Love working with adult patients' families and providing them with emotional support as well

Geriatric Psychiatry is a subspecialty that dedicates a lot of time to this very context - often, patients are not the ones with the complaints, for a variety of reasons, OR the complaints and fear are magnified by the family, and have to be adressed at lenght.

It's common for geri psych appointments to involve contact with the family in some form or the other, since patients have more medical comorbidities and are much more sensitive to medication side effects; there is a proportion of patients that have cognitive impairment as well of a varied intensity, so contact with family members to get collateral or explain drug regimens is also important. Not saying that all geri psych patients have these problems, but that they are much more common than in the adult psych cohorts.

milan95 said:

What positions would work well for someone who really enjoys this aspect of adult psychiatry? Thanks!

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Any at risk population requiring significant support. So children, geriatrics, and SPMI. I find the people I spend the most time with this though is family members of first break schizophrenia/bipolar. Sometimes they have other family with SMI/SPMI and will already be aware. Frequently a family is totally blind-sided (especially is kid was higher functioning) and need a lot of support themselves to come to terms with it, as most peopel don't understand what SMI/SPMI entails or even looks like.

I used to love working with these patients and their families (and I was really good at it because I'd take excessive time to educate family and provide resources). Now I've become more burnt out and it just adds to that feeling. If you love this then that's great, there aren't nearly enough people who actually understand SMI doing this work effectively.

Stagg737 said:

Any at risk population requiring significant support. So children, geriatrics, and SPMI. I find the people I spend the most time with this though is family members of first break schizophrenia/bipolar. Sometimes they have other family with SMI/SPMI and will already be aware. Frequently a family is totally blind-sided (especially is kid was higher functioning) and need a lot of support themselves to come to terms with it, as most peopel don't understand what SMI/SPMI entails or even looks like.

I used to love working with these patients and their families (and I was really good at it because I'd take excessive time to educate family and provide resources). Now I've become more burnt out and it just adds to that feeling. If you love this then that's great, there aren't nearly enough people who actually understand SMI doing this work effectively.

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It's much easier in a dedicated FEP clinic that's model-adherent to CSC. The restrictions on numbers essentially guarantees that you can take the time you need if you want to in most cases. although I do wish it was easier to find family therapists worth a d**n who wanted to do this work as well.

clausewitz2 said:

It's much easier in a dedicated FEP clinic that's model-adherent to CSC. The restrictions on numbers essentially guarantees that you can take the time you need if you want to in most cases. although I do wish it was easier to find family therapists worth a d**n who wanted to do this work as well.

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Not a surprise, doing FEP work is considered baller by most psychiatrists and is something every psychiatrist should have robust exposure to in training. Most family therapists hardly understand what psychosis is, much less do work around it and it doesn't carry any gravitas in their field. Even all the PhD psychologists I knew that specialized in psychosis (which can be counted on 1 hand) were considered odd balls by their peers.

I'm not so convinced by FEP (first episode psychosis?) clinics...
I had a young guy in my office, history from patient, and even collateral from parents; was clearly psychosis. Treating conservatively as cannabis induced, but cautiosly expressing schizophrenia as still a possible. Meds stopped... no cannabis on board... diagnosis flips over to schizophrenia with timeline and nature of symptoms. Family concerned, takes to FEP clinic for second opinion... told "doesn't have have psychosis or schizophrenia." I'm like, that's up to y'all to consolidate those differences in assessments, but my documentation stands - schizophrenia is diagnosis.

Fast-forward in time, clinical history manifests like so many. Patient is now in a state hospital forensic unit.

Psychosis is bread and butter for Psychiatry, not sure why it is getting labeled as special? It's our job.

Sushirolls said:

I'm not so convinced by FEP (first episode psychosis?) clinics...
I had a young guy in my office, history from patient, and even collateral from parents; was clearly psychosis. Treating conservatively as cannabis induced, but cautiosly expressing schizophrenia as still a possible. Meds stopped... no cannabis on board... diagnosis flips over to schizophrenia with timeline and nature of symptoms. Family concerned, takes to FEP clinic for second opinion... told "doesn't have have psychosis or schizophrenia." I'm like, that's up to y'all to consolidate those differences in assessments, but my documentation stands - schizophrenia is diagnosis.

Fast-forward in time, clinical history manifests like so many. Patient is now in a state hospital forensic unit.

Psychosis is bread and butter for Psychiatry, not sure why it is getting labeled as special? It's our job.

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Did you try and talk to the FEP clinic? I mean maybe they're just stupid but it would be useful to know what they were seeing that was obviously so different from what you were.

