Help needed with a sensitive situation (content warning, minor sexual assault-ish) Feeling vulnerable

[PsychiatryAndCats]

Hello wise women and men of the psychiatry board. I’m based in Northern Ireland and I’ve finished my training. I’m temporarily covering a psychiatry of intellectual disability team (I’m appropriately trained and experienced for same).

I’m not looking for protocol advice, as I’ve covered these angles (including incident report, discussion with clinical director, etc).

It’s possibly relevant to mention that I’m a woman in my thirties.

I was running a review clinic in a school a while back and a teenage boy at the school (not a patient) hugged me a few times, then groped my breasts and started touching himself. (Inappropriate sexual behaviour is not uncommon in this population. No concerns from school as to the child’s welfare.) The teachers were around and just laughed that he was a flirt. (I don’t think they saw that he touched himself, but they did see the breast-grabbing.) I tried to desexualise the situation by telling him that my breasts were for my baby and followed further attempts to hug me with a firm but gentle “no thank you”.

I don’t hold the situation against the 16YO as much as the teachers who were unoccupied enough to help out but didn’t.

I’ve had a few grabs by manic patients before (and a few bashings by people with psychosis), but the persistence of this young man has really upset me. I’m having trouble eating and sleeping. I’m nervous about covering clinics in schools.

I also feel like I’m being really intolerant of a child with a disability.

It’s relevant to point out here that I developed early and was groped a lot (against my will) as a preteen.

I’m planning some form of supportive psychotherapy for myself, but I’m just looking for a bit of support/solidarity from others here. I’m not asking for stories as such, but can anyone relate? I feel like this has hit me harder than it “should”.

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[calvnandhobbs68]

Hello wise women and men of the psychiatry board. I’m based in Northern Ireland and I’ve finished my training. I’m temporarily covering a psychiatry of intellectual disability team (I’m appropriately trained and experienced for same).

I’m not looking for protocol advice, as I’ve covered these angles (including incident report, discussion with clinical director, etc).

It’s possibly relevant to mention that I’m a woman in my thirties.

I was running a review clinic in a school a while back and a teenage boy at the school (not a patient) hugged me a few times, then groped my breasts and started touching himself. (Inappropriate sexual behaviour is not uncommon in this population. No concerns from school as to the child’s welfare.) The teachers were around and just laughed that he was a flirt. (I don’t think they saw that he touched himself, but they did see the breast-grabbing.) I tried to desexualise the situation by telling him that my breasts were for my baby and followed further attempts to hug me with a firm but gentle “no thank you”.

I don’t hold the situation against the 16YO as much as the teachers who were unoccupied enough to help out but didn’t.

I’ve had a few grabs by manic patients before (and a few bashings by people with psychosis), but the persistence of this young man has really upset me. I’m having trouble eating and sleeping. I’m nervous about covering clinics in schools.

I also feel like I’m being really intolerant of a child with a disability.

It’s relevant to point out here that I developed early and was groped a lot (against my will) as a preteen.

I’m planning some form of supportive psychotherapy for myself, but I’m just looking for a bit of support/solidarity from others here. I’m not asking for stories as such, but can anyone relate? I feel like this has hit me harder than it “should”.

Yeah so that's inappropriate behavior by the teachers. Behavioral modification does not involve positively reinforcing (laughing) at a behavior you're trying to decrease frequency of (inappropriate breast grabbing on women). In fact depending on his personality they may have just given him positive social capital for that behavior. Makes me wonder how good this school is at actual behavioral modification techniques. Certainly a more appropriate reaction would be to firmly relay to him that this is not a appropriate behavior and hopefully there is a plan in place to try to positively reinforce non-sexualized behaviors with women while continuing to neutrally respond or redirect inappropriate behaviors consistently.

Your reaction is totally valid. We run into this all the time with intellectually disabled patients who do many inappropriate and aggressive things. You can understand they have trouble with these behaviors (as you would approach a young child) while also personally feeling affected by these behaviors. I think one thing that helps with your personal emotional response to a situation like this is feeling that there's some attempt to modify or respond to the behavior that's occurring, which you definitely did not feel here.

