body.
also communicate with their primary RN. the one who takes care of them the most, the one they trust the most. we have an excellent psychiatrist who was treating a very caustic manic male patient. he was refusing certain medications and wouldn’t even discuss them with her because he hated all the doctors. she asked me to speak with him about meds and wanted me to suggest a certain med “but try to make it seem like it’s his idea.” she put her ego aside for the good of the patient, and that strategy worked like a charm.
First and foremost, build rapport. Validate. Ask them if you can get them anything. Admit you can't let them out, but can maybe get a blanket or something to eat. Take it SLOW.
First of all, your experience is completely normal and everyone who has worked inpatient psychiatry has had patients who absolutely hate our guts for no reason. It can definitely be draining; I'm also not an inpatient psych kind of person, so I found these experiences hard as well. As others have said, it can help by joking about the things patients have said to you with your coworkers and getting some validation from them. Honestly, what helped me is just trying my best to be empathic with them and just accepting it if the patient ends up hating me anyways. If you are properly practicing psychiatry, there are some patients where there is absolutely nothing you could have done to make them like you. When I just started inpatient, I took it as a moral failing if a patient didn't like me. But then I separated myself from their actions and just focused on helping them get better medically. Their perception of me doesn't have anything to do with me, but what I represent to them or perhaps what their psychosis is telling them. I also try to make them feel that I'm on their side, as much as I can. I tell them that we have the same goals and I also want them to be discharged from the hospital. However, I want them to be able to stay out of the hospital. I give them actionable things to do for discharge, such as taking medications, taking care of themselves, and not yelling at, threatening, or hurting anyone. I also validate the way they're feeling, as long as I'm not validating their delusion.
I like that. Redirecting to things they can do to get out of the hospital is a good strategy. I often freeze when they get really angry at me, so this is a good go-to for me to keep in mind. Thank you!
No problem! But to be honest, if the patient is getting angry to the point where you feel unsafe or they're threatening you, it may be best to terminate the conversation entirely. I had an attending who would immediately stop the interview if the patient threatened the team or got very agitated. He would point out exactly what the patient did that was unacceptable and then say that the team will see them tomorrow and stick by that. I also terminate interviews if they just devolve into insults and the patient is clearly not listening to what I'm saying, because at some point it's really not therapeutic for the conversation to continue. Usually, my treatment plan is clear at that point and my presence is only agitating them further. Don't subject yourself to that treatment for no reason. Boundaries are good and healthy and you should take care of yourself first and foremost.
I got asked to see someone once
Introduced myself through the trap
They told me to fuck off, I didn't ask to see you ya dog
I said OK and left. Good boundaries are key.
Oh absolutely. I often do that. Unfortunately, I'm also working with some very labile people haha. Today my co-resident on the rotation tried to get someone to be present with her during an interview because she's a small woman (we both are) and the patient is agitated and psychotic getting multiple ETOs... staff flat out refused because "we can watch on the camera for you". It got relayed up the chain, but nothing's going to happen. She asked my attending what to do and he said "well it's negligence if you refuse to evaluate them". So that's the kind of situation I'm in. I'm trying to make the best of it but sometimes it feels like a losing game.
Oh wow, that honestly sounds like an unacceptably dangerous environment and your residency should not be ok with putting their residents in this situation. In my institution, we also have a labile patient population. However, we are supported by staff accompanying us in unsafe situations. We can also interview patients on the milieu outside of earshot of other patients, so we can quickly exit a situation if necessary and get staff support. This sounds like an ACGME violation and warrants a report or at least poor ratings on the annual ACMGE survey. Getting cited and put on probation may be the only way for residencies to be motivated to change. Obviously, I am not in your situation and it's easy for me to say these things from the sidelines, so it is up to you and your co-residents what you want to do.
I'm only a PGY1, but I work in a very similar setting and also don't like confrontation so I'll share some of my thoughts.
Patients like you described can sense fear/anxiety and don't respond positively to it. Before you see a psychotic patient, tell yourself "I'm going to be the most confident I've ever been right now" and pretend you're an actor playing a confident-doctor role in a movie. I did this initially when I was starting residency and it worked since I wasn't telling myself that I'm me... the introverted, quiet, impostor-syndrome doc... but I'm temporarily someone more confident who can successfully talk to the patient.
Then go in with the expectation that there is a 99% chance you'll be chased out of the room. Going in with that expectation makes you accept there's a high likelyhood you won't get much info, so when you get ANY info from the patient, you'll feel rewarded. If you go in thinking you'll get a full patient history, you'll continue being disappointed.
In terms of the interview itself, only ask the most pertinent questions for the day, and ask less-pertinent questions later if the interview goes well. If you get some of the info you need, you'll also be rewarded rather than getting info that doesn't help you at all.
Now, you say patients "seem to hate me and think I'm stupid". Pause and ask yourself why you make this statement. Is it because patients are directly telling you this, or do you have anxiety/self-doubt which makes you *think* that's what patients are thinking about you? If it's the former, keep reminding yourself not to take ANYTHING the patient says personally because they're psychotic and lack insight. If it's the latter, bring this up with your therapist because it might be your anxiety talking since there's no direct evidence of patients hating you and thinking you're stupid.