Nope. They didn't try getting my records, or calling me first.
And this was such a slam dunk *schizophrenia* case that I had no interest or need for their assessment.
Waste of my time to chase it down.

Sushirolls said:

Nope. They didn't try getting my records, or calling me first.
And this was such a slam dunk *schizophrenia* case that I had no interest or need for their assessment.
Waste of my time to chase it down.

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I guess I would be inclined to do it out of sheer curiosity if nothing else because it being so slam dunk it's very strange that they were apparently told there was no psychosis.

I would perhaps suggest though that even in the worst interpretation of the situation, the correct conclusion is "that clinic/psychiatrist sucks" and not "the CSC model is garbage."

EDIT: The specialness is in the approach to intervention and based around the idea of providing better outcomes for people who are dealing with a potentially debilitating mental illness. BEFORE they become chronic "mental patients" so that they might end up with other options in life.

Good concept. And when this person had it, was perfecting time to get engaged there with that ideal type of services. But being told no schizophrenia, my N of 1, leaves me jaded.

But back to OP original question.
Geriatrics is the answer.

I don't think I saw eating disorder treatment mentioned yet. Best if you can do full age spectrum (CAP) but, either way, family therapy and family involvement in general are a big part of that, even for adults.

Sushirolls said:

Nope. They didn't try getting my records, or calling me first.
And this was such a slam dunk *schizophrenia* case that I had no interest or need for their assessment.
Waste of my time to chase it down.

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You would be doing your community a huge service if you took this opportunity (or others that may arise in the future) to tactfully educate the FEP team. The CSC model is great but any team is only as good as its clinicians. My local CSC team is staffed by a green NP via telehealth and a newly minted LMHP, and I have the sense that's unfortunately not uncommon. If they are as clueless as you make them sound, they are going to miss the opportunity to intervene early with other young people, to tragic effect.

In response to the OP's question, treating psychotic disorders with a family-centered approach is what I do (when patient and family are willing) and I find it incredibly rewarding. Admittedly, it can be challenging to find a gig that supports working in this manner and I feel grateful for my job.

bashir said:

You would be doing your community a huge service if you took this opportunity (or others that may arise in the future) to tactfully educate the FEP team. The CSC model is great but any team is only as good as its clinicians. My local CSC team is staffed by a green NP via telehealth and a newly minted LMHP, and I have the sense that's unfortunately not uncommon. If they are as clueless as you make them sound, they are going to miss the opportunity to intervene early with other young people, to tragic effect.

In response to the OP's question, treating psychotic disorders with a family-centered approach is what I do (when patient and family are willing) and I find it incredibly rewarding. Admittedly, it can be challenging to find a gig that supports working in this manner and I feel grateful for my job.

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This is a good point. Especially for teams in areas farther away from urban areas and thus less attractive to most psychiatrists, a telehealth NP is often the best they can swing. Statewide training initiatives usually exist but actual feedback on actual cases is invaluable for these folks so they can actually learn.

You guys are operating from the premise that a one off "teaching" moment to an ARNP is going to be educational.
Their entire foundations of their degree type is so lacking, its a waste of time.
Its not my job, or burden to remedy the clinical dumpster fire that are ARNPs because politicians and their PACs allowed them to run rampant and with independent licensure.
At some point you just say no, and fix the things you can. The clinical training deficiencies is not one of them.

I will teach med students and residents. Got some FM residents coming my away in next few months, too. They can be taught. They have the foundations to understand.

Sushirolls said:

You guys are operating from the premise that a one off "teaching" moment to an ARNP is going to be educational.
Their entire foundations of their degree type is so lacking, its a waste of time.
Its not my job, or burden to remedy the clinical dumpster fire that are ARNPs because politicians and their PACs allowed them to run rampant and with independent licensure.
At some point you just say no, and fix the things you can. The clinical training deficiencies is not one of them.

I will teach med students and residents. Got some FM residents coming my away in next few months, too. They can be taught. They have the foundations to understand.

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I generally don't disagree with this sentiment at all but I personally try to take a harm reduction approach to NP's in first episode psychosis care. A little education can go a long way sometimes.

"This is actually what schizophrenia looks like. Give them 5mg of abilify, invest in getting them to like and trust you, and switch to an LAI when you can. Read the MI bible and partner with the patient and ideally the family to identify and work towards their recovery goals." Drop the mic.

clausewitz2 said:

Did you try and talk to the FEP clinic? I mean maybe they're just stupid but it would be useful to know what they were seeing that was obviously so different from what you were.

