Tuesday, April 12, 2011

When A Thick Skin Helps

I had to follow up on Dinah's post "What Makes A Good Therapist." (Note to Dinah: I put the punctuation inside the quotation mark. I'm getting better!)

While I agree that empathy is important, it strikes me that so many times psychiatrists are also called upon to be able to tolerate a lot of negative stuff: anger, resentment, bitterness and the general nastiness that can come along with helping people sort out the awful historical relationships in their lives. Once upon a time there was a fantastic psychiatrist blogger by the name of Shiny Happy Person who suggested that in order to become a psychiatrist people should have to pass the "F-You Test." In other words, you have to be able to handle people screaming and cursing at you. Somebody is going to suggest that only happens with my patients because I treat criminals, but I know this happens with non-criminal patients too.

How do you balance empathy with a thick skin? It gets tricky. If you genuinely care about your patients and want them to get better then it would be nice if they weren't nasty to you in return. But if nastiness does happen, it's your job as a psychiatrist to not let it bother you or interfere in treatment. This is particularly true in forensic work when patients can regularly place blame on others (or on you!) for what goes on in their lives. And when a correctional patient makes demands or threats in order to get something inappropriate from you, a thick skin must be replaced with Kevlar. For the patient's own good, you have to have the toughness to do the right thing to avoid harm. (Eg. "I know you'd really like to have some Elavil for sleep, but since you're over 40 and have coronary artery disease and hepatitis C and have attempted suicide by pill overdose twice and have no recent EKG or liver function test results in your record, I really can't give that to you.")

Prisoner advocates criticize correctional health care providers for being cold or unempathic, but I think they are misinterpreting a necessary and appropriate line that a good correctional clinician has to walk. I just thought I'd bring it up because this is also sometimes necessary for non-forensic psychiatrists as well.


Anonymous said...

I don't never came close to saying f-k you to my former psychiatrist. And even if I had wanted to, I wouldn't have done so out of fear he would involuntarily commit me.

Believe it or not, that happened to someone I knew who admittedly got belligerent because the psychiatrist wouldn't take her complaints seriously about med side effects. He blamed in on her "label". By the way, this was a person who was always good about taking heavy duty meds.

Her psychiatrist not only didn't pass the toughness test, he had no business being in the field. It was his job to make this person feel like she was being heard and he failed big time.

Empathy? The word wasn't even in his dictionary.

moviedoc said...

We are all more likely to take an attack personally if we believe the attacker is correct. If we are confident that we are okay as we are, we can better empathize with the desperation of the attacker, and we are less likely to feel the need to get defensive.

Dinah said...

You are doing so well with your quotation marks! Makes me proud :)

So glad I have a job where no one curses at me. My skin is much too thin for your work.

Daniela said...

YES! Thank you! Empathy is not a synonym for door-mat or an antonym for insensitivity. Nor is it a one-size-fits-all therapeutic intervention. Rather, it is an experience, generated from both inside oneself and in relation to another. Outstanding post!

Daniela said...

YES! Thank you! Empathy is not a synonym for door mat, nor an antonym for insensitivity. Nor is it a one-size-fits-all therapeutic intervention. Rather, it is an experience generated in relationship to ones self and to others. A useful distinction for shrinks certainly, but really, useful to any thoughtful and feeling person negotiating their way through this turbulent world. Thanks for this thoughtful post.

Sunny CA said...

Your post made me think of my semester teaching in an inner city school and why I left after one semester. I used to think I was teaching "future criminals", though in truth, 3 wore tracking ankle bracelets following release from juvenile hall. I was sworn at and heard others sworn at all day, every day. It was impossible to enforce a "no swearing rule" as f--- and d--- and b--- poured out of all mouths in the room all the time. I had one student who could create nearly entire sentences out of f--- with nothing but a few pronouns tossed in.

Good luck getting better qualified teachers into teaching jobs where the school day consists of being sworn at and occasionally threatened by the students (as Obama wants). The year before I got there, one teacher at our school ended up brain damaged when trying to break up a fight and being turned on by both of those who were fighting. Add to this, that it is the teacher's fault if these kids don't learn and the pay is $50,000. Teachers are also supposed to be empathetic. And they are supposed to correct papers and plan lessons on evenings and weekend. Then go back the next day and get sworn at again.

Sunny CA said...

I need to add that after a year of substitute teaching following that semester in the inner city, I ended up at a charter school with 2 classes of 20 kids, and 3 classes of less than 15 kids and nobody has sworn at me here the entire year. In addition, I am actually teaching something and am appreciated by the kids and their parents. ALL the jobs aren't like the first one I had. No wonder they were willing to take an intern in the credential program for that first job.

Sideways Shrink said...

I am in private practice and no one curses at me, but this is Seattle where passive-aggressive behavior reigns supreme. A big one her is terminating a relatively brief therapeutic relationship by email with several sharp criticisms veiled as "observations". Until I figured out how to preempt it, people would act out by not paying their bill. Before becoming a shrink I had a thin skin. That has been rectified. The worst things were said to me when I was starting out: one guy did the classic of trying to seduce me to avoid therapeutic work, I have been yelled at by ADHD patients off their meds, bipolar patients off their meds. At this point, I have learned to verbally back patients down--literally so that they sit down and stop the verbal barrage. But no patient has ever tried to touch or hit me in the outpatient setting. I would hit them back if I had to get to the door. Shrink docs: are we allowed to hit patients back? I'm not going to be assaulted just because there is a rule against hitting a patient in self defense, but I am just curious because I have never heard it discussed per the outpatient setting where the doc has no back up.

ClinkShrink said...

Sideways: Great question: 'are doctors allowed to hit back'? That may be a post in itself. While researching it a bit I found this survey of primary care physicians that found 41% of them needed security or police to escort a patient from a clinic. That seemed amazingly high to me, but thought it was interesting so I'm putting it up. More to come if I have time.

moviedoc said...

"are we allowed to hit patients back?"

Are you kidding? Let me put it this way Sideways: If I ever hear anybody hit you, and you didn't fight back with everything you've got, I'm gonna kick your butt.

Anonymous said...

What I've found in many years of practice and supervision is that psychotherapists are happy to accept compliments as "here-and-now" emotions, but slough off criticism -- even sharp criticism! -- as "transference."

I think we need to listen to what our patients tell us. If we're criticized or even yelled at? The starting place to react should be from the position that they may well have a point, however inelegantly made.

If we've goofed in some way, or if we haven't met their reasonable expectations? Apologize.