There are many enjoyable aspects to practicing psychiatry. Humor, unfortunately, is not usually one of them. If psychiatrists are not careful, the seriousness of what we do can deplete our emotional energy, and our work can become depressing. Also, psychiatric patients are people, too. Even when they are in a melancholic state, they can still have a sliver of humor left. And, properly-timed humor can be therapeutic, right? So, is it appropriate for psychiatrists and other mental health professionals to joke with our patients? If so, when?

A psychiatric resident wrote a  NY Times article about this topic. Interestingly he mentions that when he was an intern on the internal medicine service, he regularly joked with his patients. But, when he started working on the psychiatric service, the humor stopped. He not only felt uncomfortable with the idea of joking with his new patients, but he squirmed when they attempted to joke with him. Ultimately he found a way to joke with a delusional woman in a manner that allowed him to establish enough rapport with her so that she readily gave him her history.

Although there are numerous reasons why one probably should not joke as freely with psychiatric patients as one might with other medical patients, under the right circumstances I believe humor can be incredibly therapeutic. Even in prison. In fact, especially in prison.

How and when to use humor is truly an art. There is simply not one right way to use humor with patients. If the day ever comes when we are required to use humor algorithms in the practice of medicine, then our patients may as well be treating us!

I do believe, though, that there are some general principles that make sense.

The joking should be done with the intention of establishing rapport or being supportive or therapeutic in some way. It should never be mean-spirited. And, the patient should not be very upset or in an overly-serious mood. Finally, I believe it’s easiest and most appropriate to joke with patients with whom we already have established some degree of therapeutic alliance.

What do you think?

Photo: Micky

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Several years ago I worked regularly with maximum-security female inmates. I had never really (knowingly) been around violent women prior to that, and it was an eye-opening experience for me.

I worked with many women who had killed their significant others as well as others who had been convicted of lesser but still violent offenses. I realized that while men are statistically more likely to be violent than women, it is definitely a naive and sexist view to assume that women are not violent.

Stalking is simply an extension of the violent potential of women. Women account for approximately 15-20% of stalkers. Statistically, female stalkers are most likely to be single and in their mid-30′s. They typically have personality disorders, with borderline personality disorder being fairly common. They may also suffer from delusional disorder, often believing that the persons they are stalking share the same romantic feelings toward them that they feel toward the victims. Women stalkers typically know their victims.

The topic of female stalkers is quite relevant for all mental health professionals. At some point all of us may work with patients who are stalkers or victims of stalking. Also, approximately 11% of mental health professionals become victims of stalking by their male and female patients.

(If you are interested in knowing more about female stalkers, the second reference below is a review article on the topic.)

References:

1. Meloy JR, Boyd C. Female stalkers and their victims. J Am Acad Psychiatry Law 31:211-19, 2003.

2. West SG, Hatters Friedman S. These boots are made for stalking: characteristics of female stalkers. Psychiatry (Edgemont) 2008;5(8):37–42.

Suicide is an absolutely horrible phenomenon. It destroys families and forever leaves survivors on an elusive search for why it happened. Suicide is often viewed as a very selfish act, yet I believe that in many cases those who do it truly cannot endure the emotional pain any longer and believe that they are out of options. When I was a young adult, an extended family member committed suicide. During my career I have lost a small number of patients to suicide as well. These were all very tragic experiences.

In the United States, mental health professionals have a legal responsibility to take action when our patients appear to be at risk for harming themselves. It is not possible for us to accurately predict when a person is going to commit suicide, but we are expected to assess for and document suicide risk factors. If necessary, we may have to call police or take other action to have patients involuntarily admitted to an inpatient psychiatric unit.

Involuntary commitment is a very controversial topic. What usually does not get discussed, though, is the fact that many mental health professionals, including myself, are often very uncomfortable being placed in the role of essentially being responsible for someone else’s behavior.

Although the majority of people who attempt or commit suicide suffer from mental illness, some do not. For those who do, some may be psychotic and therefore completely out of touch with reality or so clinically depressed that they have lost all hope.

In the latter two examples, the patients likely have treatable conditions, and once treated, they may change their minds about wanting to die. Even when I believe a patient simply wants to die and has “legitimate” reasons for feeling this way, I always try to dissuade them from harming themselves. I have not, and will never, shirk my professional duties.

From a philosophic standpoint, it makes perfect sense to me that mental health professionals should do all that we can to help people however we can. What I find rather odd, though, is that people in our culture do not have a right under any circumstances to end their own lives. I am not in favor of physician-assisted suicide or suicide at all for that matter. But, on a human-to-human level, who the heck am I, anyway, to tell someone that they can’t end it all if they choose to? I’ve never been suicidal, but likewise, who is anyone else to tell me I cannot do it either?

I understand firsthand that if affects people other than the one doing it, but at some level, at least, isn’t that personal choice? And, if it isn’t, then who, if anyone, should be held responsible if someone chooses to end his or her own life – psychiatrists, psychologists, therapists, primary care physicians, family, friends? In various life situations, Western society is great at assigning blame when there is a bad outcome, but I rarely hear people talk about free will.

I’m really curious what people think about this issue. I don’t hear it discussed often, but I believe it should be.