Good morning, Dr. Milford.
Good morning, Dr. Fu.
You know, we've been meeting, I think, every two weeks for a while now, and that gets me thinking. Are you trying to seduce me or something?
Why would you think that?
Well, you know, you're meeting with me so often, and you pay a lot of attention to me during these, and, you know, you're always looking good. I think you're trying to do something, and I think you know exactly what you're doing.
You think I look good?
Well, maybe this gives a little bit of a clue about today's topic. There's been something going on on the Internet over the last few weeks, and this is not a you tell me episode. So what are we talking about today?
I think today we want to talk a little bit about boundaries, a little bit about. More specifically, erotic transference. Talk a little bit about frame, reality testing, and I guess a little bit about countertransference. I'm not quite sure how this is going to evolve, but I think these are the main things we want to touch on.
yeah and i think it's important to note that as fun exciting or appalling as whatever recent subject matter may be all the feelings and thoughts that people may be having these issues are unfortunately core par for the course for any long-term treatment and in particular any long-term psychiatric treatment Knowing how to handle these issues, why we handle them in a certain way, I think is just a core competency.
And on top of that, it's going to really keep you out of trouble in the long run. So perhaps what we can do. I do want to make a disclaimer.
Whenever I hear. I'm going to say we, whenever we hear about a bad outcome or a scary outcome or someone being stalked, someone being harassed, some patient having a terrible outcome, I think it's our instinct to find the fault with the provider. I think it's a natural instinct to distance ourselves from the problem. And like, you know, identify, oh, that was a big mistake. That was a huge mistake.
And I think... Linking it to my own supervision, it's very easy to look down on providers, to find faults. And I think it's a way of distancing ourselves from those outcomes in a protective sense.
And I bring that up just... It's a defensive thing for us psychologically.
Yeah. And that like, oh, that could never happen to me.
And because X, Y, Z. As in we're so different. That bad thing wouldn't happen.
I think it's easy to look at the provider and say, oh, they're narcissistic. Oh, they're psychopathic. Oh, they're loose on boundaries. Oh, they X, Y, Z problem. And I just want to point out that I acknowledge that It's very easy to find faults in others. And it's more challenging to actually be reflective and see your own problems in your practice.
Yeah, excellent point. And the purpose of any fault finding is always, at MLB's for this episode, purely didactic. We cannot improve, we cannot repair until we look at errors and ruptures. And what we're going to talk about today assumes no facts. We're using purely hypothetical scenarios in order to jog a discussion. About our opinions on what might you do? What might you not do? Because this is not a problem that is unique to one clinician One patient or any clinician patient pair These are extremely common and universal issues that can come up and intelligent and good clinicians can't disagree But the discussion and education I think is important Absolutely
So let's get started. I think how we're going to be doing this is presenting a case that progresses over time and then kind of just give our thoughts on, in some didactic sense, on those.
We could do that. We could do that. I was thinking even that they were non-connected single encounters of any physician-patient pair, upon which that would give commentary. But, you know, I think we've given enough there and we might as well jump on in.
All right. Why don't you start us off?
All right. Well, let's say hypothetically you got a patient, not a psychiatrist. The patient is seeing the psychiatrist for monthly medication visits. A few sessions in, the patient asks the doctor to call, asked to call the doctor by his first name and then continues to use the first name thereafter. Okay. and when the doctor asks questions of the patient of certain history or clinical signs refers to his own special interest what do you think about that well i think
a big topic we're gonna be touching on today is boundaries and I think my primer education is that every clinician's boundaries are a little bit different. And there's no like, it's tempting to look at your question and say, the question is, is it okay to have a patient call you by the first name? And I want to change the question in that. There are some boundaries that are absolutely essential to every practitioner.
Things like protecting confidentiality, things like, you know, listening and doing like, yeah, there are things that absolutely cannot be changed. And then there are boundaries that are really dependent on different variables. Boundaries that depend on who the practitioner is. Boundaries that depend on the clients that the practitioner sees. Some optional ones. A provider decides if it's okay to work on the weekends. A provider decides if it's okay to contact them after 6
m. A provider decides, is it okay to text or call or email? And I think you can't look at any single... one of those boundaries in isolation in that every clinician needs to figure out the things and the boundaries that work for them. So the specifics of the boundaries are less important than that they're maintained and, I don't know, the patient understands what they are and where they lie.
