Psychiatry & Psychotherapy Podcast - Inpatient Child & Adolescent Psychiatry: Dr. Bender's Journey Through Curiosity and Connection

Episode Date: September 22, 2023

In the realm of Child and Adolescent Psychiatry, especially within an inpatient psychiatric setting, a narrative-driven and curiosity-based approach has proven invaluable. Each child who is admitted is navigating a crisis, making it imperative to deeply understand their unique situation to chart an effective treatment plan. This goes beyond clinical observations; it's about immersive engagement with both the patient and their family, diving into their lived experiences to piece together a holistic patient narrative. Through collective efforts, the capacity to deeply connect with and understand every patient and their families is enhanced. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome to the Psychiatry and Psychotherapy Podcast. I am joined today with Dr. Dan Bender, he is a child psychiatrist working inpatient. He has been a listener of the podcast, reached out, has an kind of an integrated approach to how he does inpatient adolescent practice. He does psychotherapy. And we've been in discussions about kind of just having a conversation about what his practice looks like. Welcome to the podcast. Thanks, David. Thanks for having me on. This is cool. this is cool.

Yeah. So you, how long you've been listening to the podcast? I mean, I remember listening to specific topics back in training. Okay. And then so back, I've been attending. When did you start? Because I feel like it was like. I don't know.

I'm almost at episode 200. So it's like probably about five or six years ago. Yeah, because I think back when I was like at the end of training, I would look for specific topics to listen to when I was driving. I came across years and it was the most, it was this perspective of like evidence base and sort of this, but also a curiosity about things in psychiatry. So it was talking about topics, I think, from a perspective of a psychiatrist, you know, but a curious one, not just a didactic. So I was kind of interested. I remember specifically a Joker episode you did where you guys like talked about the diagnosis of the Joker.

And I was obsessed with that. That was a fun episode. But yeah, and it's the one I tell residents or students the most about if they're interested in the topic to look you up. So, yeah, it's cool to be here. That's cool. And so just to put it out there, we have no conflicts of interest, right? You're not like... I'm on the board of Pfizer, so there's that.

I'm joking. It's not the reality. No conflicts of interest officially. We're good. Okay. Yeah, so I was thinking we could start out and just tell me a little bit about how you think your practice might be different than the average inpatient adolescent psychiatrist. So I think the first thing that's different is that I look at inpatient treatment, not as a standard practice of someone comes in in crisis. our goal is to assess, diagnose, treat with medication, and then leave.

And if we're not doing that, they don't require inpatient admission. My perspective and how, like, I treat in the hospital here and what I teach in the hospital on our unit, is sort of a more narrative-based approach of can we look at the crisis? The kid is coming in in crisis. And I work with kids, but mostly work with adolescents. someone is coming to you in a crisis, whether it's suicidality, there's aggression at home, some big thing has happened. And what we want to do is build a formulation, a differential, all the things you generally

would do, you know, in an inpatient, but what we focus the most on is understanding how this built to this point. And can we make human realistic sense of why this kid's here right now? because for me, especially with suicide, if a kid is coming in, and especially if it's their first exposure to treatment, if a kid's coming in, I'm most focused on that patient being seen, like us getting the closest thing to their reality of why they're suicidal, of what's leading up to it. And I think by how we do that is we engage families a lot. We spend a lot of time with the kids, and with the people who know the kid,

to piece together a sort of realistic narrative, almost like you're watching it play out, so that we can understand, I mean, and help a family and a kid understand how it could get to this point. Like, because when they come in frequently, it's just, it's craziness. It's like total chaos or everyone's in crisis. Everyone can't believe what's happening. So when we take it, we sort of try to contain it in a narrative.

help them make sense of it so that the parents and the kid can kind of empathize with the situation can almost make sense of how we're there. And so we spend so much time just trying to build this sort of broad narrative conceptualization. And I don't know if that's classically done inpatient. I'm sure there are people who look at their job inpatient and do this kind of thing, but I don't know how common it is. Right. I think at the best at the best places, this is, what's going on. But I think from, you know, a lot of what I've seen that happens is you have a doctor that's seen, you know, 30 patients a day or something like that where you just can't, you know,

get into the person's life. So how many patients, what's your cap right now and what was your cap when you first got hired? Like, tell me the story about that. Yeah. So that's a huge part of it because I've worked. I mean, I've covered, you know, 20, 30 patients, you know, when I was moonlighting in training or if I was even now, if I'm covering on the weekend.

But I started out with a cap of 10 patients, which I think is like crazy. I mean, it's awesome. That was one of the main things I was excited about coming in is because if I had a cap of 10 patients, it's like I can learn how to practice coming out of training, can learn how to practice. And then I can also engage and shift my efforts, like where they're necessary based on cases. I mean, you have more bandwidth to treat it. So I had 10 to start.

I have 13 cap now. And you have like, okay, so you have some auxiliary staff is what I consider, right? You have medical students, residents, right? Yes, my lovely auxiliary staff. So I generally have like two residents and two medical students. one to two medical students. I mean, it's like a big team. Yeah.

And it's almost like, so I mean, yeah, when it comes to my ability to just like focus clinically and on the case, managing a case, it's just, yeah, I'm lucky that I have that. Do you know what I mean? But I think that's academics. It's part of, you know, I sort of said it out there as very important to me that I have that bandwidth. Right. Okay. And so you have your 13 max patients and then you talk about how there's really three places where you get information. The patient, the family, and the chart, walk me through those three things and what you do differently maybe.

Yeah. Or what that, maybe not what you do differently, but what do you do? Yeah. Right. Like when a kid comes in, when a patient comes in basically, like how do I build a conceptualization? Yeah. So it's it's all about getting this story straight, right? So when I go in, I always talk with the residents about focus on why they're here right now. Like, why are they here right now? Build a clear history of present illness, like step by step, how did they literally get to the hospital? And what did it look like if you were watching it on a screen or something? And then we look basically, we go interview the kid and we see how much they can engage with that, how reliable they are as a history.

and can they give us some sense of what their internal experience was? That to me is so important. If they can relay their mindset or they can reflect on that moment before they were admitted and they can describe something of that chaos, you know, that you felt in a crisis, then I really focus on the kid and try to build a narrative with them, something that makes sense in terms of a timeline of how we got here. Now, so I'll talk to the patient. not when you work with teenagers um that's like especially inpatient like that is not your

standard your standard is uh leave me alone how do i get out of here a year in my way uh and like i'm fine this is all missing you know what i mean it's oh yeah yeah yeah when i was when i was doing my impatient adolescent child rotations um as a resident it was always like i was just grasping for anything that was beyond like, yeah, doing great, doing great. I'm like, what are all these kids doing here that are just doing great? And part of me, I think as a medical student, I remember thinking to myself, like, why do they keep them here? Right? Because they're all doing great. And then you see them on the unit playing together. Most of them are laughing, you know, having a good time with each other. Yeah, parents generally don't like that.

They want it to be like it's taken seriously. But anytime you put a kid in a setting, especially developing kid, a social setting, I mean, it's ripe for like just communication and connecting, whether good or bad, with the people you're surrounded with, you know? So, yeah, I'm very curious. How do you pull out the real story, the real emotion, especially when there's such a a secondary gain for a lot of the kids to just appear like everything's awesome. I want to go home now.

So generally when you get a kid who's like that, you get a family who is the complete opposite. You know, kid will say something like, and my parents just don't listen to me. They're not, they don't understand like what's going on. I'll talk to them. So they don't understand my life. And then you talk to the parents and they're like, this, my kid is out of control. I can't control them. I can't keep them in the house.

Like they're out drinking. they're doing all these things I can't take, you know, and I can't take care of them. And if you think about later teenagers, so when I hear that conflict, right, I'm trying to engage and challenge both perspectives. Like, I'm trying to build some sense of understanding of the parent's perspective and the kid and build some sense of the kid's perspective and the parent and find a gray area. And I think the way to engage past this, I'm fine, I'm good, is to go into like relationships and talk about their like so we'll go into their histories like we'll say what was it like growing up like any major transitions you know anything that happened in your

oh yeah well i moved when i was 10 and uh i didn't want to but we did and i didn't have friends and then covid happened or something like that you get to something in their life you sort of just curious about their human struggle you know what i mean and you start like just being i think just basically being curious beyond this, you're fine. Okay, I got the information for my note. I can write it and submit it and then we'll titrate the medication as indicate, whatever. You're just curious about this person, knowing that there's struggle in everyone, but knowing that for this person, their struggle has like peaked in a way that they're now in the hospital. So I don't really settle, I guess it's weird to say that. I struggle to settle. I'm not like,

tell me the truth. What's actually going on? It's more of a thing of, when your parents are talking about what's going on with you, it's like totally different than what you're saying. It's totally different. And so I'm sitting here and I can just believe what you're telling me or I can just believe what your parents are telling me. But like, I know there's somewhere in the middle where I'm not getting the reality of what it's like at home, right?

