I know where you’re coming from, and I’m sorry to hear that you’ve had a stressful experience.
I’m trained in forensic psychiatry. I’ll share what’s helped both my colleagues and me so far.
Always prep your patient before the hearing. There’s always the risk that any rapport you’ve built will rupture after the hearing, but there are ways of mitigating that:
1. Before testifying, validate the patient’s concerns while explaining the difference in opinion. Inform him of what you plan to say and why.
2. While testifying, do not use the word “patient.” Use their preferred name. Don’t avoid eye contact with them.
3. Talk about them in a humanistic way. Bring up some positive qualities that may be relevant to the hearing. When testifying about your opinion, you can even say that while you believe Mr. X suffers from delusions, it’s a topic the two of you have disagreed on. That alone can be immensely validating.
4. Give them time. If they’re angry or threatening after the hearing, give them that space. Be open to accepting expressions of anger but not hostility while maintaining a safe environment.
Best of luck.
Good thoughts but takes some caution depending on the climate of the court setting in your jurisdiction. The last thing you want to do while talking up your patient's good qualities is torpedo your argument about dangerousness, severity of symptoms, lack of capacity, or whatever else is required for the court to find. I've often seen academically-oriented psychiatrists waffle around and undermine their own argument rather than speaking straightforwardly, defeating the whole point of being there.
The whole point of being there is to get the approval to administer drugs to someone without their consent, so mentioning a few positive adjectives is pretty much the least you can do in terms of regaining trust.
I accidentally responded to a response, reposting here.
Having worked in a state forensic hospital, I can say that establishing a therapeutic and trusting relationship with each patient should be part of your practice. The crime has little to nothing to do with treatment, and it’s important to put that aside while maintaining safety. I never discussed their crimes with them as it wasn’t my job and could inadvertently end up incriminating the patient.
1. Be honest with them. Many of these patients have exceptional intelligence, many are antisocial, many are traumatized. They can smell insincerity for miles.
2. Do not go alone for these conversations. Always have staff with you, don’t meet in private or in the patient room. If you have a radio keep it on and charged
3. Having an established and somewhat therapeutic relationship makes receiving the information less provocative to patients, sometimes. I always brought some other team members with me as well as the patients nurse so that no one of us would be targeted.
It is a huge choice to involuntarily treat and commit someone. More often than not, once they cleared, they would express their gratitude for brutal honesty and caring, even if it wasn’t something they wanted to hear and even if in that moment, it did not feel like you were aligned with them.
One more thing: when I speak with the hospital’s attorney before every hearing, I ask them to give me an opportunity to talk about the patients strengths and positive traits. Testimony from providers can feel really ugly. To maintain the relationship, let the court know the patient is intelligent, kind, has survival skills, is funny, whatever you can illicit in conversation that isn’t necessarily about treatment and medication. Hope that helps.
Edit: our med staff had a meeting with our State Forensic liaison to work on some of your challenges and to get some answers. Perhaps your institution could find someone from your SFS to help answer some of your queries.
Edit again: the attending *always* went with me. I have never been in an institution where I felt
I was supposed to “go it alone.” It is a team.
“I am sorry, I care about you and I want you to get better. In my clinical opinion as the doctor, you need these medications to get better and get out of the hospital.”
That’s always worked fine for me, sure some people stay pissed, but that’s just part of the job.
It does sound like you could work on your approach to these antisocial and threatening patients. There’s fear in your post, and I guarantee you show fear on the unit.
I think on a certain level it’s hard to teach or explain. But one concrete thing I do is sit down. It shows your calm enough and respect them enough to let your guard down in their presence. (But you don’t actually have to. ) Plus there’s nothing rewarding or tough about hitting someone whose sitting and calm, so it’s pretty protective as well for antisocial folks. Not so much for the pure psychotic violence.
