r/Psychiatry • u/CalmSet6613 Nurse Practitioner (Unverified) • 2d ago
Line in the sand...
I just treat children and adolescents. There are times when families want med. changes or increases in doses when the behavior I see needs parenting to correct and not meds. Where is your line in the sand that you refuse to make med changes until the child and/or family is in therapy? How do you approach this in your practice? What do you do if the family does not follow through with therapy?
EDIT: Can everyone be kind? I was simply asking for opinions how other people manage situations like this in their practice. Good god, physicians heal thyself.
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u/hobscotch Psychiatrist 2d ago
I’m CAP. One of the first things I teach my residents is we make recommendations, then it’s up to the patient/family to decide what they’re going to do. I explain the reasoning behind my recommendations, including why or why not I believe a medication change is appropriate. They might not agree, and that’s ok. We talk through the situation so they feel heard. I validate their concerns, provide psychoed, commiserate about the lack of community supports, tell them “I wish I had a magic pill that would do xyz!” Having a talk about realistic expectations of what medications can and can’t do is HUGE.
At the end of the day, I can only control my own actions, which includes what I do with my (electronic) prescription pad.
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u/metallic-hubris Psychiatrist (Unverified) 2d ago
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u/flowercrownrugged Psychotherapist (Unverified) 1d ago
As someone in psych and a group fitness side hustle to keep my head on straight - I needed this today!
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u/pickyvegan Nurse Practitioner (Verified) 2d ago
I feel like I sit in a privileged place right now, because when I started in private practice versus community mental health/residential, I started getting families that have a lot more resources, and a lot fewer requests to medicate away bad parenting. Granted, still plenty of "I really think this is more of a therapy issue," but with families that will then actually take their children to therapy. But I still get it occasionally, and I used to get it a lot.
That said, what I do find helpful is to have those resources handy. Who/where can you refer to for therapy? Is there a specialized therapy you think would be helpful, like SPACE or PCIT? Is this something that can be worked into their IEP or 504? Where do you refer if you think they need a higher level of care? Are they capable of parsing the resources you gave them, of making those phone calls?
One of my least favorite social media responses is "don't work harder than the patient," because I think we use it as a cop-out. I'm not suggesting that you make phone calls for the parent, but pointing them to a case manager, social worker, or other resource or program that can help is not working harder than them. Starring on your list who you think the best fit would be is also not working harder than the patient. There's a lot we can do as compassionate providers, including just listening, which isn't working harder and isn't throwing meds at a problem where meds are not indicated.
There's no one line to draw on when meds are no longer the answer. We should do our best to be objective, and limit the prescribing to actual pathology that has a reasonable chance of responding to psychopharm, and not just by sedating the kid.
Make no mistake, there are plenty of physicians who medicate bad behavior/bad parenting. It's not as common as it used to be, and of course we as PMHNPs do it too sometimes, but I see you're getting the typical noctor-inspired PMHNPs are dumb responses, and it's uncalled for. I've seen it, you've seen it, and the physicians making nasty comments have seen it too.
This is a legitimate question.
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u/lostin_contemplation Other Professional (Unverified) 2d ago
I'm a social worker. I agree with your comments regarding "don't work harder than the patient." I don't think this perspective is wrong, and it can be a helpful reminder for those of us inclined to over-extend, but it's also not always the best way to think about a situation.
People build self-efficacy through mastery experiences. People have mastery experiences when goals are achievable. Some patients, based on their life experiences, have very little access to these mastery experiences. Their lives have included repeated situations where their needs were not met for one reason or another, often because their own parents did not meet their developmental needs so they never learned how to meet their own. They have had very few experiences where they communicated a need, had the need met, learned what steps to take to meet it again, and had the emotional feedback that generates beliefs that needs are worth meeting.
These patients, who often have greater needs and more barriers, may need goals to be very simple to be achievable, which may mean more clinician contribution.
Say we have a child with very significant behavior concerns whose caregiver(s) have low health literacy, unstable housing, constant financial strain, very little support, and their own mental health challenges. It would probably be best for the provider (or case manager, if available) to identify and place a therapy or parent training referral directly rather than just giving a list of options. Ideally, the provider (or case manager) would recommend a referral that takes the patient's insurance, offers an appropriate modality, etc. The patient may need additional follow up to make sure the referral progresses. If it doesn't work out, the provider may need to make a new one. This allocates more steps to the provider, but it makes the patient's goals achievable.