Or the reality of what your experience is. And that's okay. Like I sort of give it as like, you can talk to me. You don't have to talk to me. But I'm curious. and I'm here for it. Because I think kids are like patients just in general, I think they're so aware of like this authority differential, right?

Or like you as a doctor, you're looking for something. And generally we're looking for people to get better and impatient, right? Less suicidal or less aggressive or whatever. They know this. Like they know what you're looking for or whatever, what we should be looking for. And so I try to flip that and just be like by focusing on just, I'm curious about your life.

Like, I'm curious about your family, your relationships, your struggle. You can get rapport from a teenager differently. I mean, you're more likely to when you take that, I think, approach. I mean, at least I have. Yeah, I can feel your passion with something about the curiosity that feels really important for you. And I'm wondering, like, how did you come to this? sort of theme. And I even want like more words around curiosity. Like it almost like I feel like it may not mean as much as maybe you can describe what actually or what actually is going on.

Yeah. So I mean there's a so when we were talking like a little before this like when I was talking about how I ended up here with this perspective, I think there's a whole timeline of my own that built into. I just was feeling disenchanted with. how we were understanding what people were coming in with. And there was like a, there was a specific case in training that really, I mean, I think everyone has this. Like every resident has faced a case where it does not fit. And the person is not responding to the DSM sort of standardized inpatient approach. And I had a specific one of a woman who had no psychiatric history, really. and she presented with this, she was like a geriatric patient, she presented with this very intense,

very scary presentation of delusions, of killing people, of murdering children, horrible things. And like, it was so shocking, but no one knew why. She had no affect. So everyone did the whole workup of, you know, the neurological workup. And, you know, they did the diagnostic treatments. They trialed medications, She was considered psychotic or maybe like dissociative. It was all these sort of DSM approaches, and she just didn't change at all. And everyone was still just so confused. And so when I would face something like that, a case like that in training, it's so annoyed that like I'm like, this is it?

Like I don't understand this case. It doesn't make sense to me at all. So like nothing has helped me understand it. Nothing's helped this person feel more human, you know? And so then I brought it to a supervisor. and she gave me a reading that was like about Melanie Klein and object relations. And I don't remember exactly like all the words. I hate like the psychoanalytic language sometimes like how it's so,

it's sort of as separatist. Like if you use the words like ego, it enough, you know, people will not understand what you mean. But the idea behind this reading that she gave me was that this person was someone who grew up, and basically didn't build a sense of life in their own. Like they built a sense of life in their family. And they found a spouse who was very controlling. And they found a spouse who was this kind of like a dependent personality,

such a like type of presentation that she had throughout her whole life. But she had children. And that was like then turned into the new purpose. And this is not like a typical, you know, controlling husband. It's like she couldn't leave the house, couldn't drive, couldn't do normal. things had to stay, you know. And then basically what the ratings were saying is that when people have this fragile sense of themselves, they build it from other people. They sort of take pieces of other people's strength and build themselves, build their sense of control or, you know,

identity around it. And then what happened was like her one daughter left, went to college or something. I can't remember what it was. And then her other, and she was okay, but then the youngest daughter abruptly decided she was leaving too. And when that happened, the symptoms just like were there. It was like nothing. And then whenever that happened, now it's all this psychotic, you know, everything. So when I sort of understood it as like a dependent personality or like this sort of fragile ego built from other people. And I read this thing and it's sort of this idea of everything exploding. You know what I mean? That sort of fragile thing, barely holding on. And then when it's threatened just explodes and can throw you in all these kind of directions where nothing

in reality makes sense. To me, that was like a totally different way of thinking about this patient. And it allowed us to basically reconceptualize the case as sort of like an intense anxiety reaction. And we treated it like that. And I remember just literally talking with her about it and we treated her anxiety, not with antipsychotics or anything like that. She shifted. like she totally shifted and how she could engage with us. So when that happened, that was like, I think that was like second year or third year, you know, residency.

Right. It was formidable. That changed. Yeah. Formidable. Yeah. I, I, um, okay, so I think that through, I think it, I think it's,

there's a couple things here. One is, it's interesting to think about categories like the DSM, right? Where it's like, okay, these are a group of symptoms that some people have. that kind of clumped together, right? Like a factor analysis type thing. And it's not really, there's not really a lot of why this is going on underneath it. And so I think the pain that you had with this person was,

okay, our normal categorization system is not working exactly because people are very complex, right? I always say to patients when they want their diagnosis. I'm like, my take is like it's easier to diagnose on day one than it is like two years in because people are so much more complex at that point. It's like, so you have this patient who's not fitting the criteria whose symptoms don't make sense. And it's like, it's very aggravating to you that you're not able to help this person. And I think once you were able to relay back to them, like, oh, you,

you were so intertwined with your kids that when they left, it was so painful that you decompensated into what seems like psychosis. But it's like it's very just, it's just a decompensation of the pain of them leaving, right? I imagine that was experienced as empathy. Right. That's kind of, yeah, what I saw it as, yeah, a way to understand the pain differently. Yeah. So it's like she's like someone is now with me. I'm not alone in this pain. Someone is holding me in the pain, which stabilizes their sense of self, right? It stabilizes their personhood.

You become the distress changes in nature because it's like you are with them in that distress and now they're not alone in the distress, in the unknown, right? because also the unknown of like, oh, I'm having these like really distressing thoughts. Like that can be very disorienting in and of itself, right? The unknown and this sort of like something is wrong, I can't make sense of it. You know what I mean? It's the chaos like in your head. It's like things in reality just are not making sense to me at all. Most crises, you know what I mean?

They feel that chaotic way. that uncertainty of like what is going on why am i hearing voices why am i seeing why am i like so depressed why am i suicidal and it is like containing to make sense of it and i think inpatient right like if someone's coming to you in crisis that really is the time where you need someone to help you contain that feeling i think um to make sense of your experience you know right so so what happens i think normally impatient as kids come in and then they dissociate away from what happened three days before. It's like they have such good defenses at that age

that they're able to like just push it down, compartmentalize, not think about it, put up the social veneer, the facade, and then you as the, you know, attending are seeing that and you're like, no, I really want to know what's going on like before all those defenses came back up again. Right? The psychological defenses. And so you're using information that you gather from the chart and from the parents to often draw like a narrative, a timeline.

And then you're asking the kids about what they're, hey, this is the timeline I'm getting from the chart and getting from the parents. Like, what's true here? Like, just can you, like, correct the record? and they're like, what, no, that's not true? Like, right? Yeah, yeah. Well, I generally say, this is how I'm understanding things, okay? I honestly want to understand it.

That's the thing is like, I'm not trying to come in and like, I'm going to, you know, confront you or I'm going to tell you you're wrong. It's like, I'm just really want to understand things the best I can. Right. You're not. Yeah. Yeah. So I had a, I teach psychotherapy.

to residents and last week they're like, what do we do if a patient's lying? I'm like, everyone lies, right? It's like, I wouldn't say lie.

I would say, revealingness is what Dr. Tar taught me is like, put it, it's like, no one wants to reveal things that they feel shameful about themselves.

So of course, everyone hides what is really there because it's for fear or for shame or for, you know, it's scary to be vulnerable.

Right. Can I say about that? Just one thing. Because like the shamefulness of, there's so much of that of trying to protect against the reality of what's built in. And I think with a family, it's like very threatening. If it's a dysfunction within a family or it's a pattern that's built within a family, it's almost like even more threatening to face a reality sometimes because it implicates

like we did something wrong or we weren't aware and so we allowed something to perpetuate. Okay. Tell me, give me that like, okay, I fully see what you're saying, but I'm thinking someone from the audience doesn't know. It sounds too theoretical. So it's like, give me something,

give me an example that can give some roots to that, this idea of like the families created a dynamic. Yeah, so like, yeah, just to describe, I think it's best to use a theme that builds an impatient. I always teach, like, residents, there are patterns that present to the hospital, and the patterns are more predictable than the diagnoses, honestly. So one of the patterns that's common is a patient will come in suicidal. And, or say, yeah, we'll say they come in suicidal.