 

[Merovinge]

I also feel like I’m being really intolerant of a child with a disability.

It’s relevant to point out here that I developed early and was groped a lot (against my will) as a preteen.

I’m planning some form of supportive psychotherapy for myself, but I’m just looking for a bit of support/solidarity from others here. I’m not asking for stories as such, but can anyone relate? I feel like this has hit me harder than it “should”.

I think is a very insightful point of your post. I can see people disagreeing, but as a child/adolescent psychiatrist who has worked with a lot of ID/ASD patients, I do think these events will happen at times and there is no way to 100% protect yourself from them. Completely agree with above that this was handled poorly by the teachers and definitely reinforcing for the patient, on the other hand they work with these kids all the time and likely use humor to deflect from their own insecurities with how to handle these situations and are clearly undertrained for the work.

This is simultaneously a situation in which your reaction is completely valid (being sexually touched against your will is expected to evoke such a response), but we can then modify that response to see it as a high threat situation (sexual assault) or a low threat situation (done by person who does not know better or have ill intention). There sounds like elements of your past that are stopping your brain from modifying how it interprets the event and that absolutely is worth exploring in psychotherapy. Of course if these situations continue to happen, you may want to look into another vocational site, ID/DD schools make up a tiny portion of child/adolescent psychiatry work and it's never beholden to you to be putting yourself into harms way.

 

[PsychiatryAndCats]

Thank you both so much.

Calvnandhobbs68, you are absolutely right in terms of the school not handling it too well/positively reinforcing it, and in terms of the lack of efforts of the teachers making it so much tougher for me.

Merovinge it’s not my long term plan at all. I’m actually only covering until next month (colleague had major surgery) and I’ll be (thankfully) right back into my comfort zone of mood and eating disorders and DSH. You’re 100% correct on elements of my past not helping me reframe this.

I really appreciate that you both seem to get it.

 

[deleted1100659]

Hello wise women and men of the psychiatry board. I’m based in Northern Ireland and I’ve finished my training. I’m temporarily covering a psychiatry of intellectual disability team (I’m appropriately trained and experienced for same).

I’m not looking for protocol advice, as I’ve covered these angles (including incident report, discussion with clinical director, etc).

It’s possibly relevant to mention that I’m a woman in my thirties.

I was running a review clinic in a school a while back and a teenage boy at the school (not a patient) hugged me a few times, then groped my breasts and started touching himself. (Inappropriate sexual behaviour is not uncommon in this population. No concerns from school as to the child’s welfare.) The teachers were around and just laughed that he was a flirt. (I don’t think they saw that he touched himself, but they did see the breast-grabbing.) I tried to desexualise the situation by telling him that my breasts were for my baby and followed further attempts to hug me with a firm but gentle “no thank you”.

I don’t hold the situation against the 16YO as much as the teachers who were unoccupied enough to help out but didn’t.

I’ve had a few grabs by manic patients before (and a few bashings by people with psychosis), but the persistence of this young man has really upset me. I’m having trouble eating and sleeping. I’m nervous about covering clinics in schools.

I also feel like I’m being really intolerant of a child with a disability.

It’s relevant to point out here that I developed early and was groped a lot (against my will) as a preteen.

I’m planning some form of supportive psychotherapy for myself, but I’m just looking for a bit of support/solidarity from others here. I’m not asking for stories as such, but can anyone relate? I feel like this has hit me harder than it “should”.

The way you feel is absolutely valid. The teen probably didn't fully grasp the circumstances/problematic behavior, but your colleagues do not sound supportive at all, and that is not ok, in my opinion.

It is not intolerant by any means. People with ID can still learn/adapt different behaviors. The ignornant people are the ones who are blowing it off; they're actually doing this kid a disservice, by reinforcing in his mind that this is appropriate behavior. Now, he will keep doing this while others make a joke out of it, as it is not a joke.

Also, you don't know what patients will do- the fear of someone else being in control in that moment, is enough to inflict an emotional toll. While hes hugging you, and gropping you, hes stripping away your control of the situation. Someone should have stepped in immediately.