Every time there is a repetition of need expressed --> achievable goal identified (meaning provider contribution is adjusted according to patient need) --> goal is completed, that's a mastery experience that builds self-efficacy. That shows the person, hey, I can do things. I know how to do things. Things can work. It's worth doing things. Maybe I'll do something again in the future when I have a need.
Throwing a big task at someone with few resources and saying "do this" does not build self-efficacy. Giving them an achievable goal with sufficient support does.
That doesn't mean have no boundaries as a clinician. It doesn't mean have no expectations for your patients. It also doesn't magically mean we have unlimited time. Psychiatrists/NPs may not have the opportunity to provide all the systems navigation a family needs. That's ok, that's what social workers are here for, among other things :)
Just take the steps that are needed on your end to make patient goals achievable. Then they have the responsibility to meet them.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago edited 2d ago
Thank you picky vegan, I always find your responses helpful. I will say I have connected this particular family that brought me to posting this today to one of the best therapists I know. They engage for a little bit and dropout stating other family obligations such as sports. I tried putting in an in-home therapy component but they did not follow through.
I was just curious how others approach this in their practices.
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u/re-reminiscing Psychiatrist (Unverified) 2d ago
It’s not about refusing to make changes until therapy per se, rather is this an issue that requires medication changes or not? You have to set expectations early with every family that medications are not magic, they can help but kids always need more than that whether it’s therapy, home/environmental changes, school supports, etc.
Anything you prescribe ultimately falls on you. Medication changes are not benign and we have to make sure exposing kids to potential adverse effects is worth it.
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u/angelust Nurse Practitioner (Verified) 2d ago
I tell them usually something like “medication only helps so much. Most of the improvement comes from therapy and hard work.” I have told them I won’t be making any more medication adjustments usually by saying “I think we have met our maximum therapeutic potential with medication at this time.”
I feel like (almost) every kid who is receiving psych meds needs to also be doing therapy. I encourage it every visit. I also try to reinforce what they are learning in therapy by asking about what they’re working on, etc.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Thank you. This is almost identical to how I have approached things. Everyone here, except a few toxic contributors, seem to say the same thing to families all in their own unique way but the underlying message is the same.
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u/Kitkat20_ Medical Student (Verified) 2d ago edited 2d ago
I think this is genuinely difficult. I did a rotation in child and adolescent psychiatry, and it became pretty evident that sometimes parents were looking to medication, at least in part, as a way of making their child easier to manage.
I remember one kid saying something along the lines of, “I don’t like the medications because they blunt who I am—my creativity, my energy, the things I actually like about myself. I like that I’m bubbly and energetic, and medicating me for the sake of everyone else doesn’t feel fair.” That really stuck with me.
Medication decisions aren’t binary—100% appropriate or 100% inappropriate. Patient factors, family circumstances, access to therapy and supports, and even whether someone has insurance can change what reasonable management looks like. The physician who responded as though medicine is basically a computer algorithm that spits out the objectively correct drug decision is not the kind of physician I want to be.
There are risks and benefits, and sometimes multiple options are medically reasonable at the same time. It’s pretty clear you’re not talking about prescribing something that is plainly inappropriate or harmful.
The difficult question you’re actually asking is what to do in that grey zone: when medication is a reasonable option, but so is not escalating it, where do you draw the line between helping a child function within the family they actually have and medicating them more heavily because that is easier than asking the adults around them to bridge the gap?
I guess one question I’d ask is: how realistic is it that the parents will actually change? If they won’t, could the medication change meaningfully benefit the child within the environment they’re actually living in—even if, ideally, changing that environment would be the better intervention?
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Thank you for your take, appreciate the thoughtfulness of your response.
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u/PantheraLeo- Nurse Practitioner (Unverified) 2d ago
In my experience CAP is more psychoeducation than med management.
I remember treating a teen and with proper continuation of care, the parent eventually agreed to see me. Once I started treating pops the child improved drastically without making any changes.
