Key moments, in order
Among patients with the same Axis I diagnosis, more personality impairment means a worse prognosis, which is clear in research and clinically.
A useful mantra: it's not your fault, but it's your responsibility.
Treat the scheduled block as the whole encounter: talking, recommendations, notes and sending resources. Start on time, never early. Starting early does not help and leads to burnout.
In outpatient medication management you need a scribe or AI, or you document during the session. You can be psychotherapeutic while documenting; it just takes practice.
Do not start early. It does not actually help, and even a few idle minutes waiting for the next session is important rest time for you.
For patients who tend to go long, give a five-minutes-left reminder, even in the middle of something heated.
If you keep running over, set expectations at intake: the intake is an hour, follow-ups are 20 minutes. The expectation you set decides how the patient reads the end of the visit; cut off someone who expected an hour and they feel rushed.
Get a silent mouse and keyboard so the typing and clicking during the appointment is not noticed.
Patients always know when you are documenting, so be open about it (sometimes even say, give me a moment, I want to write that down). People do not mind documentation; they mind you doing things that are not about their treatment.
Frame and timing are tried and true psychotherapy principles, and they apply to outpatient psychiatry too.
Keep a task list and do not leave work until it is done. Unfinished tasks build up, and the stress of thinking about them is a road to burnout.
Set the expectation that the work happens in the appointment: forms, side effects and changes get done in that chunk of time. Aim for an ideal where all non-emergency matters of substance are handled in visits, and get as close as your practice allows.
Unless it is a true emergency, do not put out the fire. Offer the soonest appointment instead.
In private practice, keep a couple of 30-minute emergency blocks. If they do not fill, they become admin time for your checklist.
More contact is not necessarily better treatment. Like having an MRI available any time, it leads to panic and anxiety and keeps the patient from sticking with one set of findings.
Ideally, frontline staff such as a clerk, receptionist, nurse or social worker manage the messages.
Set expectations very early that text and email are not for clinical purposes; they are for rescheduling. Make it clear early on that you are not a friendly emailer.
The expectations you send change how the patient responds to the content of an email. Establish early that messaging is not how you work together.
No one meaningfully recovers through email and texting; it is not an acceptable treatment modality. Being overly interesting or validating in your emails implicitly encourages that mode of communication.
Anything of substance that is not a clerical or EMR error has to be handled in the appointment.
When supervisees say they are working until 8 p.m., a look at their emails usually shows messages that are way too long and way too friendly.
It is your responsibility as the clinician to set the frame and to keep it.
If a patient sends intrusive emails, talk about it in the session: say this is not how you work, ask why it is happening, and discuss what the emails say.
Boundaries protect both patient and clinician from anxiety and give the patient predictable parameters for how to interact. Rules bring a kind of freedom; working in a system without rules is anxiety provoking.
A kind environment is a predictable one: clear rules, reliable feedback, patterns that repeat.
A wicked learning environment is one where information is incomplete or hidden and the results of your actions are delayed, inconsistent or absent. A lot of difficulty in personality and development comes from growing up in one: in an inconsistent environment you do not learn confidence and trust in yourself and the world.
Let patients know that if they do this, that will happen. Those expectations are comforting and protective.
Do not break a rule or standard of practice because you think it is for the greater good. Read your state medical board's disciplinary outcomes and you will find many people who lost a license that way.
Emotions you do not communicate and experience turn into stress, anxiety, tension or actions. Find people you can safely tell, where safe means your emotions are heard and recognized, not undermined or ignored, without needing to be told they are 100% correct.
Without safe people to talk to, the other avenues are supervision, a peer discussion or support group for clinicians, or emotion-focused psychotherapy.
Just complaining about your emotions or problems is not productive. It can increase anxiety and make you feel worse.
Find a mentor or supervisor who has been through these things and can help you make sense of them. Postgraduate supervision, coaching or mentoring can make a considerable difference, even if you have to pay; just get your money's worth.
Technical containment is perceiving the inner emotional experience of another person, receiving it, digesting it yourself and communicating back that you have perceived them. That is all: you are not giving information or changing anything. You use your mind to clarify the patient's disorganized thoughts and feelings so that over time they can organize their understanding of themselves.
Contain the complaining: ten minutes on the couch with a partner to get it all out, and then you are done.
Before any analysis, interpretation or confrontation: contain, contain, contain. Show the patient you have actually heard and experienced something like what they went through.
We do not have much ability to change outcomes. We are a small piece of the system, and most of what happens with patients is determined by people who are not you.
We cannot really control or prevent bad outcomes. We will see suffering we want to change and cannot, and part of the role is learning to accept that.
Knowing what you can and cannot do is protective. It frees you to give everyone your best care without overextending in ways that do not help, keeps your care honest and makes you less likely to get wrapped up in an enactment that hurts the patient.
Know the general effect size and do not oversell it, or you give the false impression of a powerful medication that will change their problems.
How you practice today cannot just be about the next week or this one patient. Think about how you will stay a good, functioning clinician for the rest of your career.
Do not let your professional identity consume your life. You need your ordinary life, the reason you are working at all.
Schedule it. Saying you will do more of something does not work; putting it in the weekly calendar does.
Exercise, hobbies, diet, intimacy and spirituality are worth asking patients about too; psychiatry is not just medications.
To be your best at work, you need to be able to disconnect and spend time doing other things.
If you work for someone, they will always want to fill your slots. Protect yourself and prioritize the rest of your life.
Every week, schedule at least one fulfilling activity alone, one with one other person and one with a group.
Protect vacations: notifications off, use the covering clinicians, do not let work intrude.
Set your own rules about when you work and when you do not, or work will pervade your life.
Postgraduate supervision, coaching or mentoring can make a considerable difference with burnout. Even if you have to pay for it, find the right person, and get your money's worth.
The most helpful supervision is a blend of therapy and supervision: less about answering clinical questions, more about your own emotions toward patients.
Good supervision invites open-ended questioning and self-reflection from the clinician. Without that, its usefulness is limited.
Parallel process: in psychodynamic or psychoanalytic supervision, what happens between patient and therapist starts to replicate itself in the supervision session, and you have to manage that.
Some work environments make burnout impossible to avoid: an impossible number of appointments, no expectation of vacation. You cannot live a fulfilled life there.
Weigh what you contribute against what you get back. A job that does not give back at least as much as you put in is not a good job.
Clinically it looks like adjustment disorder, the standard human stress response to a bad situation when there is no severe, medically identifiable disorder.
Standard signs: general overwhelm, negative and recurrent thoughts and feelings about your work or situation, fatigue, irritability, feeling helpless and detached.
If you still feel exactly the same after a long enough vacation (more than five days), reconsider whether it is burnout or whether you need to change the job.
What you do should help your overall functioning. An escape is not the same as something helpful.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.