So I bring that up because I don't think having a patient call you by the first name is inherently important. a boundary crossing for everyone. I had attendings who preferred being called by their first name by patients. I had attendings who demanded to be called by Dr. XYZ. So I think the important thing here is when the patient asks to call me by their first name would be to investigate what that means to them as a start.
An excellent opinion and a common one. Let me offer an alternative. Generally speaking, it is true right that what's important is what is particular to the dyad in the treatment yet we don't live on an island we don't work uh solely you know without contact with other professionals and patients and clinicians have contact with other clinicians and patients there is a standard the standard is not set in stone but there is a standard of care um and i'm going to make an argument here that The less you have hard and fast rules about boundaries and frame, the more dangerous things are.
Even if nothing bad ever happens, all you're doing is that you're making it harder on yourself. You make it easier to have crossings and violations. if you set rules and the rules are even in name there is a risk there too but you don't have to think about it as much and it becomes more obvious when you're violating or changing rules around it is an interesting thing this is actually the first question that i talk about with the interns in the first patient contact lecture and i think we have to credit um whoever made the psychiatric interviewing curriculum for ADPIRP, the model curriculum, but it's an important one.
And, you know, again, good clinicians differ. My advice to the interns is stick with doctor. It's not about your ego. It's not about anything like that. It's to erect a role where it's that i'm in charge of your treatment and i'm here for your good this is not a friendship this is not a matter of equality i think rejecting the power of the physician is its own narcissism to say like oh yeah i'm just some guy you're not just some guy you got the power of the prescribing path okay you've got your years of education you've got your medical license you could legally cut someone open technically okay you gotta own that and you gotta keep the role That's my view.
People can differ.
Yeah, and I think to expand on what you're saying, boundaries exist as a way to provide protection from anxiety for the patient and the clinician. And it provides patients with predictable parameters by which to interact with the clinician. Yeah. And I think what I was trying to get at is having boundaries that are clear and that the patient knows is a little bit more important than the specific of what that boundary is.
So I guess to integrate our two perspectives, if a clinician, if there's a clinician out there who has all their patients call them by their first name, You can't say whether or not that is a, you know, objectively good or bad thing. It's in the context of how that provider controls their boundaries and communicates their boundaries and how the patient is to understand those boundaries.
Yeah. And ultimately, what are these rules for? Why do we have boundaries at all? I think that's what we have to drill down to. And you have to consider every personal clinical decision about your rules and practice around this. The boundary exists to protect the good of the patient and to a lesser extent, you, the clinician. Okay. Boundaries are just about what is good for the treatment and the patient and the clinical process and what is not good.
That's where they come from, and that's where you have to choose them from. So a crossing is anything that risks harm to the treatment process for the patient or you, and a violation is something that definitively harms the treatment process, the patient or you. Those are how I would define boundaries and how I would consider them. So yeah, having patients call you by your first name, It's permissible, but could it be harmful in some situations?
Yes, but everything we do has some risk of harm. All things that have a risk of benefit have a risk of harm. Now, how about the phrase? I'm asking you this because it's a special interest of mine.
Before we move on, I guess quickly, yeah, boundary crossing and boundary violations are two kind of different things. Browning crossings can further the work when they're processed appropriately. Boundary violations are things that are just never acceptable. One example in psychiatry is it's never acceptable to have a sexual relationship under any context. And any sort of sexual relationship is a direct boundary violation. It's not something that can be understood and processed in the dyad.
I am curious.
I mean, that's not how I define it. I feel like that's an outcomes-based one. No, they're both outcomes-based. You know what? You can define it however you want. But yes, all those facets are important. It's not exactly like a set in stone thing. That's the problem. The rules about the rules are not set in stone either. Hold on.
So, okay. I do want to do a short role play. So, it's our third appointment. We start the appointment. You say, hey, you injure yourself, and I go... So, Eric, is it okay if I call you Eric?
Well, I really prefer Dr. Food. I'm curious. Why do you suppose you'd prefer to call me by my first name?
Well, I, you know, like I think of, you know, Dr. Smith is my, my medical doctor. And I don't know, our relationship is just a little bit different. Like you're not, you know, we talk about more personal stuff. My doctor is, how's your diabetes? How's, how's your, how's your blood pressure? We're talking about my life. I just feel like I feel a little bit closer to you.
I like to, I think Eric is a little bit more appropriate.