And then, you know, they're depressed. They are meeting criteria for major depressive disorder. they agree and parents agree to start medication or, you know, something like that. We set up for disposition. They go to partial. They got a, you know, some step down and do a standard inpatient stay and they leave. Okay. They're better.

Like you said, they come in and they're just like doing great. Then they come back like a week later. Same thing. Suicidal. Oh, yeah. Well, I didn't take my meds and I think I missed two doses. so probably is, you know, why I felt so bad. And they can't really, they don't really give you history, right?

They don't really give, it doesn't make sense. You're like, okay. So you keep them on the meds, you titrate. This happens over and over. Okay, they'll come back like four times. This is a common situation. And then hopefully you get curious about what's going on. And this is something that's happened to me many times.

It's like when I'm like, what is happening? Can you walk me through the first time that you reached out together? them a therapist or whatever. So yeah, they were depressed. And then basically lead me to how it ended up with suicidality. Frequently, a parent will say that they want to do whatever they want to do. And we sort of let them because they seemed depressed and we didn't want to push them to go to school.

We didn't want to encourage them to like, you know, do too much or be around us or be around people outside of their room because we don't want to push them and make them worse. Because when we started to ask them, like, hey, you got to go to school or, hey, we got to get you like to your appointments, they would scream at me and they would threaten. Like, you don't understand how depressed I am. I'm going to kill myself. Like, they would, and they'd scare. Basically, the parents would be in this position of like, I'm horrified of pushing my kid. And the kid is sort of like stuck in this pattern of dysfunctional control, right?

because they don't want to break out of, it's hard for them to break out of a pattern of, you know, doing what they want to do, sitting in their room and just like being on their phone or on, you know, like, whatever social media they use, just like sucked into it. And the parents try to engage it and the kid just,

you know what I mean? The control in this power dynamic, the patients frequently will learn too. Like, if the parents don't buy things like, get the hell out of my room or like yelling at them, The parents are like, I'm not doing this. You really need to get to this appointment. Like, we got to go.

This is the rule. There are controls that parents cannot tolerate. They shouldn't, you know? It's like, I'm going to kill myself. Or you telling me to do this is making me more depressed. That is like so painful for a parent. And it's something that happens. You know what I mean?

So when you go into this pattern and you start to address this power dynamic, you start to bring, when I've done it in the hospital, and I start to address this power dynamic and I emphasize the struggle of the patient, of the kid, the pain that they have that sort of led into this isolation or whatever the pattern they're in. But I also acknowledge this sort of dysfunctional control that has left the parent feeling like they cannot parent their kid and they're watching their kid get worse. When you start to address it, it brings out lots of affect. But it does because I feel like it addresses a reality in this family. And it brings in like a, you know what I mean? It's closer to their actual reality. And so clinically, right, the importance of that, and I've seen this, these kids who come in over and over and over again, and we address this, we sort of bring to light this dynamic. And it's no longer in the shadows. It's sort of in treatment. It's being discussed for the doctor. I see these kids like, and they do come back. Like these are not things that just go away. But like I've seen multiple, like on frequent occasion, like that situation when we start addressing it and relate to the.

the next team, the kids are less likely to come back over and over. I'm suicidal. I'm this and that because we shifted the narrative to more of what the reality is. So I don't know if that answers or if that sort of is a long way you're looking for. Yeah. So in the IOP partial we run, we have this kind of idea as well. And if you're listening to this and this is triggering to you, then you may be missing it. in people because it happens in medical illness as well.

So a kid with psychosomatic illness, gains power over his parents, is able to do things whenever they want. Interestingly, so I told my kids the other day, I have a seven and a nine-year-old. Okay. So I said, when I was a kid, my parents only brought the TV home when I was sick.

And my nine-year-old said, well, why didn't you just say you were sick then? That's kind of scary, huh? scary my kids are smart and um and so yeah kids are vying for power especially if they feel powerless especially if um yeah there's a lot of reasons why they could feel powerless and how they deal with how do we as humans deal with our powerlessness right how do we deal with our inability to help other people for example um when we want to to help them or how do we so okay what what i also want to say is there may be something

really going on in this kid that needs help right and so it's not just a purely this kid is macavelian they're manipulative um they're just attention seeking it's like the powerlessness and then the reaction is it may be something that serves the kid and also serves the environment, right? So the psychosomatic illness, same thing. It may put the family back into equilibrium. So for example, we've seen parents are about to get divorced, psychosomatic kid gets very sick, ends up in the hospital, reboots the family system, parents now getting along with each other, being kind to each other again, six months go on, parents fighting again, kid gets sick again, right? And so it's the family system.

The kid is responding to the family system. Right. Go ahead. What are you thinking? Right. Yeah, no, I mean, like what you're talking about. I love hearing you say that because that's so much of what I teach. I think we, so when I trained, I learned a lot about structural family therapy and sort of the idea of, you know, the role of the behavior or the role of what's happening in a family, each person playing theirs to persist, you know, something of the family system.

you know and i always found that interesting i didn't know i would use that so much inpatient you know that what you're talking about but this is what i mean like um when i say that i focus when i start to address that power struggle or that control battle that includes suicidality i emphasize that i emphasize as much as i can the pain that has led to it you know and because when you get these patients when you start getting that reality you'll hear things from parents like Like they're manipulative. Like you said, they're like, you know, manipulative. They know what they're doing.

This is, and they're cynical about it. And sometimes they won't say it. But then frequently you start to address it, they'll start saying those words. So my goal, right, I think the clinical, I don't know if I feel gratification from this, is when a parent can shift from this thing of my kid's manipulative, or they're just like a sociopath who's threatening suicide to get what they want, whatever. But that they can make sense of how it got there, you know, like during, COVID, right? Like 13, 14-year-olds are people who are going through puberty in quarantine,

right, and then going back to high school, like trying to build a parent's sense of this lack of control over your body, this lack of sense of yourself. I mean, I really think that it can shift things for a family. And you can address that sort of cynicism that can just seed and grow and the further the kid gets removed into the mental health system and out of the family, a lot of the times it's like it just doesn't shift. So I feel like that is a powerful tool, you know, to build their empathy for their kid and help a kid feel seen, but not overexposed, you know? Yeah.

So one thing is like how do we help them connect out of a congruent space rather than an incongruent space. So incongruent, I'm suicidal. I mean, suicidality can be congruent as well, right? So I don't want to negate that like, but sometimes illness, okay, illness, psychosomatic illness, suicidality can also be kind of lumped into this. Some cases, it can be, it can be part of like, how an equilibrium is reached in the family system, right? And so this, this illness narrative, a narrative that the kid tells himself. It's not congruent. It's not really speaking to the real fears, what's really going on. So sometimes it's like, how do we help these people in the family reduce the shame and allow a more honest conversation, a more congruent conversation,

what's really going on, the real fears, the real feelings of powerlessness, and connect on that. because that, that, when people connect on that level, it's, it's, there's a, there's a powerful, beautiful thing that occurs, right? Yeah. And I think you cutting through with those kids and having that real connection, even if they hit you back with anger, you're like, it, it sounds like you get excited when they actually get angry because it feels more real. This is like, this is the hardest thing is because it's like, do you want them to get angry? My thing is, is like, you have to have boundary, understand your role. It's, it's any affect, any affect that you can get to at all, if it's tearfulness or they're welling. If they hate you, you know, they, like, I've told kids,

like, you just feel free to hate me all you want. Like, I prefer you don't hate your parents, right? Like, hate me, it's cool. I can contain it. And that's what I think a therapist in a situation where it's so heated and spilled so much, you have to help contain the feeling when a parent or family can't really handle their kids' intensity of emotion. But I, it's weird. Like, inpatient, I think people get so turned off of because of these like high intensity moments or, you know, potentially, I think people could see it as like potentially dangerous to work in or something. But when I get a kid who's been totally fine and enjoying and like laughing and they're like, run in the groups. I love when I hear like, oh, they could run these groups.

but they're still coming back over and over again. I want, you know what I mean? There needs to be a shift here. And so I want to see their app, and want to show them like, it's okay to feel that and help them make sense of it and redirect it to the pain, you know what I mean? Okay.

