Friday, August 13, 2010

What Good Are You?

"What good are you?"

It sounds harsh, but sometimes that's what I hear from my patients. When a prisoner first comes into my office, he may announce a list of things he wants me to do for him: get in touch with the public defender or case manager, look up a court date, make a phone call, give him the lower bunk, order extra portions of food, etc. When I explain who I am and add that I am seeing him only for psychiatric treatment, I hear "the phrase": "Then what good are you?" Apparently, I'm not good as a concierge service.

Defining the physician-patient relationship is the first step in correctional treatment. Life is simpler when it's clear what you will or will not do for a prison patient. Inexperienced correctional physicians feel uncomfortable doing this because they want to be "nice" to the patient or because they're afraid that denying a request might harm the physician-patient relationship.

The problem with complying with all these requests is that the patient will continue to take it for granted that the doctor will always do these things, which draws the focus of the appointment away from treatment. Other prisoners will learn that the physician will do errands or give privileges, and the clinician will find his clinic swamped with requests for appointments that involve issues other than mental health care.

The clinician may be tempted to pretend to help, going through the motions of a request that he knows will not be granted. Worse yet, he might promise to help but then be too swamped or overwhelmed to actually carry through on that promise. Either way, the promise is not kept and prison patient learns that the clinician can't be trusted.

All of this can be prevented by clearly establishing the boundaries of the treatment relationship and the limits of the appointment. This does not harm the physician-patient relationship. In fact, prison patients appreciate a straight answer, even if that answer is 'no'. I find it helpful to give a straightforward response: "If I can help you with something I will. If I can't help you, I'll tell you upfront I can't. This is what I CAN help you with…" and so actual treatment begins.


Anonymous said...

Reminds me of when I was in Louisiana after Katrina....always greeted with "are you from FEMA?"---people wanted help with housing, not head shrinkers!

Okay, off to hike in the adirondacks.
We've had weather in the 70's, walked around Mirror Lake yesterday, kayaked on Lake Placid, dinner on the lake, watched a movie...wonderful resort. Had a great time in Quebec City and a good day in Montreal, too. Good food, saw Tahiti at an IMAX in 3D.

Miss y'all. Hope the move is going well and can't wait to get back to the book. But for now, the breakfast buffet calls.

Maggie said...

The issues are different out in the "real world," but I certainly wish that more psychiatrists and therapists (and people in general!) were able to clearly define what they can and can't do! It's frustrating as all heck when someone won't admit to what they can't manage.

Jessa said...

I am not in prison, but I assure you that I would also greatly appreciate that straightforward approach. I'm not big and intimidating that people would want to appease me, but I am sad and pathetic which has made people want to help me. So they make promises that they can't keep. I suppose they think that if they promise me that a treatment will work, I will feel a little better immediately, held up by hope, which will tide me over until the treatment can work. However, in my experience, the more fervently I am promised a treatment will work and urged to have hope, the more likely I am to end up more damaged by the treatment than I began.

I wish those professionals would be more straightforward about what they can and can't do for me. They cannot promise me a treatment will work. They can guide me through a treatment that might work. They can promise that the treatment won't work if I don't try it.

The way things have often been done with me, making promises that can't be kept, has led to me feeling punched in the face, feeling like people are trying to hurt me, whenever they push hope or promise good things. That sucks. Not every patient will react the way I have to unfulfilled promises, but I doubt any patients would be worse off if professionals just avoided making promises they can't keep altogether.

Sunny CA said...

Thanks for your postings while Dinah is out of town. It was a very interesting post. I don't think it relates to me directly in that I have not had any such requests of my psychiatrist. He in fact has given me more than I expected and more than I would have thought to ask for. He is there waiting when I go for my appointments, on time, and concentrating on me. He is empathetic and genuinely cares about me. He has allowed me to have contact outside of office hours at times I need it, and even has encouraged me to call. I did not expect a real bonding and connection of the type I have with him and this is worth a lot more to me than I can say.

moviedoc said...

It's the same out here, Clink. Fill out this form. Sign that form. Write me a note. Get me disability. Loan me money. Get me off work. Help me win this lawsuit. Get me back to work. Get my meds paid for. Get my treatment paid for. Get me out of jury duty.

And like in your prison setting, the docs who try to be all things to all patients raise expectations for the rest of us.

Just say, "No," and stick to diagnosing and treating.