I appreciate how you feel. It sounds like you think that this is a little bit more of a different relationship than one of the medical doctor. And we do some more time together. And we talk about some things that you might not even talk about with anyone else in your life, but I'll have to insist this is still a medical relationship. The reason why we're meeting is for your good.
I'm not just here to be friends. I'm your doctor too. And we're going to be trying to look out for you and your treatment. That's the purpose of these meetings.
So I can't call you Eric.
Well, I can't stop you, but I'm telling you what I recommend.
Awesome. All right. I think these little role plays will be helpful, even if it's... Yeah,
I hope some people have mentioned they're good before. It is kind of interesting, I will say, as a clinician. By maintaining the doctor so-and-so rule, you get kind of a little bonus test of certain patients' personalities. Some people will call you Mr... Some people will call you by the first name despite your introduction and no indication. Some people will ask. I think it just shows you some variations.
It's not a sign of a particular pathology, but it does show you some personality patterns.
And it's one of those things where it can. For different patients, different doctor, mister, first name, just means different things to different people. For some people, some people raised in a medical family, it's doctor very strictly, no deviations. For some patients, I've been called mister oftentimes because they just don't understand the nature of our relationship is medical, which I think you did a great job of pointing out the reasoning and how to think about it.
All right, the second thing in your case study presentation was the special interest.
Yeah. What do you make of saying, I'm asking you because I have a special interest.
Now, this actually reminds me of when I was on the consult liaison floor and I was doing the MOCA or the mini-mental, oftentimes I would say, I have a few silly questions to ask you. And one of my really good attendings said, don't start by asking if it's silly questions. And for questions that are essential, like the... I think the special interest in this case was, what was the special interest?
Suicidal ideation, wasn't it? Or self-harm?
so that's that's standard of care that's standard of care um so the asking if it was a special interest is acting to me i i interpret it as though it's like oh i'm asking this not because i'm this is a part of our standard operating procedures i'm asking this because of of my own little you're helping me out actually uh because i'm doing my studies and this is Whereas, which it's very possible that some clinicians do that.
I have a special interest in AI. But this is not that. Asking about self-harm is standard. It should be standard in every single encounter with a patient. Yeah.
So I think I can understand why people might phrase it that way. Right. People might feel that it's awkward or that it could be off putting to a patient to ask about certain topics. And there are various ways you can try to soften that. But as you say, I do think that making a personal thing, calling it towards or referring towards a personal gratification or interest is a little dangerous.
Whenever possible, I would recommend that you refer to clinical necessity or at least something that helps clinically. I might say, hey, I'm curious. I would like to hear a little bit more about that dream you had. But at some point, if not, then I will say and then, you know, the reason why this is important is because these dreams are a reflection of your thoughts, feelings and your wishes.
And if we look closely at them, you'll get a better sense of who you are and what you're about.
Yeah. And I think the point I'm trying to say is, you know, don't minimize questions that you're really trying to extract important. And I'm not immune to this. I remember on inpatient after one week, there was, you know, our attending made sure we asked every single patient, are you hearing any voices? Are you seeing things other people don't see? Do you want to hurt yourself? Do you want to hurt others?
And... After 15 days of that with the same patient who said no for the last 14 days, I remember putting a little quip at the beginning of my standard necessity psychiatric questions. Do you have any thoughts? Are you seeing anything other people don't? There are times that I do minimize. I'm not saying if that's appropriate or not, but I think in this case where... It's really important information.
It's not just the secondary thing. Don't question it. Don't minimize it. Don't pad it. It should be asked in a straightforward manner.
Yeah. But, you know, what you're referring to, the 15-day thing, I'd do something similar, right? You know, a lot of patients need to be reassured. I say, look, I ask this of every patient, every time, every visit, and I really do. I make sure I do because I don't want that to be a lie because it is important to ask. Sometimes it does throw positive even when you know a patient for quite a long time.
And if you don't have a standard, then people will start to feel accused, and rightfully so, of having XYZ pathology when really what we're trying to do is that we're trying to detect important things.
All right. Should we move on to the next hypothetical? All right. So... the patient reports starting to see the doctor as more as a friend than a doctor. The doctor would talk about his own professional successes, his own achievements. And then another thing is the patient experienced the physician as alternating in warmth and coldness in that sometimes she felt like he was warm and engaged like a friend.
