Mind Dive

Episode 61: Milieu Therapy with Dr. Michael McClam

• The Menninger Clinic

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How much do you know about milieu therapy and how it works?  This episode of The Menninger Clinic’s Mind Dive Podcast features Michael McClam, MD, medical director for Menninger’s youth division, for a conversation about milieu therapy and how clinicians and patients play an active role in its effectiveness. It also explores the hidden dynamics that emerge within communal therapy. 

 Dr. McClam shares his wisdom about the challenges and rewards that clinicians face as they navigate patient relationships and team dynamics within milieu therapy. Drawing from his experiences running milieu treatment at Menninger, Dr. McClam addresses the complexity of authority and clinical distance while building patient trust and developing the crucial connection needed for communal therapy.  

Dr. Michael McClam, MD, FAPA, is board certified in psychiatry and works on Menninger’s Compass Program for Young Adults. He also is an assistant professor in the Menninger Department of Psychiatry & Behavioral Medicine at Baylor College of Medicine and previously served as director of admissions.

 “There’s an intentionality to our thinking about relationships,” says Dr. McClam. “We help them foster, develop, maintain relationships and be curious about the whole unit as everyone there contributes to the therapeutic environment.”  

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Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.

Dr. Bob Boland: 0:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland and Dr. Kerry Horrell.

Dr. Kerry Horrell: 0:11

Monthly we explore intriguing topics from across the mental health field and dive into hidden realities of patient treatment.

Dr. Bob Boland: 0:18

We also discuss the latest research and perspectives from the minds of distinguished colleagues near and far.

Dr. Kerry Horrell: 0:23

So, thanks for joining us.

Dr. Bob Boland: 0:25

Let's dive in.

Dr. Kerry Horrell: 0:31

Welcome back to the Mind Dive podcast. Today we are really, really excited. I am personally deeply excited to have Dr. Michael McClam here. I'll say more about how we work together but let me start with your bio. So, Dr. Michael McClam, MD, FAPA, you’re going to have to remind me what that one is.

Dr. Bob Boland: 0:48

I love the American Psychiatric Association. Yes, right, that's actually quite an honor, thank you.

Dr. Kerry Horrell: 0:58

I'm not surprised by Dr. McClam. He serves as Menninger's Medical Director for its Youth Division. Dr. McClam is board certified in psychiatry and works on the Compass Program for Young Adults. He's also an assistant professor in the Menninger Department of Psychiatry and Behavioral Medicine at Baylor College of Medicine and previously served as director of admissions. Dr. McClam earned his undergraduate degree in mathematics from Morehouse College and his medical degree from Baylor College of Medicine. Welcome, Dr. McClam, it’s good to have you.

Dr. Mike McClam: 1:23

Well, good to be here.

Dr. Kerry Horrell: 1:25

You know, as I was going to say, you're the psychiatrist I work most closely with.

Dr. Mike McClam: 1:30

over the last few years since I've been faculty right, we've been on a team together.

Dr. Kerry Horrell: 1:34

We've had...

Dr. Mike McClam: 1:35

Lots of patients like lots of patients.

Dr. Kerry Horrell: 1:37

Probably at least 100 at this point shared. So again, you're one of my closest colleagues, that I work with that company, so I'm so glad to get to have you here and share your mind with our listeners, it's always great to talk with you well.

Dr. Bob Boland: 1:50

Like we're saying before, we've been wanting to have you on the show. Thanks, thanks, so much for doing this.

Dr. Kerry Horrell: 1:55

There's so much that we could talk to you about, because you had a really interesting career, including being in the navy so that's going to be our first question. Yeah, you start, I think.

Dr. Bob Boland: 2:08

You know, tell us about that career and you know just how you became, and then also maybe you can round it to how you became interested in working in a therapeutic hospital, like here at Menninger.

Dr. Mike McClam: 2:17

All right, great. So, as you said, Kerry, that I was a mathematics major in college, but I also joined the Navy right after that and was a submarine officer.