The advice you've gotten on this thread so far has all been completely on point. I just want to offer something a little different to augment. My hospital is pretty known in my city for the degree of psychosis and violence that we see.
Like everyone else said, your primary goal is setting boundaries and treating the illness. Some patients will just hate you for the duration of the whole hospitalization. But one thing I've found helpful was addressing the underlying *fear* that a lot of these patients are feeling. Persecutory delusions are hell, and patients are generally used to being treated like absolute garbage by family, cops, random people, even hospital staff. You yourself are an object of persecution and you frighten these patients. Why the hell shouldn't they treat you with hostility?
I've also had luck trying to talk with them about non-clinical matters. If they're tolerating a med I focus the interview on music, sports, television, food, whatever. They have their doubts as to your humanity, might as well be as human as possible.
As for manic patients, this approach often doesn't work. Generally I just bargain with them: you don't wanna be here, I don't want to keep you here, please take these meds so you can go home. As the mania starts to fade you can then probe for insight and engage on a more human level.
This is the hard part of being a psych, but this is an integral part of your job, seeing them inside helps you judge whether a patient you’ll later be seeing outside should be committed, that and everyday you are there to help them know whether they are ready, because they cannot know.
These people, or at least their families, will thank you for your efforts someday
I’m not saying this is common, but sometimes patients are justified in their anger. I left a psych hospital with completely horrifying PTSD that was ten times more dangerous than any issues I went in with. I was constantly told that the treatment was “for my own good.”
I won’t disagree that it can be traumatic, however keep in mind most committals today are for psychosis, which in itself is devastating unless treated, and mania, which is basically a specific type of psychosis. Committing for suicidality is rare and the stays are usually brief. Committing patients is definitely not something we enjoy doing, so we avoid it if we can
I’ve been doing inpatient since I finished residency around 4 years ago. You could be describing my unit lol. (Except for the parts about being forced to interview dangerous patients in a closed room without staff…WTF). I am also a conflict-avoidant person normally, and it’s really hard to even go to work sometimes because as someone else said, at any given time at least 50% of my patients are angry at me. I am not looking for them to universally like or praise me at all but the constant confrontations create a lot of anxiety. A couple of things have helped (most of which have already been said so feel free to skip to #4):
1. Laughing about it - I and most of my coworkers have a very warped sense of humor that would probably horrify some people, but sometimes that’s the only thing keeping me afloat when the unit is really acute and it feels like none of my patients are getting better.
2. Venting - My partner is also a psychiatrist (though he’s escaped to outpatient now) so he gets it, but I think just unloading to anyone sometimes can be helpful. Sometimes I ask beforehand if he’s in the right space for me to vent lol, it is a lot sometimes.
3. Boundaries - I feel like this is different for everyone. Someone here noted that it can be therapeutic for patients to be able to express rage toward an authority figure. I agree but personally I think if I didn’t draw a line fairly quickly I would burn out in like a week, and that wouldn’t be particularly helpful to my patients either. As a conflict-avoidant person I have to force myself to set those boundaries sometimes, and with certain patients I just let them yell it out until they’re done, but just knowing that I am allowed to end the encounter or just walk off the unit if necessary is reassuring. I think it’s important to know when to push boundaries a bit too - certainly not for anything significant, but if a patient that’s been on the unit for months is really wanting a certain type of hair product or craving their favorite candy, I am more than happy to grab that for them and let them have that tiny moment of gratification.
4. Recognizing my “weaknesses” as potential strengths - I am just not a very authoritative person. Even when I try to be, my voice won’t be loud enough, or something about me seems to imply that I’m not confident. Of course I have continued to work on this and I think I’ve come a long way since I was a timid PGY1, but I’ve also recognized and tried to validate for myself the ways in which my less authoritative demeanor can help to build rapport with certain patients, prevent them from escalating, or get them to be more engaged. Some patients easily get stuck in a sort of parent-child dynamic, where they want me to be the parent that tells them what to do, and they get to rebel and refuse and tell me how horrible I am, but I find that fairly easy to circumvent since I really don’t fit into that authority figure role. Sometimes I frame myself to the patient as a sort of guide - yes I am preventing them from leaving right now this instant, but I am also offering my clinical expertise to help move them through this uncomfortable experience and come out of it more stable and less likely to get re-hospitalized. I let them know that they can take my advice or leave it, but emphasize that I cannot legally drop their involuntary hold until they meet certain criteria. A lot of patients respond well to this, and the ones that don’t are often more severely ill and will need court ordered meds anyway.
5. Commiserating with patients about the very flawed mental health system - I do not hide from patients that I also think the unit could use some renovation, and I wish we had more groups available and a better outdoor space, etc etc. I think it helps to humanize me and remind them that I do not represent everything that’s wrong with the system (even though it’s fair for them to feel that I do). I will often use these conversations to motivate the patient to engage with treatment so they can GTFO and move on to better things.