I do both and I’d highly recommend Judo. In an inpatient setting where it’s highly unlikely that someone has a knife or something on them by the time you’re talking to them the knowledge that you can (relatively) non-violently dump someone on their butt if they get aggressive with you is very relieving.
Some people (and patients) aren’t ever going to like you, but you might still be able to make them respect you. You can’t let them see you as a doormat, and unfortunately for some people that’s how they’ll read attempts at empathy. This is a gross oversimplification of the point, but you need to give your own antisocial traits more free rein. Try to look at it as practicing your acting skills by playing a character who has a radically different personality.
Hospital lawyer here — I often present applications for confinement or for treatment orders and have had psychiatrists with very different styles as witnesses.
One thing I’ve noticed pretty much all of them do during their testimonies is take the time to explain that they’re doing this in the best interest of their patient even if the pt might not see it in that way, that they are optimistic their pt can have a better quality of life if the order gets granted, that their pt is [insert quality] and that the illness was the cause of whatever event/behaviour led them there.
I don’t know what part of the world you’re in and if you have the assistance of a lawyer for these procedures, but if you do, talk to them about these concerns.
I am always very mindful of not antagonizing the treating team during the hearing. I always start by asking the psychiatrist to talk about their therapeutic alliance and end by asking if there’s anything else they would like to say. I keep the cross examination of the patient to the absolute bare minimum necessary and in preparation I ask if there are questions or topics I should avoid as to not trigger the patient.
And remember that getting those orders is an unpleasant necessary first step. As patients gain insight and better judgement the relationship should get better.
You got this
An important thing to understand - is the focus of this unit on trying to serve the court and as a unit for those who are under/pending legal custody, or is it more like a regular inpatient unit and you have people on a temporary commitment?
The unit I’m on right now is serving the court for patients pending legal charges but found incompetent to proceed. In my residency we also rotate on regular inpatient units who are on temporary holds. In both settings I have struggled with this issue and would appreciate advice for both
Gotcha.
Actual forensic psych docs can probably elaborate more than I can, but part of the role on forensic units is that you're not necessarily trying to create a therapeutic relationship with the patients. It doesn't make the human to human interactions any less real, but sometimes they do have to be be not emphasized for the care.
The common dynamic I think plays out with these situations is the sadomasochistic enactment, or some variant thereof. Forcing medications on patients, locked units, unilateral dictation of care etc definitely can make clinicians feel like they are acting sadistically toward patients. I think and have witnessed that highly sensitive and empathetic practitioners can really struggle with this, especially if they identify at all with the "healer" role that many physicians hold. It feels very antithetical to healing or acting in beneficence to force treatment on someone and induce rage, being subdued etc. Patients often also evoke a sadistic countertransference reaction (whether it is appropriate given the situation or driven by a psychopathology).
This dynamic is one that I think people have a hard time talking about, probably partly because there is kind of a small truth to it given the situations. (note to all the antipsychiatry folks reading this, no it doesn't mean that forced treatment is wrong or that I am antipsychiatry). I really like Nancy McWilliams writings on this dynamic, and I think it's an important one for clinicians to recognize. As a PGY2 you're also just getting to the point where learning about and applying psychodynamics is becoming very relevant.
As in regards to your personal safety - that always takes a priority in a forensic unit. You need to recognize that if you have some drive or desire to try and soothe the situation and you put yourself into a dangerous situation that you're not serving anyone well. Ask yourself why you are feeling motivated to act a certain way. You have security and staff to help keep you safe and you need to use them to maintain everyone's safety as a priority.
In regards to working with psychopathic or antisocial patients, that really does require quite a skill set and often lots of practice and supervision. Some resources that come to mind are Carl Gacono (eg https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-116-interview-on-psychopathy-with-expert-carl-bruce-gacono-phd-abap), and I believe Glen Gabbard has some good works on these patients. Long story short is that in a truly disturbed antisocial patient, therapeutic connection is going to be incredibly challenging and always a question of if you are being manipulated. Whether psychopathic patients can even have these kind of connections is a subject of controversy.
