Thursday, July 06, 2006

Out of the Office

[posted by dinah]

This post was inspired by Dr. A's account of his patient Jen in his post Bride of Hyperthyroidism and by Carrie's (NeoNurseChic, whom I always find inspiring) response to it.

"Hey, Doc," she said, "Don't forget to come to my wedding next month. It's going to be a good time." She then proceeded to tell me the entire plan for the day, which made her face light up and bring a smile to her face. "I'm sure it will be," I said, "I wouldn't miss it for anything."

And Carrie commented:
... doctors are a part of my life and hear all the negative things that happen all the time - it's nice to be able to give back and show I'm a normal human, too, and share the positives, too! Hope "Jen" gets her hyperthyroidism controlled and has a beautiful wedding!

This is the thing about being a psychiatrist-- it's this funny little world inside the office where intimacy reigns and boundaries become oh-so important. Psychotherapy mandates a number of important boundaries, sometimes they feel rigid, but mostly they serve as a protective barrier. I could ramble about the obvious-- defined meeting times and pre-determined session lengths, very restricted physical contact (I'm good with a handshake at the initial evaluation, and sometimes patients will hug me at the termination of therapy, a gesture that is beyond me to refuse), payment in exchange for the services (this, in addition to being a boundary issue helps me pay my bills), and perhaps most important, limiting meetings to the therapeutic sessions which take place in my office. In all honesty, I'd rather not see my patients anywhere else; given a choice, I don't even want to ride the elevator with them.

Mostly, I think my patients would rather not be with me outside the office, too. Of course, it's a bit inevitable. I ran into a patient one day when I was out for a walk. I introduced her to Max, my dog, and she said, "I didn't know you had a dog." I do. When I bump into patients and I'm with my kids, invariably they ask, "Who's that?" and I'm left to mutter something I hope won't lead to more questions.

People tell me about the events in their lives; usually they don't invite me, they seem to instinctively know the rule. Sometimes they'll say, "I wish you could be there."

Recently, a patient asked me to come to his art opening. He mentioned it several times, he gave me an invitation, he asked me to invite all my friends. It was important to him that people come, and he made it clear he wanted me to come.

"What would I tell people if they asked who I was?"

This is always an issue for outside the office stuff. "I'm the artist's psychiatrist"-- that just doesn't fly. It's a problem Dr. A doesn't have; he can go to a patient's wedding and just be Dr. A.

"Everyone knows I see you," he said. So I guess I could have said I was the artist's psychiatrist, I just wouldn't.

I went alone. The room was packed, my patient was holding court and doing a wonderful job, though I knew he was extremely anxious. I walked around, loved his artwork, tried to guess who was who from the puzzle of his life that I'd heard so much about inside the office. He was, for that moment, a normal human (actually, a rather talented human) with a normal life. A woman approached me and introduced herself as the artist's mother. I introduced myself by my first name only, shook her hand and simply said her son had invited me. Mostly I stayed lost in the crowd and enjoyed the artwork.

"The opening was great," the artist announced a few days later. "I wish you could have come."

"I did," I said. He looked surprised, then delighted. I told him which were my favorite pieces, told him how well I thought he did. Somehow I was pleased to have both been there and yet been just a little invisible.

19 comments:

Sarebear said...

I hope you aren't getting tired of me yet!

I've wondered, if I'm ever lucky enough, and stable enough, to have another child, does the ologist/iatrist come to the hospital and congratulate you? That's about the only out of office thing I've wondered about specifically, although I have had wandering thoughts about, what if I bumped into him HERE, or THERE . . . lol!

A kind of reverse of this situation, sort of, is that I recently found out, as he related a story about when he was a new psychologist, and they sent him into a local junior high, that he counseled at for a year or two . . . well, it was MY junior high (and HIS, thus, the story about how it was difficult to stay present and not get caught up in all the associations there).

Not only was it my junior high, but it was a very horrid time in my life where I so wished I had a counselor or something . . . . we had just moved across the country, and I was in this junior high for 5-6 weeks before graduating 9th grade and heading on to high school. Rough transition that did not happen very well at all . . .