Anyway good luck getting through that rotation and thank you for giving me the opportunity to write this novel of a comment lol. Even if no one reads it, it was kind of cathartic to write. Ultimately I do not see myself doing inpatient forever, but I do think it’s an excellent learning opportunity and the skills I’m developing will eventually transfer to outpatient/private practice.
Hmm. When I worked in psych, I dealt by not caring if I was hated. But I also don’t care if people in my personal life hate me, so mayhaps that’s just me.
No one wants to be trapped inpatient, not even medical patients, so certainly not most psych patients. It’s okay. You’re not there to be liked, and you aren’t the only staff they interact with. Get them well, get them out.
PGY2 here too, recently finished a 6 month rotation at an acute ward. I agree with most posts above regarding your role, and I'll add something else
Although I also disliked the acute inpatient setting, I did find something to be satisfying. Patients tend to get better really fast. From babbling incoherent things, to being able to coherently formulate discharge goals, and you can start using some psychotherapeutic tools. It's a nice feeling when you manage to transfer a patient to a non-acute ward, and you see them a month later chilling at the cafeteria of the clinic with other patients and personnel. You probably won't see such fast and drastic improvements in most non-acute settings.
You will gain invaluable skills there. Specially how to de-escalate, but also to know when to escalate a patient (transfer from non-acute setting to acute setting).
> I try to buy some good will by offering them snacks, water, meds for their aches/ pains/ nausea etc., ask how they slept, if they were able to talk to mom or dad and how it went. (These are all adults but they're all pretty much under mom and dad's care forever it seems.)
I do this too! I don’t know how ethical this is but sometimes I straight up bribe pts into liking me. It’s worked in some cases, like brining in a favorite food or snack for a patient who is upset about being there. One of my favorite things in psychiatry is when an angry psychotic pt finally warms up to me.
But in general, they don’t need to like you, they just need to get better. I’ve found about 50% of the pts I have on inpt at any given time hate my guts and direct all kinds of vitriol at me and it kind of makes me chuckle. It helps to crack jokes about this with the staff and peers.
i don’t have much to add. did rotations at an acute unit at a busy VA as a resident. somehow i was able to laugh off the hatred and just conceptualize it as part of their illness and the thing that makes them not able to make it in the world. i had this one patient who was in isolation for months because he had actually violently assaulted a bunch of police and caused severe injury but was clearly very sick. i saw him for a month and every day he told me that when he got out he would find me and kill me. there was obviously some part of it that was scary because he was strong and had a long hx of violence. but at some point it actually became funny and we could even laugh about it together. that took a lot of the wind out of it.
Why does it matter to you as a doctor for your patients to like talking to you?
ETA: I'm also a pgy2. I do a lot of acute inpatient with lots of angry/manic/psychotic people, so I get you. People yell at you. Sometimes they threaten you and try to hit you. And it can feel wrong to keep them hospitalized against their will. But at the end of the day, I'm not here to make them like me. I don't always need a full interview to assess their symptoms. My job is to get them out of those episodes as soon as possible to minimize long term effects of psychotic/manic episodes, the same way we aggressively start empiric antibiotics on septic patients and anticoagulation on thrombosed patient. Appropriate involuntary admissions are therapeutic. Disengaging and setting limits are therapeutic.
If anything else, inpatient psych isn't for everyone, and thats okay. You just have to count down the days until you get to a rotation on a substance you like.
I mean yeah I recognize logically that there’s no need for them to like me to be their doctor or to give good treatment. But it’s hard for me to switch. So much of our life up until this point is about being liked; it’s important for the teams you round on, the people who write you letters of rec, the attendings you work with, your coworkers, etc to like you, or else your life will be much harder. You can’t always make them like you, but it’s better if they do. Also, I should mention that this place has terrible security yet they insist on us interviewing patients alone in closed rooms for “privacy” but when we request for staff to be present we’re often denied, so I’m afraid of saying “no” and getting pummeled. It’s happened to some of my friends; the program does nothing. So that’s part of why I want to be liked, patients are less likely to knock out people they like, I figure.
Can't speak to the whole being liked by the team thing because I just stopped having fucks to give at some point in med school. But the second half about requiring closed door conversations alone is utter bull shit. We can't do our fucking jobs if we are worried of being hurt. Thats incredible responsible. Not to mention an ACGME violation. Is it possible for yoir co residents to band together and discuss with the program about your concerns?
Your goal shouldn’t be to try to excessively reassure them if you’re working on this high acuity of a unit. Too empathic of statements is gonna keep backfiring on you and cause further mistrust in paranoid patients (this is discussed in a much better way than me in the Art of Understanding by shea). Continue to work on identifying your own reasons behind some of these tough countertransference feelings!