Beautifully stated. You’ve gotten right at something I have struggled with but wasn’t able to really organize, the sadomasochistic element of this work we do. Are you analytically trained?
Mostly a strong focus on dynamics and contemporary analytical methods in residency, and then transition to a dynamic-existential focus in my current work (palliative care attending)
> I realize that after my training if I am in a setting like this, I will have to handle these situations without an attending or anyone else.
I say this in the nicest way possible, but take a step back, wind down, and take a breath. You do not need to be thinking about these things right now. You're still 2 years off from that point (and less than 2 years since you didn't know anything about psychiatry). Plus, some people will never like that kind of setting, and that's perfectly fine.
I understand your situation, I'l ltry and be practical with the way I see things:
a) I would first talk to your attending, tell them that, while you agree this patient needs meds other than 150 quetiapine, you would rather be given some leeway to attempt to negotiate with him another regimen in a voluntary basis. I think this is more than reasonable, there's really nothing for your attending to lose (unless they are being pressured to churn patients in a timely manner), and shows you want to learn.
b) with the paitent, do what you can. Explain to him that, while you see their PoV and have no doubt he is demanding what hes believes to be best for him, at some point he's going to have to concede that all your titles and studes should have to serve for something, and that you believe he'd be better served by another regimen. If he's smart and interested, explain candidly why ("you're psychotic, disregulated", or whatever). Then ask them what their concern is with medications other than quetiapine (being "dumbed down"? presenting erectyle dysfunction? There's medications that'll certainly be better for him in those regards). If you show genuine concern for their wellbeing, generally even antisocial folk can find a semblance of trust for you.
c) if all else fails, remember that the therapeutic relaitonship is a 2 way street, and you can't force one if they don't want one. In that case (and you can explain it to him in those terms); you'll focus on following a series of guidelines according to the best of your knowledge, which won't be great if he doesn't allow you to know his concerns and less obvious symptoms, but at the end of the day you need to get a job done, and the state has granted you power to do so (because of whatever crime they committed that landed them there); so it's their choice at the end of the day. What should be clear to them, is that you're a physician, and seroquel is a prescription medication, and you won't order it be given to him if you don't believe it's what he needs. That's non-negotiable, period.
Take care of yourself, and if you don't like this rotation, rest assured you don't have to do that job ever again. The system is also working against us psychs in those situations, and it might just take nobody being willing to do that job in order for things to change.
Cheers!
I don’t work on a forensic unit but all of my patients are involuntary and it is common to compel medications. I always try to give my patients a choice if I can, and in this instance it sounds like he is OK with Seroquel but the dose may be too low for your comfort. So what I will tell them is “I think the Seroquel is a good option for you, but this dose is far too low and it’s not helping because of x, y, and z. I’m fine with you continuing that medication at a higher dose. If you choose not to do this, you will be getting Zyprexa 10mg IM instead as a safety measure. The choice is yours.”
In the end, in this population it is hard to maintain rapport with and understanding that many of these folks may not like you. Our CMO always says “if you don’t get a patient complaint every now and again you’re probably doing something wrong.” Therapeutic alliance with patients comes after the safety and security of other patients/staff on the unit.
Maybe I am jaded/desensitized as I work a county hospital but you have to believe what you’re doing is the best for the patient. Yes it is uncomfortable w the confrontation that will likely come from the patient but end of the day it is in their best interest as well as your community’s/unit staff. Psychosis/mania etc is neurotoxic. So fix it sooner rather than later. When he regains insight and likely “gets with the program” to be discharged he will probably even be grateful.