Okay, so you get really good at connecting with kids and do you ever have kids who, when they get admitted, they ask to be a part of your team? It's honestly, it's honestly weird. I mean, it's different. Get kids who will, who will ask to not have me.

Frequently the ones who I'm starting to address, they'll be like, I don't want Dr. Bender. But then they'll end up with me. This is funny. They'll say, I don't want Dr. Bender. Even, honestly, like, even their parents, it's the same situation, right? It's like, when we're addressing something like that,

like we don't want him. That's a harder thing because I can't be like, no, too bad. I'm treating your kid because it's like, I work with a great co-attending. But I think that kids will be like, I don't want you. But then, like, this is what I'm trying.

I'm trying to say, like, they'll say that and be so angry. I don't want to deal with him. And then they'll sit and talk and go through and like, you know what I mean? Actually talk about what's going on in their life with me, even though they hate me. You know what I mean? That kind of thing. Well, there's, I mean, there's like transference. There's a fear of vulnerability.

There's a desire to just have a break and escape. And you're, you are having a real conversation. which I'm I'm surprised it. So you never get kids that specifically try to come back to you? I don't, I've had a few, it's honestly not. That's what's crazy, right? Like inpatient, I think it's part of inpatient. Maybe I just suck at my job.

Because they will say, like, frequently they'll end up and assume like, oh, God, here we go. And it's not an explicitly stated, like, thank you, Dr. Bender. Because they know, especially if they're coming inpatient and they're working with me that I'm not going to just like ignore the situation that's like been going on, like the reality. You know, I'm going to try to acknowledge what's going on in reality, which they're inpatient. It's painful. So that inherently means we're probably going to go into some painful things when you're here as opposed to it. You come in, you go to groups, you go to gym, you make some new friends and sneakily to take their snapshats or whatever. you know, they're like Snapchat names

so you can make friends and keep them when you leave the hospital, you can do all those things and then leave and then it doesn't shift anything. So yeah, I think it's more likely that they're like, oh, here we go, that kind of thing. Okay. Does that make sense? Yeah, yeah, yeah.

And I think it's the difference between like outpatient versus impatient. I think like there's the bond is, it's a different bond. bond that you're having and you're not just giving them what they want to hear. It's not purely supportive what you're doing. It sounds like you push them a little bit.

Right. And like I said, it's like you're inherent in your position is that you're seeing them in crisis, you know? So it's all wrapped up when you're seeing them with all these things that are usually heated and chaotic. Okay, okay. So here's what I've seen, which I think maybe you're not falling into this category. It's like people can get their connection needs met through psychiatric illness. Okay. So there was this one client who would go back to this attending over and over again, and they would talk about genetics and psychopharmacology. And she could have a half an hour conversation about this. The first time she saw me, she brought in charts, she brought in 50 pages of meds that she's tried and intricate side of side effects. And I like would just look at like, where's the real emotion? So, you know, I read micro expression. So I'm like, where's that flash of anger? Oh, what's that? Huh? And so I can

usually draw it into an emotional conversation through the micro expression. And so, so yeah, I would look for something real. I would look for real emotion. And then I get, I'd get, I'd get, kind of like uninterested in all of the psychobabble because the psychobabble itself is a defense against what's underneath it the powerlessness the family dynamics some of the trauma you know so when you yeah that's so yeah this is um when you had that situation and you start to work with that patient and they get a sense that you're not giving as much weight to the the the genesis or pharmacolide, that whole thing. Do you get that sense of like,

even though you're in tune with the emotion, it can be like invalidating. You can feel invalidating to the patient. Yeah, I think most of them like it, but they also feel challenged and they have to give up their secondary gains. Like I've had some clients, because like I said, like I run this program,

it's psychosomatic track. Some clients will have 10 specialists that they'll be seen. Yeah. And they get, they're attaching. needs from those 10 specialists. And by attachment needs, I mean, an important adult that's giving them attention in a way

that their parents never gave them attention. And so, yeah, accepting a narrative that, like, hey, there may be another way to get your attachment needs met. I have the benefit of seeing people in this program for three to six months. And there's a lot of treatment that's going on to get them to a place of being, congruent, being able to speak with emotional language, you know, like, and give an accurate, like, I feel this because of this, right? It's like, that's, that kind of statement in someone who comes in, who's psychosomatic and elixothymic, right? If you look at studies on a psychosomatic

illness, they don't read micro-expression as accurately, and they don't read their own emotional world as accurately. So they don't even have, like, a language of emotion. So, So it actually takes a lot of time. So I don't know. I feel like you are, you are doing interventions and working a whole lot faster than I work ever, which is probably why it's like kind of ripping the Band-Aid off really fast, right? Well, let me, because that's something that is like another really important piece of doing inpatient work and doing curious inpatient work, right?

So like when I'm teaching how I'm doing this, I am also teaching this, Um, like the, I think it's probably a primary importance of boundary and understanding of your role, right? So if every time I meet a kid or a patient and it's, um, I'm sort of like, I'm going to do things differently here. And I'm going to just like shift this narrative. I'm going to like figure everything out and then send you away. Like what does that do? You know what I mean? Like you're sort of exposing a reality and then they leave.

Um, and so I take that really seriously. And so I have to, you have to respect these things. you know, people bring in stacks of paperwork of all the logs of behaviors that they've seen in their kid, you have to acknowledge to get serving a purpose. You have to give it some respect and respect the defenses against the reality, right? It's not about like the Freudian like, let's unveil your truth. It doesn't work like that. I wouldn't want to just do that.

Be like, bye. So what I focus on most is like sort of addressing it. I would say it's like peeling banded, yeah, like for sure, like getting it off, trying to address it. but helping a family understand their kid for me because when you work with adults like working with a kid if I can relate it to the follow-up care I can relate it to the partial or whatever the work we did but if a parent understands how we're thinking of their kid how this pattern developed and why their son or daughter you know child is in this hospital they can advocate differently they can you know what I mean that to me is the big

thing. It's not about me figuring it. It's about them understanding each other. It doesn't matter what I know. Right. And I think since we've only given the examples of using illness to get power, I think it might be good to talk about like, when do you find that it is trauma? Like, do, how often do you, when you're tracing the story back, it's more, okay, there was some psychological trauma. here that didn't get work through. Yeah. I mean, frequently. Frequently, there's something, it's not always like abuse, do you know what I mean?

It can be like a really abrupt fracture of a family, something happening or where it's at. Yeah. How often do you see like a nasty child custody battle and then the kid starts to have issues? Pretty common. Okay. And how do the parents feel when you do. say, hey, what's really going on is you guys are having a nasty child custody battle? Like, how do the parents react to that?

First of all, that's exactly how I go about it. And I tell them exactly who's wrong. That's no, I'm joking. I mean, never. Like, so I, this is what I mean. It's like, if I'm in a situation like that, I know my role is a psychiatrist, not a mediator. I can advocate. I can build a human, realistic understanding of what their kids going through to try and

explain the behavior that they're concerned about. And I can do it in a way that's non as much as I can. And I try not to. If I feel like I'm blaming one person or the other, I usually see that as like, am I, is this countertransference? Is there something about this person that I don't, you know, I don't like or do I feel like they're offending me and how they talk, whatever? I'm trying to stay gray, neutral, and just give an objective narrative to everyone and not say, because truthfully, there are times when, I mean, objectively, someone has done something that then has caused a problem, right? But in a lot of these custody battles, it's complicated. And it's about helping the parents get an understanding of their kids' experience.

I frequently will say, like, I know that it's hard to get along with your spouse, like, or your ex. That would have fallen apart. I know it's hard to get along with them. but I want you to understand how observant your kid is. I mean, I think, like, I want them to understand how observant their kid is and how it can impact their sense of safety when they are hiding their arguments or they're hiding the conversations. I try to, like, give the kid's actual experience credit so that the parent, even if they go home and they don't change what they're doing, at least when they're screaming on the phone, they'll have had that conversation with a physician who said, who said, like, your child is aware. of the tension that's in the conflict that's ongoing in your divorce and and it doesn't feel you know it could be impacting them negatively you know for both parents so they can hold on to that and

maybe at some point they can think of it and be like yeah maybe maybe this isn't good i don't know maybe it sticks yeah so okay so um i had this addictionologist who we'd go we'd go into people's rooms after they had like a car accident and alcohol was involved you know and he'd start talking about alcohol and stuff like that once in a while i would get someone like who would just start escalating with like anger we'd walk out and he would look at me and he said yeah maybe a little bit too much truth for that one you know yeah yeah do you ever do you ever feel like even as subtle as you do it you know as like with all of the skills that you have of like hey i'm not doing this to like shame anyone.