Anyway, the point of this story is, in the week after I found out HE was there . . . . . I surprisingly found myself having alot of anger and disappointment that HE DIDN'T HELP ME. That he somehow let me down . . .

Which, on the face of it, is completely ridiculous since he had no clue, and I had no clue the school had a counselor . . .

So with all the tangled emotions associated with THAT . . . it kinda helps me understand better some of the issues with running into your patients/mental health providers in the "real" world.

I'll shuddup now. Lol.

NeoNurseChic said...
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On the Same Page said...

Hear me out before you accuse me of making this a "corrections" post, Dinah!

I interviewed a man in the hospital at San Quentin, where the only available space was the tiny staff kitchen. The room couldn't have been 12 feet in either direction. He was profoundly disabled and could really see no reason for paroling after spending the majority of his adult life in the same cell. He could predict the routine, he fed the birds at his window, and he was comfortable with staff and "friends" he'd made over the years. He was gentle, quiet, and always smiling and calling me "sir."

When we completed the interview, we both stood up, about a foot apart, and he extended his hand, which I accepted and wished him well, when he unexpectedly and suddenly hugged me for a brief moment and walked out.

I sat down and thoughts were racing through my head: I wasn't paying attention; he could have hurt me. It was an "inappropriate" interaction with a patient I really didn't know. What if corrections' staff had seen it? What will my colleagues say if I tell them? Finally, I concluded that this had been a spontaneous, benign expression of appreciation from an impaired man who may have crossed a professional boundary, but had not crossed a human boundary. I could live with that.

It had never happened before or since. Maybe that says something as well.

Sarebear said...

Just to clarify, I found out that he was there the time I was, at that age.

NeoNurseChic said...
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Nutty said...

I had therapy with a doctor and at the end of it, still unwell but in the care of others, I sent him a very emotional card, home-made, with the words of a song inside and a relevant picture on the outside. For years after, I was too embarrassed to say hello when I saw him, and I can't bring myself to listen to that music any more.

Fat Doctor said...

Beautifully written! I get invited to a ton of shindigs and patients ask me all kinds of inappropriately prying questions. I don't go to the shindigs, because I like to leave our relationships in the office.

On the other hand, I always have to physically restrain myself from going to the funerals of my patients who die. It's the family's time, I know, but I often think it would help my own grief process to be at the funeral.

Dr. A said...

Instead of leaving a comment, I blogged about your blog. Click here.

Dreaming again said...

I am soon getting a house through Habitat for Humanity. I've wondered if I should invite my psychiatrist or not. He's been so supportive and excited as we've gone through the process.

I didn't want to exclude him, but also did not want him to feel obligated.

This gives me a better idea of how to invite him. We'll be given invitations to mail to the dedication ... and I can just mail him one of those. Tell him the date of the wall raising, if he seems interested in the details ...tell him. If not ... bring pics :D

healthpsych said...

Thanks for sharing this. Maintaining boundaries and having consideration for your patient can be hard. It's great how this worked out.

TheTundraPA said...

So glad to have found your blog--through Doctor Anonymous--and will be adding you to my blogroll at Tundra Medicine Dreams and my Bloglines. This was such a well-done post; I really enjoyed it. It led me to thinking about how boundaries may differ in a mental health practice, as opposed to a general medicine practice. When it comes to social interactions with patients, my participation is dependant on the question of whether the patient is someone I would like as person and value spending time with. Those of my patients who have seen me primarily for mental health concerns--usually depression--are not generally people I would want to spend time with. These patients often are (or seem) much more emotionally dependant, and boundaries are essential. With my family practice patients, the question of social interaction feels completely different. When I practiced in big cities (Spokane, Missoula) it mostly didn't come up; I was far more anonymous. Now that I am in a small town of 5,000, and especially when I travel to my Yukon village of 500, social interactions are common and enjoyable. When I am in the village, people invite me to their homes for dinner, and I often accept. Interacting with them outside the clinic gives me an expanded view of their lives, which informs my medical management of them as patients. Attending the artist's opening probably did the same thing for you, increasing your understanding of him as a person by seeing his art. But here, too, selection is essential; if my village patient with schizophrenia, anxiety, and depression invited me to dinner, I would not accept. She is simply not someone I would enjoy spending the time with. Not that she would ask; she is usually oppositional/defiant towards me.