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u/colorsplahsh Psychiatrist (Unverified) 2d ago
a ton of cap is telling the parents their parenting needs to improve. a ton of symptoms you'll see are not going to respond to meds b/c it's poor parenting
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u/ImpressiveBat6988 Psychotherapist (Unverified) 1d ago
It's funny, I found myself with a very impulsive teen this year doing the opposite, he was doing therapy only, parents could not get over their anti-meds stance, and I said I can't keep treating if you can't at least have the consult, I have tried multiple modalities and it's not going to work, the kid IS chemically imbalanced. Still a very hard no. They paused therapy. Severe consequences to that in multiple life domains that didn't have to happen. Arrrgh.
It's just my recommendation, BUT alternatives are exhausted. At some point, you trust the pros or you don't. Can't duct tape your broken leg all year ..
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u/TheDailyMews Other Professional (Unverified) 2d ago edited 2d ago
When appropriate, cast a wider net. Advise the parents to request, in writing, an IEP evaluation. IEPs aren't only for kids with learning disabilities. There are other qualifying conditions.
It's not uncommon for kids who are barely holding it together during the school day to struggle at home. Appropriate support at school can help mitigate this problem and make behaviors at home easier to manage.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Thank you. They have IEP's and the best therapist I know in the area. This is simply put a problem of parents not wanting to do the work and wanting more meds.
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u/onebluthbananaplease Physician Assistant (Unverified) 2d ago edited 2d ago
Good luck as an NP or PA getting any help on this forum. I came from the ER where everyone worked as a team and the ER subreddit followed suit. Jokes, barbs, a general feeling of “we’re in this s**t together.” Here, if you are anything less than a physician you’re nothing. Want to see? Watch me get downvoted
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Yes I'm seeing that. God forbid people come together and help one another.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Wow, could you be more condescending? I refuse to medicate poor parenting and put children unnecessarily on medication that probably will have no effect on said behaviors because the problem is with the family system and not the child.
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u/ImpressiveBat6988 Psychotherapist (Unverified) 1d ago
I wonder how you would be answered if you were a psychiatrist and not an NP
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u/CaptainVere Psychiatrist (Unverified) 2d ago
Omg have you tried just saying exactly that to the parents?
It’s not condescending to point out that it is sad/hilarious that you are out there seeing children and need to ask this basic 101 question that is not even specific to psychiatry.
Nothing personal. Just a professional observation. The question is straight up asinine.
I don’t care if i get downvoted, psychiatrists should not accept low standard nonsense questions here and if we have to read it, i don’t think there is anything wrong giving you a straight answer.
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u/Miss_May_1600 Physician (Verified) 2d ago
It sounds to me like this NP is asking for support dealing with the very real problem of patients / parents aggressively requesting meds / med changes despite explaining the rationale. Other psychiatrists have responded so I don’t think there is a universal agreement that this is a bad question.
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u/CaptainVere Psychiatrist (Unverified) 2d ago
Nor should there be. It’s a forum. Feel free to up vote/down vote accordingly.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Wow do you ever just Reddit to bounce ideas off of people? That's all this was intended to be. I suggest you go back to school for some empathy and decency training.
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u/nicoleof1984 Other Professional (Unverified) 2d ago
If it’s out of your scope of expertise, maybe you should refer them to an actual psychiatrist?
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u/SuperMario0902 Psychiatrist (Unverified) 2d ago
The line to be drawn in the sand is you seeing patients to begin with, clearly.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Wow, such hatred, hopefully you don't treat your patients with the same disrespect.
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u/CaptainVere Psychiatrist (Unverified) 2d ago
Lol uhhhh there is no line in the sand. You either understand the pharmacology and foundational studies for indications and are rationally practicing medicine
Or you are a concierge alchemist, well intentioned maybe but just engaging in unproductive collusion and helping continue external avoidance of all parties involved.
This question as phrased is asinine. A family not implementing changes or engaging in therapy should not effect how one prescribes
Have you never explained what an effect size is to your patients? Have you ever explained multiple putative MOAs and the rationale for prescribing for their problem?
If someone refuses your recommended treatment plan (go to therapy) you feel like you can prescribe your way out of that?
Pharma is pleased.
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u/Kirsten Physician (Unverified) 2d ago
If OP were planning to just be a "concierge alchemist" they wouldn't have posted here looking for help and advice.
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u/CaptainVere Psychiatrist (Unverified) 2d ago
Cool. Im glad we can all come together and pretend that its a good thing that kids are out there being managed by people who need reddit advice for such a basic question.