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I would also mention that sometimes families are so in denial and strong-willed that they will do literally anything, including have full-on debates and travel across the country, to "prove" that their kid doesn't have schizophrenia. I've seen very good residents and even colleagues get talked out of a schizophrenia diagnosis by desperate and willful families. Sometimes the answer has to just be, "This is what I'm seeing and why I believe this is the most likely answer. We can look into other diagnoses, but you need to understand that there is a good chance that this one (schizophrenia/primary psychosis) is correct." And then you let the family decide when they're ready to accept reality.

Stagg737 said:

I would also mention that sometimes families are so in denial and strong-willed that they will do literally anything, including have full-on debates and travel across the country, to "prove" that their kid doesn't have schizophrenia. I've seen very good residents and even colleagues get talked out of a schizophrenia diagnosis by desperate and willful families. Sometimes the answer has to just be, "This is what I'm seeing and why I believe this is the most likely answer. We can look into other diagnoses, but you need to understand that there is a good chance that this one (schizophrenia/primary psychosis) is correct." And then you let the family decide when they're ready to accept reality.

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If a diagnosis of schizophrenia is not accepted by the patient or the family, it's not our job to label them as willful and write them off. If you think about it, that's actually a pretty normal human reaction to being told your loved one has arguably the most stigmatized condition in the world. If it feels like a death sentence, they will naturally go to appeal the ruling.

Our job is to help them not see it as a death sentence. To help them decouple the diagnosis from the worst case scenario they have in their head (a loved one with no job, no meaningful relationships, no real future), and instill realistic hope that with proper treatment it can be managed effectively in most cases, and that the affected person can still have a meaningful and fulfilling life. Very rarely does it serve anyone's interests to attempt to convince the person or their family that the individual is going to end up gravely disabled (you may not mean that when you diagnose schizophrenia, but that is exactly what families hear if you don't effectively lay the groundwork before using the "S" word) before that outcome has declared itself. That outcome is in fact more likely to come to fruition if the treating clinician is trying to get them to accept a diagnosis before they're ready, an approach which often only serves to push them away.

I have had better results with a softer approach where we deemphasize diagnosis (unspecified psychosis is my favorite "diagnosis") and work on developing a shared understanding between patient, family, and clinician of the patient's experiences, their impact on the individual and the family and develop a plan together for how we might reduce everyone's suffering. Generally this involves a low-dose antipsychotic and individual and family therapy. If they do end up eventually deciding to apply for disability I will formally diagnose schizophrenia at that point and we will have had enough conversations about what that means and doesn't mean that no one is too bent out of shape by using that label.

I also think the term schizophrenia is so stigmatized that it can't be saved and we need new nomenclature to give us a fresh start. Which is kind of a funny because I generally find the constant churn of PC language really tiresome. Anyway, it's unspecified psychosis for all my fep patients until the schizophrenia diagnosis is going to serve an important function for them.

bashir said:

If a diagnosis of schizophrenia is not accepted by the patient or the family, it's not our job to label them as willful and write them off. If you think about it, that's actually a pretty normal human reaction to being told your loved one has arguably the most stigmatized condition in the world. If it feels like a death sentence, they will naturally go to appeal the ruling.

Our job is to help them not see it as a death sentence. To help them decouple the diagnosis from the worst case scenario they have in their head (a loved one with no job, no meaningful relationships, no real future), and instill realistic hope that with proper treatment it can be managed effectively in most cases, and that the affected person can still have a meaningful and fulfilling life. Very rarely does it serve anyone's interests to attempt to convince the person or their family that the individual is going to end up gravely disabled (you may not mean that when you diagnose schizophrenia, but that is exactly what families hear if you don't effectively lay the groundwork before using the "S" word) before that outcome has declared itself. That outcome is in fact more likely to come to fruition if the treating clinician is trying to get them to accept a diagnosis before they're ready, an approach which often only serves to push them away.

I have had better results with a softer approach where we deemphasize diagnosis (unspecified psychosis is my favorite "diagnosis") and work on developing a shared understanding between patient, family, and clinician of the patient's experiences, their impact on the individual and the family and develop a plan together for how we might reduce everyone's suffering. Generally this involves a low-dose antipsychotic and individual and family therapy. If they do end up eventually deciding to apply for disability I will formally diagnose schizophrenia at that point and we will have had enough conversations about what that means and doesn't mean that no one is too bent out of shape by using that label.