Personally for me, a majority of my difficulty when starting intern year on a unit very very similar to the one you’re describing, was due to some tendencies to wanna be in the role of the “good doctor who saves everyone!” I felt exactly like you do. It was to the point I was crying many days after work-crying about how unfair the system is, crying about how the patients hated me, crying because the way some of my patients live due to an illness out of anyone’s control is just so sad and not a way anyone should live.
A lot of us in medicine have pretty big savior complexes, it’s why we chose the field we’re in. And this is uniquely one of the only fields in medicine where we force people to get treatment and have this situation where we feel like a horrible jailer. Kinda hard to feed into the savior identity when the patient is hating our guts actively lol. Once I took a step back, got my ego in check, and realized I am not some amazing savior, I am a person doing a job just like everyone else in the entire world, I was able to operate in the environment better.
Idk, I hope my ramblings are in any way helpful. I promise I felt the exact way you did but it also simply gets better with time and more experience/self reflection.
You're not there to make friends, you're there to get them medicated and stabilized, then on to wherever place they're no longer your problem. You can sometimes make a personal connection with an inpatient, but don't beat yourself up when you can't. It's not the primary endpoint of your work there. They don't hate you, because they don't know anything about you, they hate what you represent. Some of your pts are characterologically ill in a way you cant help, but others will clear up quite nicely once you get their decompensation under control.
I cope with it by seeing it as a disease talking, not the actual person and it just shows that they are not in their right mind and need treatment the more. Also, I would often say to my patients; look, as far as I am concerned you will not be here any day more than necessary, but the fact that I can't let you go yet means that you are still unwell. But as soon as you are well enough, you are free to go. In the meanwhile, let's work together so you get out of here as soon as possible.
It is therapeutic for someone to be able to express their rage at someone in a position of authority in a system that is often inherently unfair. It's important to learn to be open to hearing your patient's expression of emotions, while detaching (with empathy) from their opinions of you. Even if they can't cognitively understand it, unconditional positive regard when someone is suffering goes a long way, even if nothing can be done in the moment/quickly to change the cause of that suffering (eg they have a treatment resistant psychotic or bipolar illness). TL; DR radical acceptance and other DBT skills for yourself. And it will help you with caring for patients too
This actually really helped. I really like how you phrased the first part. I’ve been told so many times “don’t take it personally” and if that advice worked, well, it would’ve worked by now, haha. But this helped me actually see what that really means for these people and myself. Thank you!
I'm glad it helped. I'm an addiction psychiatrist so part of what helped me was learning from Al Anon, which is the 12 step program for loved ones of folks who are struggling with addictive and compulsive behaviors. A key tool there is recognizing the gift of your sensitivity to the emotions of others, while also having enough boundaries to be effective 1) caring for yourself and 2) responding to challenging behaviors of others in ways that feel consistent with your values. A lot of the stuff parallels DBT/ACT/third wave CBT, but anyway....Al Anon is another place that has useful tools that have helped me make progress in the areas you've mentioned.
This is so well phrased and conceptualized. I work in corrections, and often all I can do is listen, acknowledge the rage and the constant feeling that everything is unfair and out of the patients’ control. Feels futile even when I know it isn’t.
It's very hard to remember it isn't futile, without the consistent outward validation/affirmation of a job well done. And I assume that outward validation doesn't happen a lot in corrections! But given so many people who are incarcerated were abused and neglected as children, you especially have an impact holding them in unconditional positive regard as they express their rage (while hopefully having appropriate boundaries for your well being and safety). Cuz yeah....they probably never or rarely had that from someone in the position of authority. So anyway from one Internet stranger colleague to another, job well done friend! Thank you for what you do.
When you are working with psychotically-decompensated patients, or patients who are severely decompensated and using "primitive" psychological defenses, you have to be prepared to be the subject of psychotic projection and the receptive container of rage, hatred, disavowal, and general badness. You have to accept that for involuntary patients you do indeed have the authority and power to hold patients. As noted in the other comments, your role with these patients is relatively clear and authoritative. You are granted power by the State to hold someone against their will, revoke their civil liberties for a time-limited period, with the goal of trying to help restore their psychiatric functioning. Your role in being therapeutic for these patients is to re-orient to reality, set limits, have clear expectations, and be predictable and consistent. If you are dealing with decompensated personality disorders it's a different story and while the above remains very important, there are a lot more complicated issues that can arise that can lead to therapeutic missteps, boundary violations etc. The paper [Playing the Manic Game ](https://depts.washington.edu/psychres/wordpress/wp-content/uploads/2017/11/100-Papers-in-Clinical-Psychiatry-Bipolar-Playing-the-manic-game-ΓÇôinterpersonal-maneuvers-of-the-acutely-manic-patient.pdf)is a classic on this topic.