And other times there was like this cold informational collecting aspect to them. as as a result of these with the patient experience as confusing and as a friendship she began to admire and and start to develop feelings for the clinician
you know this is one of those issues where it's in my opinion impossible uh to prevent this um some even if you are a perfect doctor and there is no such thing as a perfect doctor i do think that um A lot of this kind of perception can be one-sided or even induced by one party or another. So having ups and downs, let's say, in feelings about people, some people have more of it, some people have less of it.
The only thing I can take issue about is maybe discussion of your own professional work and achievements when it's not necessarily pertinent to the treatment process. Now, have I ever done it? Yeah, occasionally I've had to. I don't know if I had to, but I felt compelled to and I did bring up, for example, an academic position in the course of a treatment. One example was when a patient said to me that perhaps I needed more education on ADHD and told me that they would send me certain articles.
I mentioned, well, I'd be very interested to read those, but keep in mind that there's a lot of misinformation out there. As a clinical professor, I'm happy to read these over and discuss them with you. You might say that that was a little self-aggrandizing. My purpose there was to try to inspire at least some degree of professional trust in a patient who was at the time perceiving me as basically not credible, you know?
I think let's talk a little bit about the experience you had of seeing the doctor as more than a friend and developing warm, loving feelings. Should we?
Yeah, well, again, that's an automatic thing. That's something that happens automatically, right? It's called a positive or even romantic transference reaction. And why is that? common well i don't know if we fundamentally know why the theory is that any relationship treatment relationship where you have two people who meet regularly it's going to take on echoes or going to be informed strongly by early parent-child relationships and relationships with significant others so it's sort of an echo reminder and was necessarily informed by those kinds of relationships and the habits that you have how you perceive other people how you perceive yourself how you act what you want and that's actually the engine of uh treatment in a second dynamic psychotherapy right but it's going to happen automatically so we need to know that this is a eventuality rather than something that is to be avoided or prevented It's going to happen, but if we maintain a strict and strong frame of treatment, if we refer to the shared project of treating the patient whenever necessary, and if we're sensitive to fluctuations in the treatment process that are not exactly the same as other patient-doctor relationships, then we can address it directly when it happens.
It doesn't always make itself apparent, though.
Yeah, one thing you said it correctly, but it could have been confusing to the listener. So transference is the inevitability, which is transference are unconscious feelings that are transposed on a significant individual. And this is something that occurs often in therapy as a result of the closeness of the relationship, but it occurs all throughout life. There's transference in your romantic relationships and your friendships and And there's like a spooky idea in that.
It's like, you know, you're seeing the father and blah, blah, blah, blah. But there's also, I think, a less spooky way to view it, which it's just the brain trying to make sense of current experiences and relationships by seeing the... past relationships in the present. It's almost like there's information from the past is being used to predict information in the present, and it's limiting the input of new information.
And as you mentioned, there's different types of transferences. So you didn't say this incorrectly, but in case that person didn't hear it correctly, this sexual or romantic transference is not a guarantee. What is a guarantee is a transference of some sort. And there's positive transferences where the relationships, they are projecting positive, enjoyable relationships of their past onto you. There's negative where painful or less desired emotions are projected onto you.
And sexual would be fantasies about the other person that are romantic, intimate, sexual, or even just reverential, like thinking, you know, you're a genius, perfect. I mean, it's not necessarily sexualized transference, but... Those tend to reflect a patient's early life impulses and fantasies that emerge in the process of getting to know someone better. And I think we're going to be talking about this. Transference and working with transference is part and parcel of psychodynamic and psychoanalytic work.
It's a little bit more difficult in psychiatric work. And I think that's going to be one of the main things we talk about today.
Yeah. And it's, you know, you can call it baggage or you can call it learning. Right. It's the human tendency to learn what to expect, what not to expect from some variety of environment. And the environment is that of another person, the most important and the most important environment to development and to being a human being. And it's going to happen, and it does happen, some kind of a transference, some kind of expectation set, whether you're working for a boss, a partner, a doctor, or a psychotherapist.
So just got to learn how to handle this kind of thing.
Now, you mentioned learn how to handle it. I think one thing that makes it a little bit more challenging for psychiatric providers is there's a very clear literature writing in terms of how to handle it in the therapeutic relationship. You know, the weekly relationship in a psychodynamic therapy. There's very clear, digestible rules about what to do when these things come up. And I think one reason why we see these problems happen more and more in medication management or psychiatric settings is there's not a clear literature that provides instructions on what to do in the monthly medication management visit.