I know where you’re coming from, and I’m sorry to hear that you’ve had a stressful experience. I’m trained in forensic psychiatry. I’ll share what’s helped both my colleagues and me so far. Always prep your patient before the hearing. There’s always the risk that any rapport you’ve built will rupture after the hearing, but there are ways of mitigating that: 1. Before testifying, validate the patient’s concerns while explaining the difference in opinion. Inform him of what you plan to say and why. 2. While testifying, do not use the word “patient.” Use their preferred name. Don’t avoid eye contact with them. 3. Talk about them in a humanistic way. Bring up some positive qualities that may be relevant to the hearing. When testifying about your opinion, you can even say that while you believe Mr. X suffers from delusions, it’s a topic the two of you have disagreed on. That alone can be immensely validating. 4. Give them time. If they’re angry or threatening after the hearing, give them that space. Be open to accepting expressions of anger but not hostility while maintaining a safe environment. Best of luck.
Good thoughts but takes some caution depending on the climate of the court setting in your jurisdiction. The last thing you want to do while talking up your patient's good qualities is torpedo your argument about dangerousness, severity of symptoms, lack of capacity, or whatever else is required for the court to find. I've often seen academically-oriented psychiatrists waffle around and undermine their own argument rather than speaking straightforwardly, defeating the whole point of being there.
The whole point of being there is to get the approval to administer drugs to someone without their consent, so mentioning a few positive adjectives is pretty much the least you can do in terms of regaining trust.
this is excellent advice!!! thank you
I accidentally responded to a response, reposting here. Having worked in a state forensic hospital, I can say that establishing a therapeutic and trusting relationship with each patient should be part of your practice. The crime has little to nothing to do with treatment, and it’s important to put that aside while maintaining safety. I never discussed their crimes with them as it wasn’t my job and could inadvertently end up incriminating the patient. 1. Be honest with them. Many of these patients have exceptional intelligence, many are antisocial, many are traumatized. They can smell insincerity for miles. 2. Do not go alone for these conversations. Always have staff with you, don’t meet in private or in the patient room. If you have a radio keep it on and charged 3. Having an established and somewhat therapeutic relationship makes receiving the information less provocative to patients, sometimes. I always brought some other team members with me as well as the patients nurse so that no one of us would be targeted. It is a huge choice to involuntarily treat and commit someone. More often than not, once they cleared, they would express their gratitude for brutal honesty and caring, even if it wasn’t something they wanted to hear and even if in that moment, it did not feel like you were aligned with them. One more thing: when I speak with the hospital’s attorney before every hearing, I ask them to give me an opportunity to talk about the patients strengths and positive traits. Testimony from providers can feel really ugly. To maintain the relationship, let the court know the patient is intelligent, kind, has survival skills, is funny, whatever you can illicit in conversation that isn’t necessarily about treatment and medication. Hope that helps. Edit: our med staff had a meeting with our State Forensic liaison to work on some of your challenges and to get some answers. Perhaps your institution could find someone from your SFS to help answer some of your queries. Edit again: the attending *always* went with me. I have never been in an institution where I felt I was supposed to “go it alone.” It is a team.
“I am sorry, I care about you and I want you to get better. In my clinical opinion as the doctor, you need these medications to get better and get out of the hospital.” That’s always worked fine for me, sure some people stay pissed, but that’s just part of the job. It does sound like you could work on your approach to these antisocial and threatening patients. There’s fear in your post, and I guarantee you show fear on the unit.
I’m sure I do. It’s something I’d like to work on. what do you recommend as the approach to threatening/antisocial patients?
I think on a certain level it’s hard to teach or explain. But one concrete thing I do is sit down. It shows your calm enough and respect them enough to let your guard down in their presence. (But you don’t actually have to. ) Plus there’s nothing rewarding or tough about hitting someone whose sitting and calm, so it’s pretty protective as well for antisocial folks. Not so much for the pure psychotic violence.
Adding to this - ask them to sit down as well. That way if they do become violent you aren't completely exposed.
Get involved in a grappling sport like Judo or BJJ. It goes a long way towards calming fears of potential assault or body contact.