I say this as someone who works in community psychiatry. I see countless patients with various levels of intellectual disability on a day to day basis. 99% of them are nothing short of respectful; because I reinforce that behavior and I make sure the caregiver is reinforcing it as well. If i saw one of the staff here laughing at one our ID patients groping a female employee, you can believe I would talk to that staff.

I am sorry you are going through that, im not sure how long you have to be at this current job, but I think setting boundaries is more than acceptable, and your colleagues need to be fully supportive of that, are they're fostering an environment of harassments.

 

[PsychiatryAndCats]

The way you feel is absolutely valid. The teen probably didn't fully grasp the circumstances/problematic behavior, but your colleagues do not sound supportive at all, and that is not ok, in my opinion.

It is not intolerant by any means. People with ID can still learn/adapt different behaviors. The ignornant people are the ones who are blowing it off; they're actually doing this kid a disservice, by reinforcing in his mind that this is appropriate behavior. Now, he will keep doing this while others make a joke out of it, as it is not a joke.

Also, you don't know what patients will do- the fear of someone else being in control in that moment, is enough to inflict an emotional toll. While hes hugging you, and gropping you, hes stripping away your control of the situation. Someone should have stepped in immediately.

I say this as someone who works in community psychiatry. I see countless patients with various levels of intellectual disability on a day to day basis. 99% of them are nothing short of respectful; because I reinforce that behavior and I make sure the caregiver is reinforcing it as well. If i saw one of the staff here laughing at one our ID patients groping a female employee, you can believe I would talk to that staff.

I am sorry you are going through that, im not sure how long you have to be at this current job, but I think setting boundaries is more than acceptable, and your colleagues need to be fully supportive of that, are they're fostering an environment of harassments.

Thank you so much.

This thread has been so helpful in terms of straightening out my emotions around this. I’m not new to this kind of thing, but this event hit me surprisingly hard. I have some leave built up, so I’m going to take a week off. I’ll get that support. And changing back to my usual job will be very, very good for me.

 

[Merovinge]

Don't let anyone tell you otherwise, being a practicing clinical physician is not an easy job. No, not even for pathologists or radiologists. The reason our work continues to pay well is because of the responsibility, the emotional and sometimes physical harm we are expected to endure, and the high level cognition we must always be applying to be at the top of our game. Take the break, you deserve it, and I am sure you will get back to work that is very good for you (I know this based on your insight and reaching out for help/perspective).

 

[whopper]

Part of being a good provider is laying down the law. We are not doing our jobs by enabling inappropriate behavior. E.g. we do not let homeless people who really just want a free meal and a roof over their head to come to the hospital whenever they want. We tell the person, hopefully respectfully, that the hospital is not for this purpose and direct them to the appropriate places better suited to help the person. Fine and dandy but when the person then starts screaming at you it becomes hard to remain empathic.

It can be very tough to turn on the empathy while at the same time laying down the law. I would tell people in my training it's like being a parent in some ways. You need to show you care but at the same time you can be doing something that can directly cause an ego-defense reaction.

 

[Merovinge]

Part of being a good provider is laying down the law. We are not doing our jobs by enabling inappropriate behavior. E.g. we do not let homeless people who really just want a free meal and a roof over their head to come to the hospital whenever they want. We tell the person, hopefully respectfully, that the hospital is not for this purpose and direct them to the appropriate places better suited to help the person. Fine and dandy but when the person then starts screaming at you it becomes hard to remain empathic.

It can be very tough to turn on the empathy while at the same time laying down the law. I would tell people in my training it's like being a parent in some ways. You need to show you care but at the same time you can be doing something that can directly cause an ego-defense reaction.

This is so true. I didn't realize at the time how profoundly good modeling my adult and child training both did with this. I am worried that the increasing focus on "customer service" with medicine is going to degrade future psychiatrists ability to do this over time.