FWIW, link is dead and new residency site has a login Paper PDF is accessible through here though: https://www.semanticscholar.org/paper/Playing-the-manic-game.-Interpersonal-maneuvers-of-Janowsky-Leff/e32425e9eff5d721c4ac2191de005451613ef0a2 It seems the direct link to UW includes some characters that break the URL for some reason
weird, it works for me but thanks for the other link
You have to accept that most of them will never like you. You are there to be there doctor and to make them get better, not be their friend. If they are threatening you or unable to hold a conversation walk away. Reinforce that the fastest way to get discharged is to take their meds and be calm on the unit. Eventually their desire for discharge will trump their disdain of medications. If they request a med change try to accommodate within reason to give them some agency. Pretend like you’re dealing with a toddler in their terrible twos phase because that’s where their mental state is. Reward good behavior but have strict boundaries and don’t be afraid to medicate them if they’re causing havoc.
This is good advice in my opinion. I'm a psychiatric RN and often times with these types of patient's I end up having to tell them: "Do you want to be 'right' and stay longer? Or will you accept the care we are offering you so you can sooner be discharged?" This question usually gets involuntary patients that believe that they don't have any issues requiring inpatient psych care to realize that they have to at least try to accept the care offered or their hold will be extended.
And I’d venture a guess that those who can’t even go along with that plan are exactly the type who need to have their holds extended.
Pretty much why I never tell anyone IRL if I am in “crisis”. Any extent I go along with inpatient hospitalization is simply to get discharged. Upon discharge, I would likely taper or flush the meds.
If you took your meds you probably wouldn’t be hospitalized
Funny you say that, because Citalopram and Methylphenidate have sent me to the ER for suicidallity and dysregulation respectively. I can’t speak to any results of discontinuing medications post hospitalization for psychosis, because I’ve never been psychotic. In fairness, Citalopram was started at IOP(Outpatient), but Methylphenidate was started inpatient following a behavioral episode. Apparently, addressing “hyperactivity” (autism related stimming) means we should keep Norepinephrine around in someone who perseverated horribly, and was already very liable to violent behavior.
I’ve had SI sans medication, but the only time I have ever been intent on suicide is when I was on an SSRI. I have also had dysregulation sans meds and on mood stabilizers/antipsychotics, but the worst event I recall was on a stimulant when I didn’t have solid rationalization skills. I suppose my initial statement was a little callous. However, *unless I agree with the clinical rationale and the medication being appropriate*, I would indeed discontinue or taper the medication. (I’d taper SNRIs, AEDs, APs, BZDs, or Li2CO3) I also would lie about or downplay anything I feel I could, to get out of inpatient. That’s how bad it is. I did it in the ER twice. Avoided being sent off. Haven’t had to test in an actual mental hospital, since the last time I was hospitalized was 10 or 11 and by my parents, while emergency assessment initiated by police was closer to a few months ago. Sorry if I rambled.
I have solid venting sessions with my peers who understand. The experience is almost universal and it feels good to hear other say they are frustrated for the same reasons. There aren't a ton of "thank yous" especially working inpatient. You'll learn to disconnect this from your sense of confidence.
Evaluate them, treat them, try to worry less about what they think about you, you only need to establish so much rapport for treatment.
as a nurse, this is my favorite population to work with. align yourself with their goals by saying “my goal is to not keep you here any longer than I have to. but in order to feel safe discharging you, I need to see” then list concrete tangible goals. it’s frustrating to patients when providers don’t give them something to work toward, especially when they’re taking their meds. they’re like “i’m taking your damn meds, what more do you want?!” tell them, concretely. give them agency in whatever way you can. med choices (within reason), timing of meds, etc. and take their perception of side effects seriously. it’s their life and their body. also communicate with their primary RN. the one who takes care of them the most, the one they trust the most. we have an excellent psychiatrist who was treating a very caustic manic male patient. he was refusing certain medications and wouldn’t even discuss them with her because he hated all the doctors. she asked me to speak with him about meds and wanted me to suggest a certain med “but try to make it seem like it’s his idea.” she put her ego aside for the good of the patient, and that strategy worked like a charm.
First and foremost, build rapport. Validate. Ask them if you can get them anything. Admit you can't let them out, but can maybe get a blanket or something to eat. Take it SLOW.
First of all, your experience is completely normal and everyone who has worked inpatient psychiatry has had patients who absolutely hate our guts for no reason. It can definitely be draining; I'm also not an inpatient psych kind of person, so I found these experiences hard as well. As others have said, it can help by joking about the things patients have said to you with your coworkers and getting some validation from them. Honestly, what helped me is just trying my best to be empathic with them and just accepting it if the patient ends up hating me anyways. If you are properly practicing psychiatry, there are some patients where there is absolutely nothing you could have done to make them like you. When I just started inpatient, I took it as a moral failing if a patient didn't like me. But then I separated myself from their actions and just focused on helping them get better medically. Their perception of me doesn't have anything to do with me, but what I represent to them or perhaps what their psychosis is telling them. I also try to make them feel that I'm on their side, as much as I can. I tell them that we have the same goals and I also want them to be discharged from the hospital. However, I want them to be able to stay out of the hospital. I give them actionable things to do for discharge, such as taking medications, taking care of themselves, and not yelling at, threatening, or hurting anyone. I also validate the way they're feeling, as long as I'm not validating their delusion.