And I think the thing that makes it difficult is in therapy, you have that the frame is very different. In meeting weekly with a therapist, there's time to unpack, to understand, to process. In monthly 30-minute visits, it's a little bit less clear.
Yeah. And, you know, I wouldn't even dispute that it's all that clear and manualized for psychoanalytic and psychodynamic psychotherapies or other therapies. You know, obviously, they spend a lot more time on it and train it and talk about it. But I don't think the rules are so clear. So I think it is an area that is bereft of rules. And as a result, you have to go to first principles.
And the first principles I would repeat and repeat, similarly to before, is that you have to keep strict boundaries in frame. then you have to refer back to that frame and the therapeutic alliance when you notice anything that is amiss and that may require you to explicitly assess the quality of the therapeutic alliance when you are encountering anything that feels or seems a little bit off just got to check in explicitly are we on the same page here about what we're doing here together what problems we're addressing and how we're addressing it by the way you guys can go listen to the other episode on therapeutic alliance if you haven't already
One thing that makes things a little bit more complicated, and maybe we'll progress to talking about this more, is even online, some people think the erotic transference is like, oh, the patient has borderline personality disorder. It's common and normal. Just because someone has an erotic transference is no diagnostic information about their psychological functioning. The presentation of the erotic transference is very different in what we call a neurotic patient.
And when I say neurotic, that's typically healthy range. It's just a weird old-timey word for the healthy range of personality functioning. There, the erotic transference presents gradually. Often, it Like it occurs in more disguised forms. The patient will be a little bit ashamed, embarrassed. They'll be able to look at it with more curiosity and more self-reflection. And they'll appreciate requests to remain in the frame of the treatment.
Usually it's in the context of a patient where they maintain boundaries. They're not asking for anything explicit. And there I think the interventions are a little bit more collaborative. Whereas patients who are in the borderline range of psychological functioning, it can present rapidly, it is often fear-driven, it's testing boundaries majorly, these things escalate really quickly, there's much more alteration session to session with the primary emotions that are coming out in the erotic transference.
And it's a lot more complicated. Often the patients aren't able to reflect in a symbolic way on those things that are coming up. And that if you were to try to understand what's occurring symbolically, it can be much more challenging. And I think what we'll be talking about is the main intervention, regardless of how you respond, is high containment. The frame... must be airtight when you're experiencing those things.
Yeah. The fact that it occurs is universal. How a particular patient responds, and frankly, how a particular clinician responds, may be more indicative of something. So you have to refer back to reality. And that brings us to the question of what is reality, which I was probably going to say for the end. But at this point, looking at the time, we may have to tease a second episode.
I think maybe it's worth making this a two-parter. We got time. I think we should do it two part. But I think in in summary, with a medication management, you can more easily remind, I think, that, hey, this is what we're meaning for. It's for a medical purpose. And that's the nature of this relationship. And you can see how people respond to that. What I would also do is try not to do deep exploration of fantasies unless you know what you're doing, and certainly not in the medication management.
Stay within the interventions that are natural and common to your particular modality of treatment. right exploring sexual fantasies is not a normal part of medication management right and if you are starting to do something in the medication management that is markedly different from what you do with other patients that's a red flag that's a warning sign you need to be seeking supervision or you need to be taking some
different steps yeah i think um to To play off what you're saying, in residency, I had a psychoanalytic interest. I was not psychoanalytically trained. Now, I think what you're saying, and it's important, is just because I read a paper on some deep psychoanalysis three times a week and how that therapist responded to sexual transference doesn't mean I do a half-baked attempt at recreating what that intervention was.
In that... My frame and treatment is very different than what that practitioner was doing, and I should not be trying half-baked efforts to do that same thing.
Mm-hmm. To scare all the listeners out there, there is a old case where a social worker therapist had a patient who had no criminal history, male, who began to express sexual and rape fantasies towards her in their psychotherapy. And what she did was, this was weekly therapy, encourage him to elaborate upon the fantasies week to week until they got so intense and one time he approached her like got up the chair and approached her during session and then she immediately terminated the session and then wrote him a termination letter in the following week and then he firebound her house and killed part of her family This is a forensic case.
That's why I'm familiar.
Dude, what are you... Whoa. You just turned the intensity from zero to ten.
Unless you have a very clear idea of what you're doing, I highly recommend that you seek supervision.