Side story, my old child PD who was certainly AARP eligible and known for being one of the sweetest and grandmothery leaders in the field bellowed at a parent who was cursing at me/staff for clinic running a few minutes late after we had to hospitalize a patient earlier in the day. Told this mother in no uncertain terms to leave before security came and it shook my bones with how loud and firm she was. Seeing this really helped me as a young attending feel comfortable confronting a (white) dad who kept calling his (white) son the n-word, after the second time when I was sure I did not mishear him I made sure he know that he needed to leave the clinic. The halls rang with him screaming "****ing shrink!!!" repeatedly as he walked out.

 

[PsychiatryAndCats]

Part of being a good provider is laying down the law. We are not doing our jobs by enabling inappropriate behavior. E.g. we do not let homeless people who really just want a free meal and a roof over their head to come to the hospital whenever they want. We tell the person, hopefully respectfully, that the hospital is not for this purpose and direct them to the appropriate places better suited to help the person. Fine and dandy but when the person then starts screaming at you it becomes hard to remain empathic.

It can be very tough to turn on the empathy while at the same time laying down the law. I would tell people in my training it's like being a parent in some ways. You need to show you care but at the same time you can be doing something that can directly cause an ego-defense reaction.

I agree with the above as a general concept. However, the person in question wasn’t a patient of mine and was a lot bigger than I am. (I had no idea of his level of disability or his existing diagnoses at the time.) I had no duty of care, but also no “rights” as his doctor.

I’m largely assertive. I think I just need to be more on my guard when running school clinics (which isn’t part of my usual role, but when I did them as a trainee/registrar I had more support). And based on my prior experience and my discussion with my clinical director, the teachers really should have assisted.

 

[PsychiatryAndCats]

This is so true. I didn't realize at the time how profoundly good modeling my adult and child training both did with this. I am worried that the increasing focus on "customer service" with medicine is going to degrade future psychiatrists ability to do this over time.

Side story, my old child PD who was certainly AARP eligible and known for being one of the sweetest and grandmothery leaders in the field bellowed at a parent who was cursing at me/staff for clinic running a few minutes late after we had to hospitalize a patient earlier in the day. Told this mother in no uncertain terms to leave before security came and it shook my bones with how loud and firm she was. Seeing this really helped me as a young attending feel comfortable confronting a (white) dad who kept calling his (white) son the n-word, after the second time when I was sure I did not mishear him I made sure he know that he needed to leave the clinic. The halls rang with him screaming "****ing shrink!!!" repeatedly as he walked out.

I’m grateful that the NHS remains public, so there’s not so much focus on customer service. Since the pandemic, however, there is a lot more “I pay your salary with my taxes” attitude. I mean, people aren’t technically incorrect, but it’s usually accompanied by an unreasonable request.

All food for thought, though.

Again, very grateful for all these replies.

 

[Crayola227]

I agree with the above as a general concept. However, the person in question wasn’t a patient of mine and was a lot bigger than I am. (I had no idea of his level of disability or his existing diagnoses at the time.) I had no duty of care, but also no “rights” as his doctor.

I’m largely assertive. I think I just need to be more on my guard when running school clinics (which isn’t part of my usual role, but when I did them as a trainee/registrar I had more support). And based on my prior experience and my discussion with my clinical director, the teachers really should have assisted.

I didn't read it as whopper was saying you should have laid down the law. I read it as he was validating that the other staff members should have acted differently.

 

[PsychiatryAndCats]

I didn't read it as whopper was saying you should have laid down the law. I read it as he was validating that the other staff members should have acted differently.

That’s possible, and if so, Whopper, I’m sorry for any inadvertent defensiveness! If anything, the word “provider” threw me as it isn’t one I’ve come across in the UK or the ROI, and I’ve always read it to mean “doctor” on sites such as this one (and all the other professionals were teachers (plus one nurse from our team).

Actually, anyone who can clarify the scope of the word “provider” in general would help me a lot!

 

[calvnandhobbs68]

That’s possible, and if so, Whopper, I’m sorry for any inadvertent defensiveness! If anything, the word “provider” threw me as it isn’t one I’ve come across in the UK or the ROI, and I’ve always read it to mean “doctor” on sites such as this one (and all the other professionals were teachers (plus one nurse from our team).

Actually, anyone who can clarify the scope of the word “provider” in general would help me a lot!