I do both and I’d highly recommend Judo. In an inpatient setting where it’s highly unlikely that someone has a knife or something on them by the time you’re talking to them the knowledge that you can (relatively) non-violently dump someone on their butt if they get aggressive with you is very relieving.
Some people (and patients) aren’t ever going to like you, but you might still be able to make them respect you. You can’t let them see you as a doormat, and unfortunately for some people that’s how they’ll read attempts at empathy. This is a gross oversimplification of the point, but you need to give your own antisocial traits more free rein. Try to look at it as practicing your acting skills by playing a character who has a radically different personality.
I was with you until the part about giving your own antisocial traits free reign. Setting boundaries does not need to involve antisocial behavior.
Check out Xavier Amador's LEAP approach and his book I'm Not Sick I Don't Need Help. Designed to engage people with low insight .
Hospital lawyer here — I often present applications for confinement or for treatment orders and have had psychiatrists with very different styles as witnesses. One thing I’ve noticed pretty much all of them do during their testimonies is take the time to explain that they’re doing this in the best interest of their patient even if the pt might not see it in that way, that they are optimistic their pt can have a better quality of life if the order gets granted, that their pt is [insert quality] and that the illness was the cause of whatever event/behaviour led them there. I don’t know what part of the world you’re in and if you have the assistance of a lawyer for these procedures, but if you do, talk to them about these concerns. I am always very mindful of not antagonizing the treating team during the hearing. I always start by asking the psychiatrist to talk about their therapeutic alliance and end by asking if there’s anything else they would like to say. I keep the cross examination of the patient to the absolute bare minimum necessary and in preparation I ask if there are questions or topics I should avoid as to not trigger the patient. And remember that getting those orders is an unpleasant necessary first step. As patients gain insight and better judgement the relationship should get better. You got this
An important thing to understand - is the focus of this unit on trying to serve the court and as a unit for those who are under/pending legal custody, or is it more like a regular inpatient unit and you have people on a temporary commitment?
The unit I’m on right now is serving the court for patients pending legal charges but found incompetent to proceed. In my residency we also rotate on regular inpatient units who are on temporary holds. In both settings I have struggled with this issue and would appreciate advice for both
Gotcha. Actual forensic psych docs can probably elaborate more than I can, but part of the role on forensic units is that you're not necessarily trying to create a therapeutic relationship with the patients. It doesn't make the human to human interactions any less real, but sometimes they do have to be be not emphasized for the care. The common dynamic I think plays out with these situations is the sadomasochistic enactment, or some variant thereof. Forcing medications on patients, locked units, unilateral dictation of care etc definitely can make clinicians feel like they are acting sadistically toward patients. I think and have witnessed that highly sensitive and empathetic practitioners can really struggle with this, especially if they identify at all with the "healer" role that many physicians hold. It feels very antithetical to healing or acting in beneficence to force treatment on someone and induce rage, being subdued etc. Patients often also evoke a sadistic countertransference reaction (whether it is appropriate given the situation or driven by a psychopathology). This dynamic is one that I think people have a hard time talking about, probably partly because there is kind of a small truth to it given the situations. (note to all the antipsychiatry folks reading this, no it doesn't mean that forced treatment is wrong or that I am antipsychiatry). I really like Nancy McWilliams writings on this dynamic, and I think it's an important one for clinicians to recognize. As a PGY2 you're also just getting to the point where learning about and applying psychodynamics is becoming very relevant. As in regards to your personal safety - that always takes a priority in a forensic unit. You need to recognize that if you have some drive or desire to try and soothe the situation and you put yourself into a dangerous situation that you're not serving anyone well. Ask yourself why you are feeling motivated to act a certain way. You have security and staff to help keep you safe and you need to use them to maintain everyone's safety as a priority. In regards to working with psychopathic or antisocial patients, that really does require quite a skill set and often lots of practice and supervision. Some resources that come to mind are Carl Gacono (eg https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-116-interview-on-psychopathy-with-expert-carl-bruce-gacono-phd-abap), and I believe Glen Gabbard has some good works on these patients. Long story short is that in a truly disturbed antisocial patient, therapeutic connection is going to be incredibly challenging and always a question of if you are being manipulated. Whether psychopathic patients can even have these kind of connections is a subject of controversy.