This is a family-friendly podcast, Dr. Fu. What are you doing?
yeah um and you know i haven't checked my insurance policy by the way but i think that this was enough of a problem in the past that malpractice insurance might specifically exclude coverage for mishandling the transference which actually is a uh disguised way of saying having sex with your patients uh but you know it's it's an issue it's an issue enough that at least in history was mentioned in malpractice insurance for therapists and psychiatrists
Could we do a role play in terms of you be the practitioner, I be the borderline presenting patient with the erotic transference? Sure. Let's try. I guess I'll use the beginning. So, Dr. Fu, you moved our appointments in person, and I have to say, I... My feelings that I've been feeling towards you in terms of romance, it's pretty clear to me that you feel them too. And I'm pretty excited about it.
I know you as a doctor, you're not allowed to do anything, but I think we can consider ending the treatment relationship and maybe engaging in the relationship we both want.
Well, I'm sorry. I don't mean to be mean or rejecting anyway, but, you know, I'm not feeling those feelings. And what I feel is care for your well-being as a patient. That's my job here. And that's always going to be my job as long as we're working together. Now, if that's going to be a problem moving forward, it might be a better idea for us to find someone else.
I'm not kicking you out of treatment. If you want to keep going on and we'll work on this problem, your ADHD together, I think we can do so. But just keep in mind, this is medical treatment. I'm here to take care of you in terms of your ADHD and not anything else. And I also should mention sex can never be a part of any relationship with a psychiatrist and frankly, with a therapist.
In fact, I have a pamphlet here that I'm legally obligated to show you if this ever happens to you. This is actually true for my state. There's no mandatory reporting. You have to show them a pamphlet. This mandatory pamphlet. I'm not kidding. Let's go back to the role play.
So I'm so glad.
And by the way, yes, basically, I would specifically even mention that we're ethically bound to never have a romantic relationship with any patient. We are not like other doctors. And anyway, go on.
So I'm glad you bring that up because I think I agree. I think we could terminate and maybe wait a month or two and then start this thing.
no no no that's not what i'm saying even if i stop being your doctor ethically uh a doctor can never a psychiatrist type doctor can never have a romantic relationship a patient in the long term long term and i don't even keep friendships with patients after we terminate i know some doctors do that but that's beyond my boundaries and again the reason why i have these roles is to make sure that your well-being is at the forefront because I think this is really the best thing for you and all my patients.
So just because this is going to be a challenge, I think we better talk about getting you a new doctor. Sorry.
So just because you want to have sex with me, you're going to make me get a new doctor.
Well, that's not what I'm saying here.
What are you saying?
I'm saying that we better talk about what to do with your treatment moving forward.
And we're just going to leave this elephant in the room.
I think we're talking about it now.
we both have feelings and we're just going to talk about stimulant medication. I feel like that's That's ridiculous.
Well, how about this? Let's talk about the stimulant medication. And if you feel like you can't let go of this issue, I'd like next time for us to talk about what to do with the treatment. I'm going to get a list of other doctors that you're going to be able to see. And, you know, we'll be able to talk about how much time we'll have left together next time.
But for today, if you're willing, let's talk about how you've been doing any medication.
So you asked me to bring in the emotions and what I'm feeling, and then you abandoned me as soon as I'd be honest with you.
It must be very disappointing. And I imagine that most people in your situation would feel pretty hurt. But I hope you can hear and know, even if not right now, that I'm doing this because I'm trying to protect you. How? I know you don't see it, but that's the reality.
All right. That was pretty good. That was enjoyable. I don't know. It's saying it's the reality is interesting, but.
Well, I happen to be a believer in reality. We can talk about a definition of reality. But yeah, I mean, everyone's going to handle that one a bit differently. But if you have somebody who is not able to come to the same level of or rather version of reality as you. come to an agreement about what is real with you, then there is not really much point in negotiating.
Refer back repeatedly to the treatment frame, to the plan, and do whatever you can. To be honest, if it gets to that point for just a plain medication management, not for a psychotherapy, you are in some hot water, my friend, the clinician, and I would begin to call your risk management.
Yeah, I mean, I think some of the key principles in terms of how you're responding, I think you're acknowledging what's going on without encouraging enactment at all. You're recognizing the feelings, but not colluding, not reciprocating. You're not reinforcing the fantasy. Now, one thing I see in terms of literature that for, again, the therapeutic thing is when to connect it to the past. I'm glad that you didn't connect it to the past because I think that would be inappropriate in this ADHD medication session.
Yeah.