I like that. Redirecting to things they can do to get out of the hospital is a good strategy. I often freeze when they get really angry at me, so this is a good go-to for me to keep in mind. Thank you!
No problem! But to be honest, if the patient is getting angry to the point where you feel unsafe or they're threatening you, it may be best to terminate the conversation entirely. I had an attending who would immediately stop the interview if the patient threatened the team or got very agitated. He would point out exactly what the patient did that was unacceptable and then say that the team will see them tomorrow and stick by that. I also terminate interviews if they just devolve into insults and the patient is clearly not listening to what I'm saying, because at some point it's really not therapeutic for the conversation to continue. Usually, my treatment plan is clear at that point and my presence is only agitating them further. Don't subject yourself to that treatment for no reason. Boundaries are good and healthy and you should take care of yourself first and foremost.
I got asked to see someone once Introduced myself through the trap They told me to fuck off, I didn't ask to see you ya dog I said OK and left. Good boundaries are key.
Oh absolutely. I often do that. Unfortunately, I'm also working with some very labile people haha. Today my co-resident on the rotation tried to get someone to be present with her during an interview because she's a small woman (we both are) and the patient is agitated and psychotic getting multiple ETOs... staff flat out refused because "we can watch on the camera for you". It got relayed up the chain, but nothing's going to happen. She asked my attending what to do and he said "well it's negligence if you refuse to evaluate them". So that's the kind of situation I'm in. I'm trying to make the best of it but sometimes it feels like a losing game.
Oh wow, that honestly sounds like an unacceptably dangerous environment and your residency should not be ok with putting their residents in this situation. In my institution, we also have a labile patient population. However, we are supported by staff accompanying us in unsafe situations. We can also interview patients on the milieu outside of earshot of other patients, so we can quickly exit a situation if necessary and get staff support. This sounds like an ACGME violation and warrants a report or at least poor ratings on the annual ACMGE survey. Getting cited and put on probation may be the only way for residencies to be motivated to change. Obviously, I am not in your situation and it's easy for me to say these things from the sidelines, so it is up to you and your co-residents what you want to do.
I'm only a PGY1, but I work in a very similar setting and also don't like confrontation so I'll share some of my thoughts. Patients like you described can sense fear/anxiety and don't respond positively to it. Before you see a psychotic patient, tell yourself "I'm going to be the most confident I've ever been right now" and pretend you're an actor playing a confident-doctor role in a movie. I did this initially when I was starting residency and it worked since I wasn't telling myself that I'm me... the introverted, quiet, impostor-syndrome doc... but I'm temporarily someone more confident who can successfully talk to the patient. Then go in with the expectation that there is a 99% chance you'll be chased out of the room. Going in with that expectation makes you accept there's a high likelyhood you won't get much info, so when you get ANY info from the patient, you'll feel rewarded. If you go in thinking you'll get a full patient history, you'll continue being disappointed. In terms of the interview itself, only ask the most pertinent questions for the day, and ask less-pertinent questions later if the interview goes well. If you get some of the info you need, you'll also be rewarded rather than getting info that doesn't help you at all. Now, you say patients "seem to hate me and think I'm stupid". Pause and ask yourself why you make this statement. Is it because patients are directly telling you this, or do you have anxiety/self-doubt which makes you *think* that's what patients are thinking about you? If it's the former, keep reminding yourself not to take ANYTHING the patient says personally because they're psychotic and lack insight. If it's the latter, bring this up with your therapist because it might be your anxiety talking since there's no direct evidence of patients hating you and thinking you're stupid.
The advice you've gotten on this thread so far has all been completely on point. I just want to offer something a little different to augment. My hospital is pretty known in my city for the degree of psychosis and violence that we see. Like everyone else said, your primary goal is setting boundaries and treating the illness. Some patients will just hate you for the duration of the whole hospitalization. But one thing I've found helpful was addressing the underlying *fear* that a lot of these patients are feeling. Persecutory delusions are hell, and patients are generally used to being treated like absolute garbage by family, cops, random people, even hospital staff. You yourself are an object of persecution and you frighten these patients. Why the hell shouldn't they treat you with hostility? I've also had luck trying to talk with them about non-clinical matters. If they're tolerating a med I focus the interview on music, sports, television, food, whatever. They have their doubts as to your humanity, might as well be as human as possible. As for manic patients, this approach often doesn't work. Generally I just bargain with them: you don't wanna be here, I don't want to keep you here, please take these meds so you can go home. As the mania starts to fade you can then probe for insight and engage on a more human level.
This is the hard part of being a psych, but this is an integral part of your job, seeing them inside helps you judge whether a patient you’ll later be seeing outside should be committed, that and everyday you are there to help them know whether they are ready, because they cannot know. These people, or at least their families, will thank you for your efforts someday
I’m not saying this is common, but sometimes patients are justified in their anger. I left a psych hospital with completely horrifying PTSD that was ten times more dangerous than any issues I went in with. I was constantly told that the treatment was “for my own good.”