I'm just trying to give this like information, right? Do you feel like the parents react with you with like gratitude? Or are they more like, I feel blamed. I feel shame here. This isn't my fault. I think that like what's more free, like, no, I think that a lot of times I get a response where parents are like, grateful for like an understanding of their kid that makes sense.

You know, even if it's like painful to understand what their kid is going through or to make sense of their struggle or whatever, that it's important. They see it as important. It can be hard, but it's important and thankful that we've gone to that point. But yeah, I mean, there's inpatient. It's like this. Like people are in and out, you know, frequently it's like week-long admission. I mean, that's basically what it is impatient. And so a lot of times parents, when we start to give them a little too much truth,

Or, like, my understanding of what's going on, it doesn't fit their narrative that's built for years and years or months and months. And so they can see that. And instead of being like, you don't get it, they'll just sort of defensively be like, okay, onto the next one. But that's the point. It's like, I'm not banking on convincing everyone of, like, their kid's reality. I'm not banking on that. And I'm just trying to shine a light on it. That's all.

you can take it or not and maybe someday you look at it and it'll stick but um okay okay so here's here's my other question is like how how do you assess for temperament as an influence in in the in the things that you're seeing because like a lot of what you're talking about is like this stress occurred and this there was this trauma or there was this power dynamic thing there's this you know but how much of it is like temperament like this kid has is high highly or has a hard time with emotional regulation. This kid has, you know, more, it's, there's a more biological wiring. And how do you look at that or how do you assess that?

Yeah. So it's hard because I think, I think that's that people are drawn to temperament. Like when we talk about the manipulative thing of parents being like, it's just this kid is just doing this. They've always been this way. I think that's a narrative that's tough. My goal is to do everything I can to shine a light on the things that are not just temperament while acknowledging that temperament exists.

There was a, I don't know if you ever, did you ever read the book, The Longshad of Temperament by Kagan. It's like, it was like a study. I can't remember where they were from, but I read it in training. And it basically was like a longitudinal study trying to control for every available and GOS focus on temperament. Okay. And it was basically like, because it's a hard thing to assess, do you know what I mean?

How do you control for everything in twin studies, I guess, stuff like that. But they looked at it and they saw basically like you're more, you're less likely, there were like two types of temperament. And like very basically, it's sort of the risk taking temperament and the inhibiting, like sort of more anxious temperament. That's sort of like the most consistent ones they found. And in the book, it suggests that you can, you know, grow up. and shift into some level of gray between those temperaments.

Most people do, but it's less likely that you're going to just like flip into this, you know, to be sort of an inhibited, like generally, I don't know, risk avoidant person and shift into a risk-taking person. It was like less likely that you would do that, but it still would happen. Now, so when I think of temperament, right? I think of what is the, like, if I'm going to say to the parent that this kid, like, like, yeah, your kid was born with this biological, like, they are this way, right? They have a risk for this.

And it's sort of like who they are and you've had no role on it. I need to like feel pretty convinced that I've looked at their life. You know what I mean? And have, you know, have done everything I could to understand their narrative of development of symptoms. And then like, they can, you know, bring in temperament. I don't know. Does that make sense? Yeah.

It's like you're hesitant to bring up the temperament thing because there's there's so many unknown factors that you just don't know, right? Like you don't know how much all these other things are impacting it. And I think like if you go back to my big five episodes on neuroticism, trauma impacts neuroticism, child development, you know, like early, early experiences. it's not like someone has a, you know, in the Big Five, openness, extroversion, you know, agreeableness, neuroticism is one of them. So neuroticism, people who are higher in neuroticism tend to have personality disorders. We know that. And neuroticism can change over time and treatment can change neuroticism too, which was interesting.

So like psychotherapy can change neuroticism. I've seen that in some of my clients that I've tested and then retested. So I'm not saying that I think purely there's like a temperamental thing, but I do see that like if I have a, if I have, you know, parents that are very, very neurotic, right, stress reactive. So they're, you know, they're more prone to depression, more prone to anxiety, right? And then I have kids of that. It's kind of like, yeah, kind of makes sense. this kid is more, they're kind of wired to have issues with affect regulation, you know, stuff like that.

So I'm just curious, like, how is that part of your narrative, or how is that part of how you communicate that with parents and with the kid? You have to include it, right? It's kind of like kids who have had exposure in utero or something, you know, it's similar in my, in that sense that there are inherent risk factors with them developing, you know, like you said, affective dysregulation or, you know, low distress tolerance, things like that. But I think that what I am, what I've seen become problematic is when you're, when you get a narrative of bad seed. And I don't think that that's what temperament alludes to. I don't think that's the intent of discussing temperament. But when you shift the conversation away from the kids' existence and their families' like sort of development, you can get into an area where it's

like, well, this is what they are. And like, that happens with people who will get reactive attachment disorder diagnosis. And I've heard people say, like, oh, we can't do anything with that. I mean, that's like so hard to treat. I have people say that to me. Or I've had people say, you know, they have borderline personality disorder when they're, you know, 12 years old. these things that sort of like it's like they can limit your ability to stay curious because you're now it's something you can't really argue do you know what I mean it's inherent in them it's something that's part of them that you didn't have any role in and that is just there you know and I said okay that is that is like there's an allurement to that kind of way of seen things and I see that

with like the bipolar like okay you know your kid has bipolar and it's a gym genetic disease, there's nothing you can do about it, right? It's not because of you. It's not because of bad parenting. And the parents just are like, oh, thank God, you know? You've appeased my life. Right, right, right. And so you're not having that conversation with people? I don't have that conversation. I do not have this thing. Yeah, you have this. Your kid has this diagnosis. And so the medicine's going to change it. Congratulations. Your life's going to get better from here on. That is, um, Because, I mean, I think I've had those early on in training of like, this is what's going to help. And then I see it fail, fail, fail, and kids come back. But I think that what I would talk, what are you talking about, right? It's like the idea, temperament is a real thing. And when you're talking about things like patterns developing leading to suicidality or, you know, really intense things in kids, that it can lead to the sense in a parent of like, what did I do wrong? Like, what?

Like, it becomes very self-blaming for parents. And it's, and I'm very aware of that. So when you ask what I do about this, it's like I'm, I sort of am trying to make sense of their, like, their role and like what, how things developed and how it's not someone's fault. It's not a fault of anyone. These things have developed over time. And this is just life. Life is complicated. And so I will say things, too, about like how their kid had, may have had risk factors.

You know, it's not, you can't always plan and protect your child from like these things developing. But, um, yeah, I think that I, my approach and it's definitely not what, you know, I think is standard, like you said, like here's your, your kid's bipolar. Here's your medication. They're going to get better. My approach is generally just trying to build a broader sense of their kid. And so if explaining temperament and giving credence to their perspective of how the kid was when they were very little, um, helps them under. their kid in a broader way and doesn't push them further away from their child, you know, it draws them closer in understanding and empathizing, then I do include it, yeah. Great point. If what you're saying allows the parent to empathize and connect with their patient or connect with their kid better, right, your patient, then you're doing your job. If you as a

provider are connecting and have less countertransference towards your patients, then you, whatever system or however you're thinking about it, it's better, right? I think that there's not to point out that there's no bipolar because there's, I treat patients who are really bipolar and some people get loosely diagnosed with that. And it's kind of like then they develop a narrative around it. And there's a reason why the narrative is so helpful because it is genetic and it is, you know, there's less psychotherapy that's going to help, right, in a lot of people's minds.