Yeah. It would be handled very differently if it was a long term psychotherapy relationship. But that's not the focus of this particular podcast. This is more or less how I would handle it for a supportive psychotherapy, though, if we were ostensibly doing a supportive mixed with medication modality. But I'm not a fan of that. I don't usually recommend that unless you can avoid it.
Now, unless you can't avoid it. Um, I, I know we need to continue cause we have more things that I feel like we're, when in medication management, if a patient presents with these erotic transferences, when do you think it's appropriate to switch providers? When, let me, let me phrase this. When is it appropriate to bring up the potentially switching providers? When is it appropriate to, um, be more like, like essentially said that you are going to be switching providers?
uh you know that might have seen quick for the purposes of a role play but at least for me and again good clinicians can differ if it's purely medication management and that's happening i'm doing it that session i'm not kicking out the patient but i'm making it clear that we have to be able to proceed professionally and if And I don't want to shame you. And I know it can feel awful and embarrassing and like I'm rejecting you or that you're being kicked out of treatment here.
But this is for your own good. If we can't move forward together without this getting in the way of focusing on your treatment, it's the best thing for you if we can find you a new doctor. I could do it that session. I would just assume that in a med management session, I would need the rest of the time to check on the meds and then let them cook and appreciate their situation a little bit before the next visit and also gives me some time to get some referrals on board.
Awesome.
All right, let's keep moving.
I think we've got to do a part two. This is a very rich topic and I think we can do one more hypothetical.
We got like 15, 20 minutes left, but let's move on to the next one.
uh maybe for you i got eval scheduled okay um so let's say your patient presents to a med management visit uh she says uh you know yesterday i was in a car accident i went to an urgent care and they told me to go to the emergency room because they thought i might have internal bleeding But, you know, I really wanted to see you, so I didn't go just yet.
I'd like to finish the session today first. What do you do about that?
Oh, boy. These are not easy questions. And especially I can't. I mean, right now I have the grace of not feeling the pressure and the time intensity and having this pop out of nowhere.
Yeah. Imagine that just coming to your office and putting you on the spot. That is hard.
Again, basic principles is first try to understand what's going on, be nonjudgmental, assess the situation. So I would probably just ask clarifying questions so that this way I'm not responding in a way that the patient won't resonate with because I missed some sort of thing. So I would get a lot of the details and try to just better understand the situation. And then this also buys me time to process, to think carefully, While I'm doing a detail, you know, just figuring out what's going on, I get a time to breathe in, assess my emotions, assess the decrease the intensity of my own emotional reaction.
So that's where I would start.
Getting a history, right?
Just get a history. And it's serving two purposes. One, I'm less likely to jump in and say something by my own misinterpretations where it's like, oh, no, no, no. They, of course, discharged me. They said I had an appointment at 30. I pushed it to 4. It's just some weird thing that you missed. And it also gives me the time to calm down my own nervous system and my own like, oh, God, what is going on?
Yeah, I mean, it's absolutely clarified the facts. I would say that we have a little bit of leeway as physicians versus the psychotherapists. But as a physician, I think there may be a choice to get a little bit more of a medical history to get your own independent appraisal of how serious this is and whether any alarm signs. Now, if you don't have the training experience or confidence to do so, then I would just do what I would recommend to a psychotherapist.
Unfortunately, this is a situation where, in my opinion, it warrants termination of the session earlier or cancellation of the session. OK, the number one thing in a psychotherapy or psychiatric relationship is the safety, the physical safety of the patient. Right. And if that is that threat for any reason, you need to change gears and you need to start addressing that. Okay, and if it means that you have to say, I'm sorry, I must insist, I would like you to proceed directly to the emergency room today, we must cancel the rest of our session, and I will see you at the next time, then that's what you have to do.
Now, what if she says,
And sorry, just to emphasize, because I just want to emphasize a great point you made. It's not the psychiatrist's role to be able to practice every form of medicine. I'm far enough away from internal bleeding to be able to properly think through safety for if that presents. And that's okay. So... I say that as someone with an MD. For therapists, for social workers, clinicians, it's not their role to do a medical assessment and then determine that they're safe enough to proceed.
If there's any question mark, You shouldn't be going outside your role and doing a medical assessment to continue on with the psychiatric assessment. If you're not sure and you don't know how to think through something, don't pretend. Again, this is the same thing I'm saying before. Don't do a half-paked emergency doctor visit if you don't know what you're doing.
yeah and so again the number one priority of course is the physical safety of a patient in a psychotherapeutic context right you cannot continue a psychotherapy if you're dead this is the same thing as if um a suicidal ideation that was serious enough to warrant hold came up in the session right you would uh not go like well let's keep doing our cbt triangles or do our free association you would stop the proceedings Do whatever assessment and counseling is necessary and refer to whatever treatment is necessary.