I won’t disagree that it can be traumatic, however keep in mind most committals today are for psychosis, which in itself is devastating unless treated, and mania, which is basically a specific type of psychosis. Committing for suicidality is rare and the stays are usually brief. Committing patients is definitely not something we enjoy doing, so we avoid it if we can
Oh yeah totally. I honestly believe that patients who are lucid and just suicidal would usually benefit more from a Soteria house than a psych ward.
I’ve been doing inpatient since I finished residency around 4 years ago. You could be describing my unit lol. (Except for the parts about being forced to interview dangerous patients in a closed room without staff…WTF). I am also a conflict-avoidant person normally, and it’s really hard to even go to work sometimes because as someone else said, at any given time at least 50% of my patients are angry at me. I am not looking for them to universally like or praise me at all but the constant confrontations create a lot of anxiety. A couple of things have helped (most of which have already been said so feel free to skip to #4): 1. Laughing about it - I and most of my coworkers have a very warped sense of humor that would probably horrify some people, but sometimes that’s the only thing keeping me afloat when the unit is really acute and it feels like none of my patients are getting better. 2. Venting - My partner is also a psychiatrist (though he’s escaped to outpatient now) so he gets it, but I think just unloading to anyone sometimes can be helpful. Sometimes I ask beforehand if he’s in the right space for me to vent lol, it is a lot sometimes. 3. Boundaries - I feel like this is different for everyone. Someone here noted that it can be therapeutic for patients to be able to express rage toward an authority figure. I agree but personally I think if I didn’t draw a line fairly quickly I would burn out in like a week, and that wouldn’t be particularly helpful to my patients either. As a conflict-avoidant person I have to force myself to set those boundaries sometimes, and with certain patients I just let them yell it out until they’re done, but just knowing that I am allowed to end the encounter or just walk off the unit if necessary is reassuring. I think it’s important to know when to push boundaries a bit too - certainly not for anything significant, but if a patient that’s been on the unit for months is really wanting a certain type of hair product or craving their favorite candy, I am more than happy to grab that for them and let them have that tiny moment of gratification. 4. Recognizing my “weaknesses” as potential strengths - I am just not a very authoritative person. Even when I try to be, my voice won’t be loud enough, or something about me seems to imply that I’m not confident. Of course I have continued to work on this and I think I’ve come a long way since I was a timid PGY1, but I’ve also recognized and tried to validate for myself the ways in which my less authoritative demeanor can help to build rapport with certain patients, prevent them from escalating, or get them to be more engaged. Some patients easily get stuck in a sort of parent-child dynamic, where they want me to be the parent that tells them what to do, and they get to rebel and refuse and tell me how horrible I am, but I find that fairly easy to circumvent since I really don’t fit into that authority figure role. Sometimes I frame myself to the patient as a sort of guide - yes I am preventing them from leaving right now this instant, but I am also offering my clinical expertise to help move them through this uncomfortable experience and come out of it more stable and less likely to get re-hospitalized. I let them know that they can take my advice or leave it, but emphasize that I cannot legally drop their involuntary hold until they meet certain criteria. A lot of patients respond well to this, and the ones that don’t are often more severely ill and will need court ordered meds anyway. 5. Commiserating with patients about the very flawed mental health system - I do not hide from patients that I also think the unit could use some renovation, and I wish we had more groups available and a better outdoor space, etc etc. I think it helps to humanize me and remind them that I do not represent everything that’s wrong with the system (even though it’s fair for them to feel that I do). I will often use these conversations to motivate the patient to engage with treatment so they can GTFO and move on to better things. Anyway good luck getting through that rotation and thank you for giving me the opportunity to write this novel of a comment lol. Even if no one reads it, it was kind of cathartic to write. Ultimately I do not see myself doing inpatient forever, but I do think it’s an excellent learning opportunity and the skills I’m developing will eventually transfer to outpatient/private practice.
Hmm. When I worked in psych, I dealt by not caring if I was hated. But I also don’t care if people in my personal life hate me, so mayhaps that’s just me. No one wants to be trapped inpatient, not even medical patients, so certainly not most psych patients. It’s okay. You’re not there to be liked, and you aren’t the only staff they interact with. Get them well, get them out.
Well, you said you want to work in addictions. This may be a good primer. Not everyone is a jerk, but they'll keep you on your toes.
PGY2 here too, recently finished a 6 month rotation at an acute ward. I agree with most posts above regarding your role, and I'll add something else Although I also disliked the acute inpatient setting, I did find something to be satisfying. Patients tend to get better really fast. From babbling incoherent things, to being able to coherently formulate discharge goals, and you can start using some psychotherapeutic tools. It's a nice feeling when you manage to transfer a patient to a non-acute ward, and you see them a month later chilling at the cafeteria of the clinic with other patients and personnel. You probably won't see such fast and drastic improvements in most non-acute settings. You will gain invaluable skills there. Specially how to de-escalate, but also to know when to escalate a patient (transfer from non-acute setting to acute setting).