I also think the term schizophrenia is so stigmatized that it can't be saved and we need new nomenclature to give us a fresh start. Which is kind of a funny because I generally find the constant churn of PC language really tiresome. Anyway, it's unspecified psychosis for all my fep patients until the schizophrenia diagnosis is going to serve an important function for them.

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So much this. I definitely talk about the schizophrenia diagnosis with many FEP folks but initially from a 'you're going to hear people using this word, what's your take on what it means for your life?' kind of perspective. Relentless focus on what they're actually experiencing, genuine curiosity and epistemic humility about what they have to say, and examination of whether these experiences are or are not interfering with them accomplishing their goals.

bashir said:

If a diagnosis of schizophrenia is not accepted by the patient or the family, it's not our job to label them as willful and write them off. If you think about it, that's actually a pretty normal human reaction to being told your loved one has arguably the most stigmatized condition in the world. If it feels like a death sentence, they will naturally go to appeal the ruling.

Our job is to help them not see it as a death sentence. To help them decouple the diagnosis from the worst case scenario they have in their head (a loved one with no job, no meaningful relationships, no real future), and instill realistic hope that with proper treatment it can be managed effectively in most cases, and that the affected person can still have a meaningful and fulfilling life. Very rarely does it serve anyone's interests to attempt to convince the person or their family that the individual is going to end up gravely disabled (you may not mean that when you diagnose schizophrenia, but that is exactly what families hear if you don't effectively lay the groundwork before using the "S" word) before that outcome has declared itself. That outcome is in fact more likely to come to fruition if the treating clinician is trying to get them to accept a diagnosis before they're ready, an approach which often only serves to push them away.

I have had better results with a softer approach where we deemphasize diagnosis (unspecified psychosis is my favorite "diagnosis") and work on developing a shared understanding between patient, family, and clinician of the patient's experiences, their impact on the individual and the family and develop a plan together for how we might reduce everyone's suffering. Generally this involves a low-dose antipsychotic and individual and family therapy. If they do end up eventually deciding to apply for disability I will formally diagnose schizophrenia at that point and we will have had enough conversations about what that means and doesn't mean that no one is too bent out of shape by using that label.

I also think the term schizophrenia is so stigmatized that it can't be saved and we need new nomenclature to give us a fresh start. Which is kind of a funny because I generally find the constant churn of PC language really tiresome. Anyway, it's unspecified psychosis for all my fep patients until the schizophrenia diagnosis is going to serve an important function for them.

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Sure, this isn't really what I was referring to though. I'm more referring to the families who refuse to believe that the psychosis is likely not a medical problem that is "curable". I wouldn't diagnose or say schizophrenia until much later anyway, I usually just say "a psychotic disorder" since we aren't going to know the prognosis any time soon and the outcome can vary widely. The families I'm talking about refuse to believe that life will be different and that their high functioning future doctor isn't going to be on that road anymore and anything short of that is unacceptable and lacks meaning. These people eventually come around (whether by choice or forced acceptance when their kid doesn't get better) but would never be willing to go to an FEP in the first place due to their perspectives or denial.

I've been dealing with 2 families like this recently. One is in the earlier phases and we're still doing the million dollar medical work-up (family is actually much more accepting of possibilities, but just struggling as this is a very atypical presentation and actually warrants the work-up). I'm still hopeful that this isn't actually schizophrenia (hoping bipolar with psychotic features) but they've been inpatient bounding between medical hospitals and psych units for 2+ months now. The other is nearing the 1 year mark and is finally moving out of the denial phase that their kid isn't going to be a doctor and just wants them to not be a basement dweller. Given how that situation has gone, they'll probably be lucky if the kid can hold down a long-term job or even stay compliant with meds. Probably wouldn't have made a massive difference, but also probably didn't help that mom refused to let us give antipsychotics for weeks to months until the full medical work-up including all the autoimmune, radiology, and neuro tests was complete. And once we did find a decently effective med mom said it wasn't good enough and demanded a change.

milan95 said:

What positions would work well for someone who really enjoys this aspect of adult psychiatry? Thanks!

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General adult psychiatry.

Stagg737 said:

but also probably didn't help that mom refused to let us give antipsychotics for weeks to months until the full medical work-up including all the autoimmune, radiology, and neuro tests was complete. And once we did find a decently effective med mom said it wasn't good enough and demanded a change.

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There's probably no mother in history that comes to their adult offspring's appointment to tell the doctor they disagree with the diagnosis of gonorrhea and demand a change of antibiotics that has helped them stop urinating flames. I'd also wager $1 million this mother has zero interest in challenging the radiologist's and neurologist's assessment of their respective imaging or EEG reads. She should give her mechanic her opinion on how to change her timing belt and see how well it goes.

