Curbside Supervision

One of the new Psychiatry residents came to me for help about a very difficult patient encounter in which the patient was angry with everything he did. She was furious that she had to see a new psychiatrist, furious that her meds weren't working, furious that she wasn't getting better, etc, etc. This was the first time they had met and the poor resident was totally unprepared for such an introduction. At the end of the visit, the patient stood up to walk out and said, “I made you uncomfortable, didn’t I?” The resident didn’t know what to say, was exhausted by the whole encounter, and fumbled something to shepherd the patient out of his office. The patient is someone who suffers symptoms of what is most unfortunately and vaguely called Borderline Personality Disorder. 

The resident's supervisor suggested that he say, “Most people’s anger is here (raising his hand to a level). Your anger is here (raising hand much, much higher). Where does that come from?” This was meant to be a way to join with the patient.

My gut reaction was, "Yuck!" Diplomatically, I asked, “How would you feel if someone said that to you?”

The resident replied, “Not good. …probably criticized, judged.”

I think to myself, “Good, you're able to put yourself in your patient's shoes! But, then what makes you think that the patient would feel any other way? Trust your instincts and your common sense.”

Before I throw out my suggestion, I ask, “How did the patient say it?” because one has to know the intention behind a statement before responding to the statement. 

The resident said that she sounded “Almost apologetic, sad.”

Now that is workable. That sounds like remorse for the way she treated him and possibly fear that he was going to fire her and abandon her like she thinks everyone else in life is ready to do (this is a common fear for people with Borderline). I suggest saying, “You’re right, I was uncomfortable, but that’s okay. I'm not leaving. I’m not going to give up. We're going to figure this out. I’ll see you at our next appointment.”