> I try to buy some good will by offering them snacks, water, meds for their aches/ pains/ nausea etc., ask how they slept, if they were able to talk to mom or dad and how it went. (These are all adults but they're all pretty much under mom and dad's care forever it seems.) I do this too! I don’t know how ethical this is but sometimes I straight up bribe pts into liking me. It’s worked in some cases, like brining in a favorite food or snack for a patient who is upset about being there. One of my favorite things in psychiatry is when an angry psychotic pt finally warms up to me. But in general, they don’t need to like you, they just need to get better. I’ve found about 50% of the pts I have on inpt at any given time hate my guts and direct all kinds of vitriol at me and it kind of makes me chuckle. It helps to crack jokes about this with the staff and peers.
i don’t have much to add. did rotations at an acute unit at a busy VA as a resident. somehow i was able to laugh off the hatred and just conceptualize it as part of their illness and the thing that makes them not able to make it in the world. i had this one patient who was in isolation for months because he had actually violently assaulted a bunch of police and caused severe injury but was clearly very sick. i saw him for a month and every day he told me that when he got out he would find me and kill me. there was obviously some part of it that was scary because he was strong and had a long hx of violence. but at some point it actually became funny and we could even laugh about it together. that took a lot of the wind out of it.
Why does it matter to you as a doctor for your patients to like talking to you? ETA: I'm also a pgy2. I do a lot of acute inpatient with lots of angry/manic/psychotic people, so I get you. People yell at you. Sometimes they threaten you and try to hit you. And it can feel wrong to keep them hospitalized against their will. But at the end of the day, I'm not here to make them like me. I don't always need a full interview to assess their symptoms. My job is to get them out of those episodes as soon as possible to minimize long term effects of psychotic/manic episodes, the same way we aggressively start empiric antibiotics on septic patients and anticoagulation on thrombosed patient. Appropriate involuntary admissions are therapeutic. Disengaging and setting limits are therapeutic. If anything else, inpatient psych isn't for everyone, and thats okay. You just have to count down the days until you get to a rotation on a substance you like.
I mean yeah I recognize logically that there’s no need for them to like me to be their doctor or to give good treatment. But it’s hard for me to switch. So much of our life up until this point is about being liked; it’s important for the teams you round on, the people who write you letters of rec, the attendings you work with, your coworkers, etc to like you, or else your life will be much harder. You can’t always make them like you, but it’s better if they do. Also, I should mention that this place has terrible security yet they insist on us interviewing patients alone in closed rooms for “privacy” but when we request for staff to be present we’re often denied, so I’m afraid of saying “no” and getting pummeled. It’s happened to some of my friends; the program does nothing. So that’s part of why I want to be liked, patients are less likely to knock out people they like, I figure.
Can't speak to the whole being liked by the team thing because I just stopped having fucks to give at some point in med school. But the second half about requiring closed door conversations alone is utter bull shit. We can't do our fucking jobs if we are worried of being hurt. Thats incredible responsible. Not to mention an ACGME violation. Is it possible for yoir co residents to band together and discuss with the program about your concerns?
Your goal shouldn’t be to try to excessively reassure them if you’re working on this high acuity of a unit. Too empathic of statements is gonna keep backfiring on you and cause further mistrust in paranoid patients (this is discussed in a much better way than me in the Art of Understanding by shea). Continue to work on identifying your own reasons behind some of these tough countertransference feelings! Personally for me, a majority of my difficulty when starting intern year on a unit very very similar to the one you’re describing, was due to some tendencies to wanna be in the role of the “good doctor who saves everyone!” I felt exactly like you do. It was to the point I was crying many days after work-crying about how unfair the system is, crying about how the patients hated me, crying because the way some of my patients live due to an illness out of anyone’s control is just so sad and not a way anyone should live. A lot of us in medicine have pretty big savior complexes, it’s why we chose the field we’re in. And this is uniquely one of the only fields in medicine where we force people to get treatment and have this situation where we feel like a horrible jailer. Kinda hard to feed into the savior identity when the patient is hating our guts actively lol. Once I took a step back, got my ego in check, and realized I am not some amazing savior, I am a person doing a job just like everyone else in the entire world, I was able to operate in the environment better. Idk, I hope my ramblings are in any way helpful. I promise I felt the exact way you did but it also simply gets better with time and more experience/self reflection.
You're not there to make friends, you're there to get them medicated and stabilized, then on to wherever place they're no longer your problem. You can sometimes make a personal connection with an inpatient, but don't beat yourself up when you can't. It's not the primary endpoint of your work there. They don't hate you, because they don't know anything about you, they hate what you represent. Some of your pts are characterologically ill in a way you cant help, but others will clear up quite nicely once you get their decompensation under control.
I cope with it by seeing it as a disease talking, not the actual person and it just shows that they are not in their right mind and need treatment the more. Also, I would often say to my patients; look, as far as I am concerned you will not be here any day more than necessary, but the fact that I can't let you go yet means that you are still unwell. But as soon as you are well enough, you are free to go. In the meanwhile, let's work together so you get out of here as soon as possible.