There will be time in the future to address something else. That's what I would do. Now, what if the patient refuses? Unfortunately, I would still probably stop that session. OK, I would say based on what I'm hearing, we cannot continue today. That's my recommendation. I hope you do go get some treatment. And certainly if you're not going to go right away, you start feeling worse. You have to call 911 or go to the hospital.
And I'm going to see you next time.
All right, let's do a quick role play. All right. So, yeah, yes. I mean, yesterday I had this like crazy stomach pain. So I went to the ER. They wanted to work up this internal bleeding. And they said that if they saw anything, the surgery would leave me for like three days in the hospital. And we have our appointment today. And I was like, there's no way I'm missing my appointment with Dr.
Fu, which is too important. So I left AMA. And I'm glad because, you know, we get to spend some time together.
Well, I mean, I appreciate that you hold me in such high regard, but I'm really concerned about what happened here. This sounds like you could be in a very dangerous medical situation. And I don't want you to ever put these sessions above the importance of your physical health, because that is really what we're trying to work at here. Your general health and the physical health comes first.
So I know you left the hospital, but I'd like you to stop the session now with me. We're going to stop today.
No, no, I get it. I get it. I'm not going to sue you, Dr. Fu. Like the stomach pain is totally gone. I'm not suing you. Don't make a big deal about this. I'm fine. Like the pain stopped like an hour after I was discharged. Like it's totally fine to continue this appointment. I'm all better.
I hear you. You want to continue the session. You feel like you're doing okay. But as your doctor, I need to stop the session. This is for your own good. I want you to go back to the emergency room and continue whatever recommended care they did there. And I want you to tell me about what happens at the next session. Our next session is scheduled for XYZ.
At what time? I hope you can make it. And please, please, if you don't get an emergency room right after I disconnect or right after you leave, if you start feeling worse, you got to go. You got to call 911. OK, please. And don't refuse medical advice in the future. Really, they try to work their best for your own good.
I mean, I'm not going. The emergency room is terrible. There's zero chance I'm going. I think, can we just like, last time you gave me a tough time about reality. Let's address reality here. I'm not going. So we might as well just finish the appointment. I need my medications. I need you. There's no way you're not prescribed.
I understand you're going to get your medications. I'm not hearing something that would make me stop them right now. But again, you have to follow medical advice. And this is my advice to you. You can take it or leave it. But we're going to stop right here. And I'm sorry about what happened.
But you put such a focus on reality last time. And the reality is I'm not going. So why are we pretending that I'm going to the emergency room? I'm not. So let's just finish the appointment.
I'm not pretending. I'm giving you my recommendation. And we're going to have to finish right now. okay and then at this point i would get up open the door of the office uh you know just disconnect the video call uh whatever mode i'll do oh i'm doing a good job and on these role plays okay different people will handle that differently different people will handle that differently but um i'm gonna reiterate i think that um it's easier to do unpleasant things as long as you know they're safe and therefore the good of the treatment it's easier to live a life with certain rules and regulations because it saves you from having to think about or negotiate all the nuances now that can have its own detriment okay but uh this is at least maybe most of you listening this is the united states and uh the courts and society love to hold clinicians accountable OK, even for things that are outside their control.
So because of that, my recommendation, my personal recommendation is that you follow some pretty strict rules and boundaries.
I'm assuming you're you have to go at one thirty.
Yeah, we should finish up.
Well, so Dr. Fu, given how well this podcast has been going, I'm wondering if maybe we should meet next week instead of two weeks.
Oh, I don't think so. We need to adhere to the plans that we've made already in advance. I'm sorry I'm not available.
But I think we've been doing such a good job. I think I really need a podcast in one week. I don't know if I can wait.
I appreciate that, but I think we're both going to be just fine with that. I think this is a good one. Yeah, definitely we need a part two here. It's an extremely rich case that, you know, all these kinds of hypotheticals that a lot of people, I think, can really learn from. Hopefully you guys enjoy. Let us know in the comments.
I hope you appreciate it. I was going back to the beginning.
Oh, yeah. All right. See you next time.
All right. Bye. Thank you.