It means like....anything in the US. From physicians to NPs/PAs to psychotherapists to occupational therapists to speech pathologists. It's like a catch-all term people use.

 

[FlowRate]

a teenage boy at the school (not a patient) hugged me a few times

I’ve had a few grabs by manic patients before (and a few bashings by people with psychosis), but the persistence of this young man has really upset me. I’m having trouble eating and sleeping. I’m nervous about covering clinics in schools.

I'm not sure what the general feelings are about this sort of thing in your locale but I trained in a very psychodynamic and emergency psychiatry heavy training program and both models of care emphasized safe distancing/generally not engaging in physical contact. Sometimes physical touch (whether violent or not) comes completely out of the blue and out of your field of view. In my experience, most of the time it does not. I think it would be appropriate to enforce more global boundaries around personal space in order to help you feel more safe.

I'm obviously making some not-super-generous assumptions here in case the above is helpful to you or anyone else who's had recurrent issues with this sort of thing. If it doesn't apply, maybe it will help someone else to know there are cultures of psychiatry where essentially no touch is the norm and close attention to distance from more volatile types of patients and careful arranging of the physical environment is emphasized.

 

[PsychiatryAndCats]

I'm not sure what the general feelings are about this sort of thing in your locale but I trained in a very psychodynamic and emergency psychiatry heavy training program and both models of care emphasized safe distancing/generally not engaging in physical contact. Sometimes physical touch (whether violent or not) comes completely out of the blue and out of your field of view. In my experience, most of the time it does not. I think it would be appropriate to enforce more global boundaries around personal space in order to help you feel more safe.

I'm obviously making some not-super-generous assumptions here in case the above is helpful to you or anyone else who's had recurrent issues with this sort of thing. If it doesn't apply, maybe it will help someone else to know there are cultures of psychiatry where essentially no touch is the norm and close attention to distance from more volatile types of patients and careful arranging of the physical environment is emphasized.

Thanks for the reply. My training scheme was poorly structured (and involved moving from ROI to the UK for family reasons), but spanned quite a lot, from forensics to a trainer who had a penchant for systemic family therapy to general inpatient/outpatient child and adolescent psychiatry.

Unsolicited physical contact has only ever before happened to me in an inpatient setting with acutely unwell patients (and these people were largely all over all staff, male or female, young or old).

Interestingly (or perhaps not), I emerged completely untouched from my forensic jobs.

As a rule, I don’t engage in physical contact with patients.

This scenario was strange, in that the young person in question wasn’t even a patient and he was unsupervised. Inappropriate sexual behaviour is extremely common in teenagers with intellectual disabilities, but generally responds well to consistent redirecting from teaching or social care staff.

It’s worth noting that I have almost comically large breasts. I’m otherwise very slight and they’re impossible to disguise. I was warned against being too approachable in an early training post I had and I’ve been at least somewhat conscious to avoid same since.

That said, many young people in these schools have autism, and will be less inclined to pick up on my lack of obvious approachability.

 

[Crayola227]

Thanks for the reply. My training scheme was poorly structured (and involved moving from ROI to the UK for family reasons), but spanned quite a lot, from forensics to a trainer who had a penchant for systemic family therapy to general inpatient/outpatient child and adolescent psychiatry.

Unsolicited physical contact has only ever before happened to me in an inpatient setting with acutely unwell patients (and these people were largely all over all staff, male or female, young or old).

Interestingly (or perhaps not), I emerged completely untouched from my forensic jobs.

As a rule, I don’t engage in physical contact with patients.

This scenario was strange, in that the young person in question wasn’t even a patient and he was unsupervised. Inappropriate sexual behaviour is extremely common in teenagers with intellectual disabilities, but generally responds well to consistent redirecting from teaching or social care staff.

It’s worth noting that I have almost comically large breasts. I’m otherwise very slight and they’re impossible to disguise. I was warned against being too approachable in an early training post I had and I’ve been at least somewhat conscious to avoid same since.

