Thursday, December 29, 2005

Psychiatrist as "Ice Queen."

Maria tries not to reinforce unhealthy behavior.
...the goal is to discharge patients who repeatedly engage in self-harm behaviors (stabbing or slashing themselves, etc.) as soon as possible because, unfortunately, some people reap great rewards from hospitalization (three meals; a bed; warm attention from other human beings; etc.) and thus may continue to physically hurt themselves so they will emotionally feel better. Ultimately, these people benefit greatly from consistent outpatient care where, in the non-crisis situation, they can learn how to obtain these emotional rewards without resorting to these dangerous (and potentially lethal) methods.

These outpatient providers thus ask us to not be warm to them so that, in comparison, the outpatient providers are more appealing and amiable than those cold-hearted, aloof, and seemingly unkind hospital psychiatrist bastards. (It is honestly difficult to act like a jerk, though, because we’ve been trained to exude warmth and that is what we usually do.)

So I put forth my best efforts in not being warm today and it worked. Which totally sucked for the patient and it wasn’t fun for me, either. Ultimately, perhaps, it was the best thing I could have done for the patient, but I just don’t enjoy being an Ice Queen...


Blogger Fallen Angels said...

I said it there and I'll say it here...SI (in absence of some other cause) is ALL about feeling better emotionally. Until other coping sills are learned, people who SI will keep on doing it regardless of what happens in the hospital. I know many who SI (and struggle with it myself) and the hospital is absolutely without a doubt the last place on earth I (and others I know) want to be. Warm, caring people or cold, aloof people...I won't go, either way. So there is no way you will find me SI'ing so I can go back!

7:59 PM  
Blogger Bob said...

I used to work at a little community psych hospital that just about trained people to attempt self-harm, rather than teach them coping skills.

11:07 AM  
Blogger Joel said...

I liked the staff in the ward better than the staff in outpatient.

Is something wrong with me?

2:29 PM  
Blogger shrinkette said...

I think that we don't actually have to become "ice queens" to discourage non-therapeutic (or counter-therapeutic) use of the inpatient ward. A resident might feel like an "ice queen" while trying to be firm and reinforce healthy behaviors (especially if, like Maria, warmth comes so naturally to her).

Whatever Maria's doing, it doesn't feel right to her. I'm thinking that she'll find a more authentic way to reinforce behaviors that are healthy.

This gets into the concept of "counter-transference," i.e. the psychiatrist's unconscious feelings toward patients. A doc might exude warmth because of her own emotional needs (the need to have the patient reciprocate warmth, or the need to nurture the patient, or the need to be liked and approved of.) But what if that warmth causes problems for the patient? Maria is learning how to put the patient's needs first.

5:12 PM  
Blogger Kat said...

I said it at Maria's blog and I'll say it here - while some patients may benefit from that, others might not. A commenter at Intueri mentioned someone treating all Borderline patients the same way. The disorder has 9 criteria, of which you only need 5 to be diagnosed - it can take on hundreds of configurations. Treatment needs to be determined individually, and not lump everyone with a diagnosis into the same thing. Even among non-psychiatric illnesses, different patients respond differently to various treatments.

5:45 PM  
Blogger Fallen Angels said...

Agree whole-heartedly with Kat. My GP treats me with compassion, warmth and where do I go on the (very) few occasions I need wound care? You guessed it...I go to my GP. I do want to point out that not everyone who SI's is borderline...and not all borderline's SI. Kind of reinforces Kat's point though.

7:15 PM  
Anonymous Anonymous said...

Why can't the physician simply be honest about what they are trying to accomplish?

11:04 PM  
Anonymous flaweplan said...

Quite. Of course p-docs can be honest, if they are willing to abandon their superiority and maintain affective congruence, rather than infantilizing the defective patient by attempting the manipulative strategizing we see here. Not only is such dishonesty transparent, it is a breeding ground for resentment, if not paranoia. Does Maria think she can feel one thing and express something else and not contribute to mental confusion? And all in the name of avoiding secondary gain? As if cutting is all about her...such hubris is mind-boggling indeed.

I believe affective congruency has been shown to be a necessary component in healers, sounds to me like Maria needs to revisit her Rogerian textbooks, stat!

2:40 AM  
Blogger mike said...

I imagine being an ice queen would be good practice for dealing with telemarketers.

1:29 AM  

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