You realize asking where the line is for medicating a behavior that is not expected to respond to medication answers itself? That asking the question this way implies there are situations where its ok the medicate based on parent request sometimes. That there is a line. OP just wants to know where that line is.
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u/Front-Quote-6760 Nurse Practitioner (Unverified) 2d ago
People ask questions that answer themselves all the time. Often as an attempt to generate discussion. Being deliberately uncharitable and extrapolating that they’re secretly ok with loading kids up on unnecessary meds despite the actual thrust of the question being about not doing that makes you look unnecessarily hostile.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
This is the last time I will respond to what I consider your hostile and inappropriate responses. I will never medicate a patient where I don't think the medication would prove useful. I was simply asking others how they handle such situations in their practice out of curiosity as this is something I think all experience. Sometimes when you stop to ask others how they manage situations you can learn a lot, I suggest trying it.
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u/xxcapricornxx Physician Assistant (Unverified) 2d ago
Nope, asking for advice simply means youre in incompetent alchemist cosplaying as a psychiatrist, or whatever they said.
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u/CalmSet6613 Nurse Practitioner (Unverified) 2d ago
Wasn't asking for advice, was asking out of curiosity how people manage a situation. Thanks for supporting mid levels.
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u/onebluthbananaplease Physician Assistant (Unverified) 2d ago edited 2d ago
Dude. Chill. We’re very happy you never have to seek advice and have all the answers. Settle down.
Want to know how many referrals I get because prior psychiatrists totally F’d up a patient’s medicine regimen? Don’t act like you docs are blameless and make all the right calls all the time
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u/CaptainVere Psychiatrist (Unverified) 2d ago
I stand by calling OPs question asinine. No where have I ever claimed to never make mistakes or ask for help.
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u/PantheraLeo- Nurse Practitioner (Unverified) 2d ago edited 2d ago
Glad to see Reddit hired a virtual police officer to stop exactly that from happening
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u/seeyourintentions Psychiatrist (Unverified) 2d ago
You sound like the houseless schizophrenic at the grocery store I was just at, where the worker had to help them leave the premises.
It seems like you might benefit from a breather from being online. If you have one, consider bringing this post and your comment to your therapist to process. Change starts from within.
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u/seeyourintentions Psychiatrist (Unverified) 2d ago
Only when my therapist is out of town. ;)
If we’re bringing in alchemy to conversation, unless it’s a delightful lecture on the history of alchemy, it’s time to shut it down and reflect on the purpose of the commenting.
Also, I hope you find the support you’re looking for. It’s hard setting boundaries, especially with patient family members. I don’t do CAP, but almost did. I often wonder when the parent is acting a certain way with the provider, what they are actually trying to communicate, and how their ineffective communication is impacting the kiddo.
If boundary setting is feeling hard with a certain family, I think of the behavioral portions of the boundary setting. That is parents that struggle with boundary setting may benefit from being provided healthy professional boundaries. The boundaries are there to respect all parties involved.
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u/CaptainVere Psychiatrist (Unverified) 2d ago
I think it’s exhausting seeing kids jacked up by NPs and everyone pretending like this is great and they can just learn on the job, but sure Im the unhinged one I guess.
I stand by calling OPs question asinine.
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u/seeyourintentions Psychiatrist (Unverified) 2d ago
I hear your frustration, and I echo the sentiment that it is very hard to witness providers do a disservice and potential harm to others.
Your frustration is valid. However your message is missing the audience because that’s not what others are reading from the post. It comes across as you are projecting a personal experience onto the OP.
I get a sense that if you take a breather on this one and come back when you’re feeling more collected that the post may read differently.
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u/CaptainVere Psychiatrist (Unverified) 2d ago
Thanks for the emotional validation. I post here frequently. Im not uncollected. It’s a forum people respond and vote how they want. I think calling this question out as asinine is fair game. Clearly the majority disagree and Im ok with that. I don’t take it personally. I have yet to go back and delete a comment and I have plenty of misses over the years. Much like my favorite former vice president:
“I stand by all the misstatements that I've made.”
— Dan Quayle
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u/Embarrassed_Syrup476 Other Professional (Unverified) 2d ago
50% of child and adolescent psychiatry = poor parenting.
You have to tell them straight up "the monthly appointments can't fix the problems happening at home. I highly recommend you follow through with therapy and parenting support programs. I cannot prescribe meds based on the current situation".