That said, many young people in these schools have autism, and will be less inclined to pick up on my lack of obvious approachability.

yeah I don't have anything to add here, except that I can empathize. I know it's discouraged in psychiatry to wear a white coat. I use loose blouses and a white coat to disguise mine. Although I also have atrocious posture and I'm sure that's partly why but it does help to hide, not that I can recommend that.

But ultimately it's not about anything that the person with the outstanding feature can really do. I do wish they had reacted differently.

Do you think it might help you get some closure to report this incident to the appropriate authority? The inappropriate response of the staff is basically almost in that category of creating a hostile work environment or encouraging sexual harassment. Appropriate consequences for the student and the staff would seem to be in order regardless, but maybe knowing that sort of justice happened might help?

 

[deleted1100659]

It’s worth noting that I have almost comically large breasts. I’m otherwise very slight and they’re impossible to disguise. I was warned against being too approachable in an early training post I had and I’ve been at least somewhat conscious to avoid same since.

That said, many young people in these schools have autism, and will be less inclined to pick up on my lack of obvious approachability.

for some reason my first thought was "seems like that would cause a lot of back pain". I always associate large breasts with back pain.

But regardless of your breasts having some visibility due to their size, I think its more an issue of regulation and control in the setting that needs to be accounted for, better staff training, more awareness. As a whole, even in the united states I suspect this stuff is way underreported in the mental health setting and that women deal with verbal/physical acts too often. I have not been impressed with how my facility handles comments by patients made to female staff.

 

[Merovinge]

for some reason my first thought was "seems like that would cause a lot of back pain". I always associate large breasts with back pain.

But regardless of your breasts having some visibility due to their size, I think its more an issue of regulation and control in the setting that needs to be accounted for, better staff training, more awareness. As a whole, even in the united states I suspect this stuff is way underreported in the mental health setting and that women deal with verbal/physical acts too often. I have not been impressed with how my facility handles comments by patients made to female staff.

It is relatively unusual for my wife to not be sexually harassed on a monthly basis from patients, many of whom are older and are the "customer" which apparently also makes them right. She would (very unfortunately) be unemployable if she brought up every case of this and made sure something came about it. Which is only to say that yes, in the US, this continues to be way underreported in health care (not specifically mental health).

 

[PsychiatryAndCats]

yeah I don't have anything to add here, except that I can empathize. I know it's discouraged in psychiatry to wear a white coat. I use loose blouses and a white coat to disguise mine. Although I also have atrocious posture and I'm sure that's partly why but it does help to hide, not that I can recommend that.

But ultimately it's not about anything that the person with the outstanding feature can really do. I do wish they had reacted differently.

Do you think it might help you get some closure to report this incident to the appropriate authority? The inappropriate response of the staff is basically almost in that category of creating a hostile work environment or encouraging sexual harassment. Appropriate consequences for the student and the staff would seem to be in order regardless, but maybe knowing that sort of justice happened might help?

Thanks for this. I filled an incident form a few days after the event, but you gave me a lot to think about and I’ll also write to the school to express my concerns regarding how the staff responded.

for some reason my first thought was "seems like that would cause a lot of back pain". I always associate large breasts with back pain.

But regardless of your breasts having some visibility due to their size, I think its more an issue of regulation and control in the setting that needs to be accounted for, better staff training, more awareness. As a whole, even in the united states I suspect this stuff is way underreported in the mental health setting and that women deal with verbal/physical acts too often. I have not been impressed with how my facility handles comments by patients made to female staff.

Yes, my back is very displeased by this burden! Strongly considering a breast reduction once I’m done with breastfeeding.

Harassment is so common and can be so poorly dealt with. To be fair, our clinical director is extremely supportive when it’s a patient doing the harassing. I think the whole not a patient and the child with intellectual disability combination has made this all harder to approach.

It is relatively unusual for my wife to not be sexually harassed on a monthly basis from patients, many of whom are older and are the "customer" which apparently also makes them right. She would (very unfortunately) be unemployable if she brought up every case of this and made sure something came about it. Which is only to say that yes, in the US, this continues to be way underreported in health care (not specifically mental health).

This is so sad. The patient as customer culture really seems to complicate matters. (It has advantages too, obviously.)