This is one of the biggest drawbacks of our specialty: (1) we're not allowed to simply do our work because everyone and their momma wants to give us their (uneducated) opinion, and (2) even when they vehemently disagree with our opinion, they will still come back to attempt to dictate our work.

Sushirolls said:

You guys are operating from the premise that a one off "teaching" moment to an ARNP is going to be educational.

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I never ever teach an NP without obtaining explicit written consent. Implied consent for teaching only occurs in two specific instances: the NP is a med student or medical resident. Otherwise, they consider it assault.

Candidate2017 said:

There's probably no mother in history that comes to their adult offspring's appointment to tell the doctor they disagree with the diagnosis of gonorrhea and demand a change of antibiotics that has helped them stop urinating flames. I'd also wager $1 million this mother has zero interest in challenging the radiologist's and neurologist's assessment of their respective imaging or EEG reads. She should give her mechanic her opinion on how to change her timing belt and see how well it goes.

This is one of the biggest drawbacks of our specialty: (1) we're not allowed to simply do our work because everyone and their momma wants to give us their (uneducated) opinion, and (2) even when they vehemently disagree with our opinion, they will still come back to attempt to dictate our work.

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To be (slightly) fair to the mom, he had been on 1 antipsychotic previously which caused mild dystonic side effects and I was seeing him after he was admitted to the medical floor for the million dollar work-up. So wasn't outpatient at that point.

But yes, I do agree that too many people try and get in our lane without any understanding of the pathology or treatments while simultaneously crapping on the field as a whole.

I recently read an article about Sarah Paulson, the actress, describing still being furious more than a decade later that another, older, actress, who had performed the same role in a theatrical performance, gave Paulson "notes" after seeing Paulson perform the role. I just could not relate to the rage. I spend most of my day getting extensive unsolicited feedback about my work...

Sushirolls said:

You guys are operating from the premise that a one off "teaching" moment to an ARNP is going to be educational.
Their entire foundations of their degree type is so lacking, its a waste of time.
Its not my job, or burden to remedy the clinical dumpster fire that are ARNPs because politicians and their PACs allowed them to run rampant and with independent licensure.
At some point you just say no, and fix the things you can. The clinical training deficiencies is not one of them.

I will teach med students and residents. Got some FM residents coming my away in next few months, too. They can be taught. They have the foundations to understand.

Click to expand...

Just one of the many reasons I plan to exit medicine by the end of the decade. Don't want to be around for nurse surgeon or nurse GI scope/ heart cath in the future. I'd much rather have an AI robot operate and scope even if it will probably be the end of us all soon thereafter.

Stagg737 said:

Sure, this isn't really what I was referring to though. I'm more referring to the families who refuse to believe that the psychosis is likely not a medical problem that is "curable". I wouldn't diagnose or say schizophrenia until much later anyway, I usually just say "a psychotic disorder" since we aren't going to know the prognosis any time soon and the outcome can vary widely. The families I'm talking about refuse to believe that life will be different and that their high functioning future doctor isn't going to be on that road anymore and anything short of that is unacceptable and lacks meaning. These people eventually come around (whether by choice or forced acceptance when their kid doesn't get better) but would never be willing to go to an FEP in the first place due to their perspectives or denial.

I've been dealing with 2 families like this recently. One is in the earlier phases and we're still doing the million dollar medical work-up (family is actually much more accepting of possibilities, but just struggling as this is a very atypical presentation and actually warrants the work-up). I'm still hopeful that this isn't actually schizophrenia (hoping bipolar with psychotic features) but they've been inpatient bounding between medical hospitals and psych units for 2+ months now. The other is nearing the 1 year mark and is finally moving out of the denial phase that their kid isn't going to be a doctor and just wants them to not be a basement dweller. Given how that situation has gone, they'll probably be lucky if the kid can hold down a long-term job or even stay compliant with meds. Probably wouldn't have made a massive difference, but also probably didn't help that mom refused to let us give antipsychotics for weeks to months until the full medical work-up including all the autoimmune, radiology, and neuro tests was complete. And once we did find a decently effective med mom said it wasn't good enough and demanded a change.

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That sounds really difficult. I'm sorry for you but honestly my heart really goes out to the adult child who is getting the message from their parents that they are damaged goods, and anything less than being a physician means their life is not worthwhile. Young people who develop schizophrenia whose parents see them as nothing more than an object for their own ego gratification--is there any worse position to be in? Makes me wanna cry. Poor kid.