When You Just Can't Win

There are times as a behavioral health worker where you have to say no to care - if it feels unsafe, untenable or harmful to either side, NO is okay

If any of you have ever seen the classic sitcom 30 Rock, there’s an episode where several characters are auditioning and one of them, Dot Com, has a rough encounter right before his big moment. Every so often, all I can picture is him on stage, starting his audition with zest and skill – then pausing to shake it off. “I’m sorry, someone really messed with my head right before I came on. Can I start over?”

This patient hates me. And I hate this kind of a situation.

That is how my whole day feels after crossing a situation where I Just Can’t Win. It gets under my skin, or bothers my day, I rehash it in my brain. Sometimes I have to take a quick walk around the block to shake it.

We’re in the business to help. It’s hard to accept a loss!

I had one this morning.

A few weeks ago, a patient called seeking Psych Nurse Practitioner services (medication management in this case). This patient was referred from a reliable source, and I had no red flags while we were on the phone. I am usually pretty thorough with expectations on both sides; I remember this was a pleasant conversation. We set this patient up with an appointment about 3 weeks out. The next day I had a cancelation, so I was able to move up this patient up a day, which was great because they were concerned about cutting it close to the time they would need refills of their current meds. No unusual. I mean, it was only a day, but sometimes a day makes a difference.

Time goes by, about a week before the intake the patient calls needing refills, but we cannot provide refills for someone who is not a formal patient yet, so I leave them a voicemail about that. Go to your PCP, we’ll see you next week. No word comes back.

Then it’s intake day. The patient does not show up. I call, leave a voicemail. I (secure) text a couple of times.

Finally, the patient replies back on the text end, saying they forgot. Oh man, rough break, but if they forgot it really is on them, still I would like to help if I can – I offer two days out if I can clear space, they say they can do that. OK, let me work on it. Sadly existing patients can’t shift out so we are out of luck, a quick turn around won’t go. It’s another few weeks before an appointment. I call the patient the following morning, they answer, I let them know where we’re at.

Well, here is where it gets ugly. The patient is furious – suddenly they swear I have not been communicating with them about anything, that it takes days for me to reply to anything, that they needed meds last week and I ignored them, that they can’t wait a few more weeks for an intake; they will not acknowledge that they missed their appointment yesterday.

I do not sit and argue with patients. It does no good for anyone, but I am also pretty quick to realize when there is nothing I am going to say or do that is going to end well. Still, one more try – I explain to this patient that they missed their intake and there was nothing more available until X date, but I do want to get them in, and can their PCP refill one more time? Well, that was all kinds of wrong to say. To this patient in this moment, that was absolutely unacceptable. So began the name calling, accusations, anger, fury, and finally an angry “just schedule me someone” and then they hung up on me.

Unfortunately, that is not the end of it because I need them to know they do not have an intake scheduled, so I texted them to inform them – and that received a capitalized F**** YOU right back.

At this point I offered them referrals and notified the Psych NP. We got a few more angry messages over the portal throughout the rest of the day, abusing now the provider as well as trying to get me in trouble with the provider.

This patient hates me. And I hate this kind of a situation.

“I’m sorry, someone really messed with my head before I came on. Can I start over?”

I hate this because I aways leave feeling like I should have done something differently. My instinct is to think I did something wrong. Last week, I left a voicemail reminding this patient of the med policy they had signed and directing them to their PCP, but should I have called again to make sure they got the message? Should I have sent a secure message in the portal on top of it? Should I have called them again and made sure their PCP filled their meds? (The PCP had refilled, it turns out, but that was no longer the point I suppose.)

For that matter, how long did it take me to call them on initial contact?

Was it really days before I reached out?

If we had not moved the initially scheduled intake, would they have come to their appointment?

We were trying to help the situation, but maybe that was a bad move or confusing, what if the patient forgot to change it in their calendar after we changed it over the phone! Did their reminders go out?

When they missed their initial intake, I called and texted, but what if I had called once more to track them down?

I hate letting people down. I hate feeling like I could have or should have done something more or differently. Hindsight really is 20/20, which sometimes does not make anyone feel better. Honestly, in this case, I can truly say I did what I could. It does not help.

Look. I am not new to the industry. Maybe this person has some addiction issues I did not previously pick up on, maybe they were incredibly stressed with a difficult situation, maybe they had a personality disorder. In and of themselves, these are not problems for us. Behavioral care professionals are trained to work with addiction, stress, you name it. For myself, I am comfortable working with a whole range of issues and in a million stressful situations, I am not easily frazzled.

The problem is this: Abusive patients are never okay. And do not confuse difficult patients for abusive ones! We were still ready to help this patient until the name calling began. It was not really until the multiple portal messages throughout the day that I accepted that there was not going to be a happy ending here.

Verbal, Emotional or Physical Abuse to any provider, staff member or fellow patient will not be tolerated – it does not matter if these behaviors come from the patient, relative or companion. It does not really matter the reasons behind them, particularly from someone you have not yet seen and have no context for. These behaviors are not safe and they are not to be accepted, ever. If something like the above story happens, process your doubts, questions, guilt and disappointments and then realize:

1) This person probably does need help

2) If they view or your staff as a punching bag, then you are not the provider for them

You are a human being. You deserve respect.

Hard Stop.