But a lot of people got overly diagnosed with bipolar, mostly 10 years ago to about 20 years ago, somewhere in that timeframe, it was like very popular. And the people really have borderline per size order. And so they're not getting the therapy that they need to actually overcome the problem. They have affectus regulation issues, right? that's like the bigger the bigger issue now i'm not saying that bipolar doesn't exist i don't

how often do you diagnose someone with bipolar on your unit um like not frequent not commonly i've had i mean this is a thing it's like when i diagnose kids with bipolar i'm i'm looking for bipolar disorder i'm not looking for affective dysregulation like you said um so i've had cases of kids who come in and they've had manic episodes or they're in a manic episodes frequently like older teenagers. And that's where it's like very important to treat it. But I mean, I frequently I'm just educating people about why I don't see that as the diagnosis and try to explain, you know, why the kid is there. I'll say another thing too, like with borderline personality disorder, just in the sense of differential, diagnostically, like, what are we doing? I've had lots of,

like, good conversations with residents about like, why aren't we diagnosing these kids who are constantly self-harming and suicidal with bipolar or with borderline? personality disorder. Why aren't you, why are you just saying like potentially traits or whatever? And I think there's something about the narrative, right, that you're giving a kid in a family. If you're giving a kid, this is, I'm sure people see it differently, but when you give a kid in a family a narrative of this is their diagnosis, they have borderline personality disorder, right, when it's a 13-year-old kid and they're going through, you know, their first relationship and break, or they're going through like a crazy seventh, eighth grade year or whatever.

you basically it can serve a purpose to be like see i figured out what's wrong with your kid and the family can be like oh thank god i understand it and they can sort of move away from their kid when frequently the behavior that their kid is presenting with you can build a narrative of how things like powerlessness helplessness control feeling overwhelmed feeling you know like chaotic how those things had built and you can help a parent empathize with it because i mean ultimately when you're looking at borderline personality disorder, what do you hope for? You'd hope a parent could become aware of their kid's experience and maybe like shift how they contain their, or do their best to shift how they can contain their kid, you know? So what you're saying is it's actually, I'm learning from you here.

I think it's like you are using words that allow the parent to better empathize with what's going on with the kid. you're you're trying to stay away from words that would keep them that would give them some some distance right oh this is something a professional handles it's like right i don't need to do anything different or i can move away even um no you're saying like what's going on here is the you know like there's this relationship conflict and they don't feel hurt about this and you're trying to coach the parent into better connection with their kid. I like that. Yeah.

But I think also that's not what is typically. That's what I mean. I say I had lots of stimulating conversations about this. Because I had a resident who was like I really loved working with. And she's like, it could be doing harm to these kids to not diagnose them with borderline personality disorder at a young age. Because they could be in treatment that addresses it from a young age. and it's hard because I'm like, I get what you're saying. All I know is clinically, if the goal is to help a kid feel better and feel more human.

I mean, that's how I see it. It's like you want a kid to be human, to feel human, to feel content in a different way than they have been. I frequently shift the focus on how can I help a family do that with their kid. Like understand them, contain them, give them an emotional space. and, you know, an emotional respect that is in line with reality as opposed to disconnecting. I just have seen that. To me, that's like humanistic hair as opposed to like professional, this kind of like, you know, I am the professional here.

I am going to give you your treatment, that kind of side of psychiatry, which I just don't. I always struggle with. Okay. So I think the resident who said that the, if I were to agree with an aspect of it, I would agree with if it leads to the right intensity and good care, right? So if the parents won't go to partial or won't take their kid to therapy unless they have a diagnosis, then it's like, okay, maybe we're going to go there. But, you know, and I have the same problem with like men who come older men who are in their like 30s, 40s, a little bit narcissistic, having interpersonal conflict.

it's like they come in because someone told them to come in. They don't want to do therapy. How do I tell them that their problem is such that actually therapy will help them, right? But they're going to have to do enough and they're not going to want to do it. And they're going to have to make sacrifices to do the work and it's going to take time. It's like such a hard conversation to have, right? I think what I'm saying is that a good inpatient doctor, like Dr. Pro, she hears this, Dr. Pro is masterful at this. She gets the patients to go to partial better than any other inpatient doctor I've ever seen.

It is magical, right? And I don't think the administration understands how powerful someone is like that, because we have some of the biggest partial programs that I've ever seen, like any academic institution have, we probably have like 200 to 250 people in partial in IOPs every week. Like that's how many programs we have, child, adolescent, adult. Yeah. My program has about 40.

So, but it's like you have to be kind of the Pied Piper to get people to progress in treatment. So how do you use your power and all, of this hard work to get them to get to go to treatment to get them into the next step right you want them to go into partial you want them i mean do you have good iopis and part of your system that you're in yeah yeah and yeah i'm lucky enough i mean i'm in at pit and um pit has a lot of resources um move partial um the star program is a big thing here at pit uh iop's yeah um so what i would tell you is like, I frequently take the stance because a lot of our kids, I'm thinking about the common patient who's like, think about this summer, kids who come in in the summer for something like

suicidal threats or aggression or whatever, they don't want to go to partial. They want to be home for the summer, right? And so I acknowledge that immediately. Why would you want to do that? You know, why would you want to go to school, right? And then I sort of try to paint a broader picture of what the potentials are, right? And honestly, it all lands in, I feel like if a kid, especially with kids first coming in to treatment, if they're feeling like they're meeting a doctor or a therapist or whoever's, who understands, like, in a human way, what's going on, or they're on to something, they can see a potential in that it can make them feel, you know what I mean, they see a potential. These kids will cry when we do family meetings because it's painful,

but they will still come and do them because they feel something happening. They see, what we're talking about. And so if we can let them see that and then we say, this is where you're going to continue doing it, there's the hope is that they can, you know, get a human sense of what treatment's capable of and go and follow up. But I frequently just say like, I know you're, I mean, I'm not, you're not, you're not arrested. Like you can't, we're not going to lock, like handcuff you and walk you to partial. But here's why. I mean, trying to acknowledge the cynical reality, I think, of an adolescent is as underutilized. Yeah. Yeah. Absolutely. It's like you don't you want them to put words to the resistance or their apprehension or their disconnection.

And I think their connection with you as an individual builds on the transference towards the institution as a whole. It's like, okay, this is an academic center. If this doctor was good and he listened to me, I'll probably get something similar and partial. And so it builds like an, I call it like an institutional transference. There are some patients that literally just come and they seem to be just hanging out. It's like, hey, what are you doing? You have a doctor's appointment today? No, just sitting here.

It's like, oh, it's like they have an institutional transference. It's just sitting in this location. Good things happened here. That's the ideal. It doesn't always happen. Unfortunately, some patients inpatient have an awful experience. I just got an email from someone in Europe, and it was like, let me tell you horrible things that happened when I was seeking treatment, you know?

Yeah. And how do you deal with that kind of stuff? Like maybe a patient attacks another patient, you know, or stuff like that. Like, has that happened? Like, what do you do? What do I do? So, well, first of all, can I just say the institutional transference thing is very interesting to me because I also see another side of it, which is when there isn't a family

structure or social structure for a kid and they grow up inside. I mean, this is a type of case, a kid who grows up inside of institutionalized settings like inpatient hospitals because their behavior is so scary for everyone. They grow up and develop this sense of the transference to the hospital as a family. I mean, this is like where I live. This is my home. And it's very, it's so, so yeah, it can be this really dangerous thing. And I'm like constantly aware of with kids. So that's, I mean, these types of cases are good examples. right of when there are I will I think it's really important for patients and parents to understand what inpatient is when they're coming in right like we are not like I think sometimes there's this

idea of like why would you know we're coming inpatient we're here for help but then the reality is is like you're on an inpatient unit with a bunch of kids who have different situations that are going on some could be aggressive some could be self-harming some and things like that can happen on an inpatient unit, like very intense sort of like, you know, moments can happen like a fight or, you know, like I had a kid dump apple juice on me. I had a kid jump on top of me once and like rip my badge off and throw it. So I couldn't like, you know.

So like these things can happen. But when I think about relaying the reality of treatment, when I get a young kid who their parent is seeking inpatient mission, I want them to understand when I talk to them, of like, this is what it looks like. And these are the potential things that could happen. To me, that's a risk, right, of staying in the hospital. And I'll put out there a lot of times, like, if that seems too much, I mean, you can

take your kid home. We'll understand there's risk, you know, and I'll talk to them about that. But I think just being realistic about the potential of being exposed to things like cussing and violence can happen on the inpatient unit. But I don't think it's a, it's like people will paint inpatient as one flew over the cuckoo's nest. And then some people will paint it as like, you know, it should be some place where it's like just like always therapeutic. It's never. It's like the reality is you're in a building.