I think you struck the perfect balance in attending your artist patient's opening, present and under the radar. I'm sure he felt incredibly supported to know, even after the fact, that you were there. I agree with Carrie; one can't really know an artist without experiencing his/her creations (writers included).

ClinkShrink said...

Ah, such a contrast from "inside the wall" life. My patients don't try to invite me into their lives as much as they try to insert themselves into mine. They have nothing else to do but to watch the lives of those around them. They know when I come to work, where I park, the kind of car I drive and when I leave. Sometimes they mention things as small talk ("Say doc, I see you got a new car.") and sometimes just to see if I get uncomfortable. It's a very closed system.

NeoNurseChic said...
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knomad said...

I enjoyed reading your thoughtful post about maintaining boundaries. It sounds like you live in a big enough city that you don't see your patients in the course of the rest of your life.

I am a retired Social Worker and some of my clients belonged to the same church as I did. It seems more difficult to have clear boundaries when the community you live in is small and you keeping meeting clients in a social setting. They knew a lot about my life and family. I needed to explain many times that I could not be friends outside of the office.

Anonymous said...

I've been to all sorts of patient events over the years: weddings, high school or med school graudations, even visiting new homes. My rule of thumb is just that we always have to talk in advance about why we're doing what we're doing in the way we're doing it. Sometimes it still seems a good idea, and sometimes the talk is what it's all about. Such a frequent dilemma for all of us I guess.

Sarebear said...

Carrie, in addition to depression I'm all those things you say, Oh, but I'm not THESE horrid things you certainly wouldn't want anywhere near you . . . you didn't say it like that, but this is pretty much how the world treats me. EVEN THOUGH I TRY AS HARD AS I CAN.

This post, that part of it, had and IS bugging me too . . . WHO, then, will be friends with someone like me . . . I am not saying I expect or am asking for any of you or all of you or anything, to be, but say I end up socializing w/some people in your profession somewhere IRL, and they express this . . . . mental health professionals certainly aren't obligated or, I hope, EXPECTED to be the befrienders of the down and out, but at the same time, this attitude coming from those who are supposed to be more understanding of why we are the way we are, and that at least part of it is biological and stuff . . .

Well, for my part, I TRY as hard as I can. I'm a nice person, and people tell me they enjoy my unique perspective.

And yet, I'm punished for being a way that I did not choose. I am fighting it, so much, but I DID NOT CHOOSE THIS!

Anyway, off my soap box, and please don't see it as a request for friendship, although I am always open to opportunities for new friendships and associations.

It's just a more rant on the state of things like this, from my point of view. Oh yeah, and I blogged on this today.

Dr X said...

The internet creates a new set of problems, leaving the protective boundaries of therapy ever more porous. For those of us who believe that relative anonymity is helpful to the way we work, keeping our own blogs anonymous is important, but one has to become a virtual hermit to keep all information of a personal nature off of the net.

Anonymous said...

Yes, I know that this is rather late to post a reply to this, but I only just found your blog!
The thing about therapy is that in order to properly express how something feels, you sometimes need to know where the therapist comes from on similar topics.
In a discussion with a therapist about feeling like I'm stupid, I expressed that it hurt not to have been in advanced math when I was in elementary school, largely because I'm the child of a math professor. Her response was that my mother's education isn't genetic. (For the sake of this post, I'll leave the genetic aspects of mathematical ability out of it for now, that's not what I was taking up with a therapist.)
I may have crossed a boundary by asking if she had children, and if they spoke fluent psychobabble, but it was the first demonstration of the concept of how parents teach their own world-view to their children, and pass on more than just genetics. Honestly, I was caught a bit off-guard, it hadn't occurred to me that I'd have to explain this to a therapist.

Anonymous said...

Good to know that psychiatrist like to see their patient doing good. I somehow can never come to believe that their patients are matter much and are not mechanical. Though it gets dangerous when it comes to opposite gender doc-patient.