Hard Out Here...TGIF

Just a few hours ago I found myself at a place where I really didn't want to be, but I was there...

Instead of aborting my session with a 16 y.o. girl with severe conduct disorder and oppositional-defiant behavior when it started to heat up I decided to explore a little further. She picked the wrong psychiatrist to try intimidating though anger and verbal aggression today. I think what got me going was her calling me stupid and a fake. She was the one court ordered to the care of a group home after another assault charge and repeated incidents of anger related aggression, yet I was the one who is stupid and just seeing her to get paid. She felt telling me how much she hated me would really make me go away, but it didn't. I wanted to know how could she hate me so much after only seeing me twice before today. Had there not been a chaperone and witness from the group home it would have been extremely foolish for me to take this any further.

Instinctively, I felt I needed to not let her have this victory for her ego or I would never have a chance to help her. I let her take me to the pits of her anger (which she denied having) and found myself in the awkward position of participating in a brief shouting match with an angry adolescent. I felt it important to not allow her to believe that intimidation is the way to solve any problem. I made it clear that I was not frightened of her and that she could not threaten me away until I was ready for that to happen. Next came her F it strategy which was totally useless because I've already been there and done that when I was much younger. She proclaimed that she didn't care how many level reductions or punitive measures it required she would never talk to this stupid doctor again. She stated she was willing to accept any punishment that could be inflicted. This left me with a perfect confrontation opportunity of asking her if it was really worth all that as a response to just being asked what she was feeling today. Actually, it sort of surprised myself when I didn't back down from the implicit threat of violence and threat of trashing my office. Fortunately, I have done a bit of acting a few years back and I decided to let her know that I am not a total stranger to getting "Ghetto" if I need to. The temptation was far too great and I found myself going there. I had doubts of whether I had handled this situation appropriately until the end of the session after we both had some time to de-escalate. Now, I feel it was the right call and was worth the discomfort to let this play out in a safe environment. In an unsafe environment violence would have been imminent and almost inevitable. Letting her do it in the office allowed me the opportunity to make a point that had already proven futile through the means of normal conversation. I think now she can better accept the fact she has anger management issues, even if she sees it being my fault that she does. She refused to shake my hand as a gesture of a truce at departure and stated she would not be back, but I have a feeling that she will.

I had gone through a similar confrontation with an adult patient yesterday, though much less intense. She was apparently manic and somehow got the brilliant idea to stop by the office unannounced to give me a few pointers on psychopharmacology. When people are experiencing delusions of grandeur it appears to them that it is you the doctor who is an idiot. It is pointless to try convincing them otherwise. Denial is a real B, mainly because it is only the one who denies who sees no denial. With her husband along as a witness, I felt compelled to give a brief but poorly received lecture on the list of symptoms of bipolar disorder being exhibited before our very eyes. She insisted I prove to her how I know she has bipolar disorder. This is a job for Moses I would think. The simplest way I could put it is that most people with bipolar disorder, one way or another, eventually make it to the office of a psychiatrist. There has never been a need to go out looking for patients to treat. From her perspective she did not have bipolar disorder but a more acceptable explanation was that the Depakote prescribed to her started all of her newfound problems. I really love when this happens because it enables me to come back with " well if you figured out the cause of all your problems was taking a sub therapeutic dose of Depakote for a few days then stopping that medication should have fixed all of your problems. Right? What do you need me to do?" She then clarified that it was coming off the sub-therapeutic dose of Depakote and the side effects of "not feeling right" that must be the actual cause of all those problems worsening. For most patients going through this it is inconceivable that it may have been that Klonopin prescribed as needed for anxiety (that is being over taken) that could be the main cause of the not feeling right. When a determined patient continues to come at you with non sense that they are convinced is fact, eventually you have to spring the topper of asking where they received their training to practice medicine? The only option left at that time is for them to devalue you and inform you that you are not worthy of the privilege of treating them any more. By this time, I'm usually ready to show them the door anyway.

Sometimes it gets this bad but usually not. It actually is this uncertainty that keeps the work interesting. The next time I see either of those patients again they may be totally different people or to punish me they may move on to the next psychiatrist or therapist. Even parents occasionally have to let their kids learn things the hard way. I really find it humorous when a difficult patient fires me. It's much like the little kid running away from home with just a back pack and a packed lunch because mama wouldn't give him his way. It's hard out there for one in need of a good and caring therapist. Whether those who self terminate treatment choose to return to me or not, usually I know a day will come when they will see the grass is never greener and there is no such thing as a magic pill that fixes everything.

Update on Mon, April 30, 2007 at 07:31PM by HEADoc

Looks like I received a little bashing from a psychology colleague. I always appreciate any positive input. Unfortunately, most  psychiatrists don't receive a whole lot of training in theory of direct behavioral intervention with adolescents with aggression problems. On the job training is more the norm. I'm sure majority of my colleagues tend to practice avoidance when it comes to potential violent confrontation. I'm a former football player and was once conditioned to seek out the action instead of avoiding it.  To my newfound cohort, I do especially appreciate the inclusion of alternatives to shouting and being reduced to a primitive level of behavior. This form of behavior is of course a last resort and fortunately this situation occurs only rarely for me. I don't think practicing self defense is any indication of illness in this physician. There is a time and place for everything. If I am threatened with violence it is not my nature to run. I certainly won't make exceptions for an aggressor behaving in an antisocial manner. If this is seen as wrong then so be it. I have been face to face with murderers, psychopaths, and common thugs during my work at the County Detention Facility. I have a good instinct for keeping violence in check. I will never allow anyone to abuse me in my own office if there is anything I can do about it. My patience is quite long but limited. Sometimes the textbook must be thrown out the window. My job is to help those who want help and are able to cooperate with that help. If those criteria aren't met it is not necessarily my problem. Logic isn't always effective when confronting ignorance.

Comments

[Sigh]

Dominance games with patients is a dangerous enterprise.

Instinctively, you reacted to a dominance challenge, and wound up caught in a very primitive game.

You won the contest, and weakened her self-esteem. Congratulations, you've failed.

Anger control is correlated directly to strength of self-esteem and situation control. The more you have, the less angry you are. You were losing control, so you resorted to anger and dominance. Take what you felt, magnify it by 100, and that is her life.

Did you do the right thing?

Even lemur monkeys transfer agression visited upon them by dominant members of their troop to other members of their troop who are unable to establish dominance over them.

For your efforts and success, she will , in all probability, visit the pain of her defeat upon someone else.

Physician, heal thyself.

[Sigh]

That said, learning is the key to a sense of control.

You are smart, and it bears mentioning that your consideration of the situation will strengthen your ability in the future.

Strengthen them along with yourself. Might I suggest, as a means of strengthening your control in such situations, if voices raise, change the thought-pattern.

For instance, in the middle of shouting at them, stop, lower your voice and ask them what their favorite food is? Tell them all this shouting has made you hungry, and you thank them for it, and need to get some food. Since it has made you hungry, you think they might be hungry also, and if we are going to get some food, we should get something you like.

Or, ask where they bought their shoes, because a friend of yours has been looking all over for them.

Or, stop, say something along the lines of 'oh, shit, am I shouting?'.

Try them out, the mind is a funny device sitting atop a funny creature