You can be therapeutic, but you're in a building with, you know, 20 people who are in crisis. Right. And 20 kids, adolescents who are in crisis. Sure. There are like, there's a lot of energy and like things that could happen. but it's like the risk of that it's the risk of that versus the risk of being in the community and I I frequently are on the side of a parent is seeing something and they don't feel like it's helpful they feel like it's worsening their situation I generally try to I frequently

respect their autonomy with that even with a kid who came in for an attempt or something like that I would never discharge someone I thought was like imminently you know what I mean suicidal or something, but it's like you said, when adolescents come in, it's frequently like they're out of crisis. Do you know what I mean? And so the standard, like, we need to keep you for this period of time, because that's what people do. I don't, I just don't see that as like clinical a lot of times. Yeah. Yeah. Okay. How do you deal with your own powerlessness? How do I deal with my own powerlessness. Do you, do you, have you come up against that where it's like, you know, I really can't

stop this person from killing themselves if they're going to kill themselves? Like someone who actually was very suicidal, who like, it wasn't just, you know, self-harm, for the sake of self-harm. It was like, this person actually has a real plan. Well, yeah. I think that that's probably been my biggest tool that I've built throughout training and throughout like just like working as an attending in an inpatient setting is sort of embracing the powerlessness, right?

Trying to get away from this like fantasy of like someone coming in with really complicated suicidality. And I'm going to come in and I'm going to fix that or I'm going to, you know, I'm going to get rid of that for you. Trying to embrace this sense of like there are things I'm capable of. And I'm capable of trying to help you make sense. of what's going on with, I am capable of doing everything I can

to understand your situation, your clinical situation, and I'm capable of trying to convey that to the people who matter to you most, right? That to me is like very power. That is like my power pretty much. Now, and then I can prescribe medication, right?

I can do that, and I do do that, and I see it benefit people, but it's not a, if that's my, my focus, right? The power doesn't feel real. So I frequently feel in this position of my power, in a sense, is in understanding, not in saving. Like, I can't save everyone. And I had to, and it takes a long time. And I think that psychiatry and self, like, builds up a sense of burnout because you're consistently put up against this thing of like, I want to change. I want to save people. I want to help

people, like in this very, like, I want to see them, like, really thrive. And then in training, it's just you, you aren't running into that, like near as much as maybe you expected, right? And I think it breeds this sort of burnout in people where you're sort of progressively shut down in your sense of what you're capable of. Like, dang it, I did, I thought that was actually working. I thought this, I thought, like, well, Boutrin was the thing that was going to do. And then it's just like, you're constantly like, what am I good at? What am I capable of doing? And it's just, and then I think people get out of training and they're like, whatever. Whatever.

I'm not doing anything for these people who come to see me. So I think embracing the sense of like, what am I looking to do? If I'm looking to understand and help a family and help a child empathize and really address like a human problem, right? Like address a human problem, bring it to like help help a family and a patient feel contained and help them like in a state of crisis. That to me is like where I build gratification from, right? And so I deal with my powerlessness by sort of shifting it into my biggest, like, I think, tool strength, do you know?

Yeah. Yeah, I think it's painful, especially when we come up against, like, are, am I making things better? I think the difficulty that residents have is there often, they, you know, they start impatient and they start in the ER. and the people that come impatient that they'll remember are people that they've seen before. And so any case that's good, they go on to partial, they go on to outpatient, they're better, they don't come back. So by the end of like two years of this, like you'll remember mostly cases that were failures. That's true.

Yeah. That's your training. And as an attending, that's the same thing. It's like you know, and we all have, if you've done this work, there's certain patients that when they come on your list, impatient, you're like, oh, them again. It's like, oh, God, what happened? And I've had cases where it's like you wake up in the middle of the night

after the first couple weeks of seeing this person, outpatient, mostly did outpatient as an attending. I'd be like, I don't know if this person's going to make it. Like, I don't know if there's anything I can do. And then the patient does impatient. They do partial. They do DBT track. They do the CBT track.

They do the, you know, they come in on my track for six months. You know, it's like they're admitted again. And it's like two years later, they've done a ton of work at this point, two years of work, right? and they don't look like the same person. They don't scare you at all anymore. It's like they have a new set of ways of seeing the world. And it's one person in particular moved and then reached out to me about two years later and said, hey, I'm doing a lot better.

And it was like, it's kind of like it instills hope. but I don't think that, I don't think I had that as a resident, you know, because I didn't get to see people longitudinally in the same way that I did as an attending. Right. So I don't know. I kind of, I feel like that's the tough point for you as an inpatient doctor. It's like, how do you know what happens? Well, I think that's why when I'm like teaching or I'm working with residents,

it's because I had that same experience, right? Like I had the same experience of like just not feeling gratified, not seeing change or, you know, just feeling constantly put up against this wall. Like this is what we do. Like this is what we're capable of helping. Is this, you know, because I was just seeing things be ineffective in multiple different settings. And like not ineffective. I think it can be effective. The standard of care is effective for many people.

but when I teach residents, it's this thing of how do you get, how do you sense, get a sense of gratification inpatient then or in training then? How do you get it? You can't get that. You can't get the longitudinal experience. And so I shifted towards these moments, right? Every interaction you have with a patient, if you're in tune with their situation and you can see it, like you can, or even if you understand a case clearly in a way that is just

like, wow, this case was not making sense to anyone else. And we just built this understanding that is like, no one can really argue. Like, it's like a human understanding of the case. Like, it's a gratifying thing inpatient, right? And you can see how a patient can react or how our parent can react when you're going into and you're talking about things differently. You can sense an effect of like entombment. Right. That is in itself like gratifying. The connection, the empathy, the work, the hard work that you do, and it is hard work, leads to that connection. And that moment of connection is enough. It is.

I mean, I think it should be. I think, like, seeing someone in crisis, right? Like, seeing someone, really, like, seeing the kid who's coming in in a chaotic situation and really just sitting with their feeling, whatever is, as bad as it is or as, like, helpless as it feels, sitting with it with them. I mean, man, like, to me, that is powerful. And you can feel it. And residents and students, like, they can feel it when you have those moments.

When you're in a family meeting, and you see a patient who's been disconnected, really listening to what their parents saying and really, like, wanting to say something, like engaging differently. It's so gratifying. I mean, it's a human, it's gratifying in a human way, not like in the way I think you're, you're built into thinking you're going to feel gratified when you go to med school. you're going to be gratified by this longitudinal

you build a successful person or something you build a healthy person that I mean and that's like yeah I think that is gratifying when that happens it's it's often the case that there's setbacks and there's yeah it's like how do you remain hope how do you remain hopeful

and and I think that your solution is to focus in with your with your energy on the moment to moment connection you can produce by getting into someone's story deeper maybe than they expected than the family expected and to relaying that story back in a really powerful way so that they're not alone in it. They're not alone in that chaos anymore. You're you are entering into it with them. And that's meaningful.

And you get there by curiosity. You get there by listening deeply and by making sacrifices. Financial sacrifice. You told me earlier, I'll brag for you. You made a huge sacrifice financially. Which is interestingly, at the beginning of my career, I took a huge pay cut to do psychotherapy, right? Now I probably make more than some of the people who would have chosen a different

path. But initially in my career, I took a huge pay cut to spend more time with people. And I didn't choose jobs that wouldn't allow me to do that. And I chose a job that I got to be mentored by someone like Dr. Tar. I get nurse practitioners who are always like, what do I do? I'm like, look, if you don't get a first job where you have good mentors, like you need to find another job. Because residents have four years of good supervision and you've had a thousand hours you need people around you who you can get good supervision by if you're going to be a psychiatrist or be a mental health professional um and you i think you chose your job as well because you had a good boss that would support you tell me a little bit about that yeah well i mean like coming out of training it was one of

those things of i ended up thinking i wanted to do inpatient in some way um with and there's like a whole idea of why I wanted to do inpatient and not do like private practice or whatever. But when I'm looking at jobs, yeah, I mean, there were like, it was definitely going to make more money doing something like if I opened up a unit myself, it was like the point person at a, like a more community hospital or did inpatient and outpatient, you know, like sort of did inpatient work and then did clinic in the afternoon and saw, you know, 20 kids and then did outpatient work. So it can make a ton of money doing that.

And it was hard. I mean, it's like hard because I think coming out of training, it's like there's this huge pull of like I did all this work. And you do want to make money for all this like expertise you're trying to build. But then I did put weight in when I interviewed and I met a supervisor who like I still have who just clinically can like vibe with what I was looking to do. Like clinically understood how much I cared about teaching. and clinically understood, like, and just sort of was a more seasoned person who viewed treatment

in a similar way to me, sort of like in from a humanistic perspective, right? Somebody who's like sustained in this field. And so that was, I put a lot of weight into that since I got from him. And it's been like, it was like the right call. It was like, I'm grateful that I did. And it's funny when you're gratified in your work. I mean, I haven't thought about the financial component of work. I mean, I know that is also, I'm very different from people.