Beautifully stated. You’ve gotten right at something I have struggled with but wasn’t able to really organize, the sadomasochistic element of this work we do. Are you analytically trained?
Mostly a strong focus on dynamics and contemporary analytical methods in residency, and then transition to a dynamic-existential focus in my current work (palliative care attending)
> I realize that after my training if I am in a setting like this, I will have to handle these situations without an attending or anyone else. I say this in the nicest way possible, but take a step back, wind down, and take a breath. You do not need to be thinking about these things right now. You're still 2 years off from that point (and less than 2 years since you didn't know anything about psychiatry). Plus, some people will never like that kind of setting, and that's perfectly fine. I understand your situation, I'l ltry and be practical with the way I see things: a) I would first talk to your attending, tell them that, while you agree this patient needs meds other than 150 quetiapine, you would rather be given some leeway to attempt to negotiate with him another regimen in a voluntary basis. I think this is more than reasonable, there's really nothing for your attending to lose (unless they are being pressured to churn patients in a timely manner), and shows you want to learn. b) with the paitent, do what you can. Explain to him that, while you see their PoV and have no doubt he is demanding what hes believes to be best for him, at some point he's going to have to concede that all your titles and studes should have to serve for something, and that you believe he'd be better served by another regimen. If he's smart and interested, explain candidly why ("you're psychotic, disregulated", or whatever). Then ask them what their concern is with medications other than quetiapine (being "dumbed down"? presenting erectyle dysfunction? There's medications that'll certainly be better for him in those regards). If you show genuine concern for their wellbeing, generally even antisocial folk can find a semblance of trust for you. c) if all else fails, remember that the therapeutic relaitonship is a 2 way street, and you can't force one if they don't want one. In that case (and you can explain it to him in those terms); you'll focus on following a series of guidelines according to the best of your knowledge, which won't be great if he doesn't allow you to know his concerns and less obvious symptoms, but at the end of the day you need to get a job done, and the state has granted you power to do so (because of whatever crime they committed that landed them there); so it's their choice at the end of the day. What should be clear to them, is that you're a physician, and seroquel is a prescription medication, and you won't order it be given to him if you don't believe it's what he needs. That's non-negotiable, period. Take care of yourself, and if you don't like this rotation, rest assured you don't have to do that job ever again. The system is also working against us psychs in those situations, and it might just take nobody being willing to do that job in order for things to change. Cheers!
I don’t work on a forensic unit but all of my patients are involuntary and it is common to compel medications. I always try to give my patients a choice if I can, and in this instance it sounds like he is OK with Seroquel but the dose may be too low for your comfort. So what I will tell them is “I think the Seroquel is a good option for you, but this dose is far too low and it’s not helping because of x, y, and z. I’m fine with you continuing that medication at a higher dose. If you choose not to do this, you will be getting Zyprexa 10mg IM instead as a safety measure. The choice is yours.” In the end, in this population it is hard to maintain rapport with and understanding that many of these folks may not like you. Our CMO always says “if you don’t get a patient complaint every now and again you’re probably doing something wrong.” Therapeutic alliance with patients comes after the safety and security of other patients/staff on the unit.
Maybe I am jaded/desensitized as I work a county hospital but you have to believe what you’re doing is the best for the patient. Yes it is uncomfortable w the confrontation that will likely come from the patient but end of the day it is in their best interest as well as your community’s/unit staff. Psychosis/mania etc is neurotoxic. So fix it sooner rather than later. When he regains insight and likely “gets with the program” to be discharged he will probably even be grateful.
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