And like, I'm lucky enough my wife, Molly, is a physician. Like, so we are fine. But I haven't thought about the financial implication of working in academics. Right. As I've done it now for years, you know. Yeah. It's just like gratified. I think, I think a couple things to say.

One is if you have a busy practice and that's what you've chosen, more power to you. That's your choice as a provider. So if you're listening to this and you're like, well, I have a busy practice and I'm seeing, you know, blah, blah, blah. Sometimes you got to do what you got to do. You know, you have different people at different places in their life have different things that they're going to choose to do.

But what I think that you've chosen to do, which is really cool, is to educate the next generation and to build a practice and have, you know, a model that people can witness and say, okay, that's, I'm, I'm able to, you know, invest in my clients really deeply. And I'm, your students are seeing that. And that's really cool. So. Yeah.

Well, and I would say this too. I think that psychiatrary, like being a psychiatrist, it's there all, it takes all different kinds of psychiatrists. And not everyone looks for gratification kind of the way that I did that I do in the job. And I think people draw gratification and see clinically, like, they do. different clinical work, I think, and, you know, can make a lot of money and do clinic work and inpatient outpatient, do all that, and sustain doing that. And it's, it's effective and it's giving them that sense that they're doing really great work. It's just for me, right? And it's what

you said. It's like, I think it's important for residents or trainees or anyone who's, I don't know, coming up or starting out to know that you don't have to fit a mold of the treatment setting you're in, you know like if you go into inpatient work if you're clear about what you're effective at and you're clear at what your what your skill set is the thing that makes you most effective and you advocate for the things that allow you to use those skills right like patient cap or whatever then people will see you be effective and like you will feel that and feel gratified and and you can do that in any setting um and it's not just because i i i Like I were saying before, too, it's like I think there's a pool of like if you're interested in psychodynamic therapy when you're in residency training.

It's like, well, I should just do that, like private practice. They'll just do that private practice. There's so many tools in psychodynamic and cognitive behavioral therapy training and DBT training that you can just take and build an expertise in any field in psychiatry and just do something different. You know what I mean? Like there's so many skills you can take into whatever setting. I take a majority psychodynamic approach to the inpatient setting and like it's effective and I feel effective and I feel I'm like gratified in it, you know? So I think as long as residents, I think it's good for residents to feel like there is a, you know, there are a lot of options to practice the way that you are effective at no matter of setting. Yeah.

And I think some medical students will. tell me, oh, I told such and such a person that I wanted to do more therapy, and they said, oh, psychiatrists don't do that. And I would say, well, that's what they've chosen to believe. You know, I choose, I choose to believe from what I think is very data supported. Everyone's doing therapy all the time. Some is just good therapy, some's not good therapy. You know, like any, any time you're interacting with a patient, it's good therapy or not good therapy, but it's therapy. Like it is going on. It could be just purely supportive.

You could say nothing empathic the whole time you interact with a person, or you could say multiple things that are empathic. I would rather train people to say multiple things that are empathic, even if they're short encounters. Right. And that's the point of inpatient, right? Like what I'm saying is that you can bring those components you learn about empathy, transference, countertransference, you know, self-awareness when you're treating, understanding your role, understanding what you're capable of and just build an attunement in the interaction, right?

And I think students, residents can feel gratified in that. I think it can, you know what I mean? It's something that stands out in psychiatry. Being aware of that, I don't think any other field of medicine allows you to be, or, you know, at least typically, it doesn't allow you to be as curious as we can be and as insightful and as, like, aware as we can be, you know? Well, yeah, I would say the best rheumatologists I know are very empathic, or the best family docs I know are very empathic. And there's data to support that that changes outcomes as well. Or the best HIV doctor I know, who I learned so much from, he was incredibly empathic and warm

and connecting. And his patients took his meds. You know, there's data to support that therapeutic Alliance and HIV clinics increases adherence to medication regimens. You know, it's like, so it's like it plays out differently, but I think what you're saying is that uniquely in psychiatry, we are, our role is to actually dig deeper into the psychological aspects, which is a lot of fun. Right. And do you think those people like those, those sort of people that you see family medicine doctors or rheumatologists that are effective, empathic, it's not something that it's, I mean, I would say the majority of people who are really good at that and their patients like really engage with them that they're not really thinking of like why is this happening

why am i effective i think a lot of people are just good and empathizing and they but i don't know what you see if you if you meet people who are in those fields and they're aware of why they're effective or they think about what why i know okay so this one h this one hiv doctor who was like a mentor of mine he would think about it and he would think but it was a very sort of um For him, it was a very spiritual thing. And he wasn't talking in spiritual language to patients, but for him it was like an internally spiritual thing of like, how do I love this person that's in front of me?

And it was just like, how do I communicate that love? And it would work for him. His patients loved him. His patients, it's out, like, you shadow him, and it's like you're watching a guru, you know? But it came out of pain. That's the thing. It's like a lot of people's ability to do that

and do that well, if you hear their story, it came out of immense pain and their own suffering and their own journey out of that suffering, right? So yeah, I think different people have their own journey. And I think you've had your journey to kind of like, how do you come out of burnout? How do you come out of the pain? How do you find something meaningful? And I hope as you're listening to this, realize you have your own journey. It doesn't need to be exactly like ours. It doesn't need to be, like you could be in the middle of it right it's like it's okay to struggle with finding what is meaningful as a provider as a mental professional you know and to wrestle with like the powerlessness that we sometimes feel how do we deal with you know people who commit suicide

people who um you know like the worst things right the worst things that happen um those things are really, really tough. You know, I think in mental health, and we'll wrap it up pretty soon, but this is like a final thought that I had, only in mental health, it's like, okay, so in cardiology, I have some friends who are heart failure doctors, there is no delusion that they are going to help every person that comes in with heart failure. They know they'll be able to prolong the life, potentially, but some people are like they're going to die of heart failure. And I think in mental health, we are under a delusion that everyone we see is not going

to commit suicide. And some people will because that's the field we're in. Like I know a good, like he opened up a clinic purely for people who are suicidal. I don't know why you would ever want to do that. That seems like absolute torture. The star clinic in Pittsburgh, David Brent sort of cultivated. That's his whole, yeah. It's the same.

The people who have that passion, it's like, wow. People are going to die, right? I think he shared, he had several deaths. And so I think it can be hard as we can be hit by it uniquely, I think, in this field, because we have such hope to make a difference. And we need to look at those small moments like you do, like the connection. how do I build this connection? How do I increase the empathy in this family structure?

I think that's beautiful. So thanks for sharing. Well, if I can say one thing, too, I always, it's always in my head, especially inpatient, like the fear, right, the fear of an outcome like that of suicide or, you know, some serious negative thing happening, like the reality that that could happen. And when that's a potential reality, that's what I mean is like, if you were a physician who gets a case like that and a kid ended up completing surgery. suicide, you know, you would hope, right, that when you had that case, you did what you could

to make the most sense of that kid's experience. For me, this is my approach, right? Like, if I did the most that I could understand the pain, understand the experience, the best that they could give me or the family could give me, and I could help a family who would then be grieving, right? Help that they had an awareness of their kids' pain. It doesn't change how horrible suicide is or how awful that would be. But you would think that it would give them a sense of their kid in a different way. Should anything like that happen, they could have this, this realistic view of their son, their daughter, their child, like. And I think that's so important. And I think that's like when I say the power of being curious, the power of really being

focused humanistically on the narrative of the realistic, the internal reality of the kid. it's for that, right? It's like if something were to happen, we really felt like we looked at this case and dove in and looked at everything we could have done to understand it and to help. And so I think that, you know, that's something that helps me.

It's like if that were to happen and it's happened, like, but it's that this sense that you've communicated and you've let the people in this kid's life, the ones who matter the most of them, understand them differently, you know? So that to me is a very important sort of like powerful responsibility we can have as psychiatrists. Yeah, beautiful. I think it's a good place then.

Well, thank you so much for coming on, Daniel. Yeah, this was great. Thank you so much for having me, David. Yeah. I appreciate it. I will leave it there. And yeah, I imagine someone's going to listen to this who's like a medical student. They're like, how do I rotate with Dan Bender?

What is there any way? I guess you could reach out to me and I'll give them. I'll give you their info. That sounds good. Awesome. All right, we'll leave it there.