Dr. Kerry Horrell: 2:27

Wait, can I take one beat? Sur Dr. McClam will sometimes help our adolescent patients with their math. There's times in which I guess, when they're struggling, he will be like well, let's work on your math together. It's so sweet. Anyways, I always love remembering that you studied math.

Dr. Mike McClam: 2:45

Yes.

Dr. Kerry Horrell: 2:46

You use that as a therapeutic intervention?

Dr. Mike McClam: 2:48

Yes, I have. So I started off as a submarine officer in the Navy. This was back in the early 90s and I was on the USS Atlanta SSN 712. And I went to different missions throughout that time and spent a lot of time at the end of the Cold War. So I mean that's another whole kind of podcast.

Dr. Kerry Horrell: 3:11

Yeah, that's a whole 'nother podcast

Dr. Mike McClam: 3:12

But suffice it to say I spent six years in acting the military officer and then I went to medical school. So I trained here at Baylor College of Medicine, both residency and medical school, and then went back into the military as a psychiatrist. My first job out was a military psychiatrist at the Portsmouth Naval Hospital and I did various things there. So I mean I was in administrative roles, clinical roles. This was during the big war, you know, during Iraq and all of that. So I ended up going to the Middle East for a while, did some treatment there, some treated our warfighters over there, and then spent six months in Guantanamo Bay where I did detainee care only. And that's yet another that could be a talking.

Dr. Bob Boland: 3:53

Honestly, we should have you back to talk about that.

Dr. Mike McClam: 3:57

Yeah, that's just another podcast, but anyway, I came back here in 2011, spent about 15 months at the VA and then this is a little-known story. But I came back here in 2011, spent about 15 months at the VA and then this is a little known story, but I actually wrote a small white paper about how I could benefit Menninger by treating some of the active duty military officers or some of the retired officers here on the professionals program back when we had that, and that got the attention of Dr. Oldham who said well, we may not be able to do that at this point in time, but would you like to have a job here? And so I came here on December of ‘12 and then started work on the professionals unit. When we had the professional’s unit, I was one of the doctors there.

Dr. Kerry Horrell: 4:36

And you were there for a while.

Dr. Mike McClam: 4:39

Yeah, I ended up being the medical director for the professionals unit and then also being the medical director for both the HOPE and professionals unit at that point.

Dr. Kerry Horrell: 4:49

When I was. I think this is right. Honestly, I could be wrong when I was an intern. See now, I might be wrong with this. You might have been in admissions at that point, but I think you might have been the medical director of HOPE when I was an intern and I worked at HOPE for a little bit. Because you came to morning meetings and you would consult with us.

Dr. Mike McClam: 5:04

That's right. Yeah, it depends on the year. I think in 20, when I left admissions, I spent a year as a program director for Hope.

Dr. Kerry Horrell: 5:11

I was 2018.

Dr. Mike McClam: 5:12

Okay, Was it then? So 2018, I think 2018, I was actually holding the admissions director. I was also the assistant medical director under Ed Poe and by 2018, I'd also was still covering. I was covering for one of the attendings who had a long-term absence, so I was actually seeing patients in the professional unit.

Dr. Bob Boland: 5:34

Then I wanted to correct one thing about the bio. Now they look at it too. Dr. McClaim is an associate professor, not an assistant professor. Oh, that's right Having recently been promoted by Baylor, yes, which anyone who works at Baylor, or really any university, knows. That's a big deal.

Dr. Kerry Horrell: 5:48

That's a behemoth task.

Dr. Bob Boland: 5:49

Yes, so congratulations for that as well. Thank you, yeah.

Dr. Kerry Horrell: 5:54

Also now, what I'm just thinking is, you also won a couple different awards this year, including a faculty teaching award. I did. Education award this year, which is true, cause that's one of my favorite things that working on compass is that because we have teachers like Dr. McClam, we have fellows and residents who are taking their compass and that's a really fun part of the work.

Dr. Kerry Horrell: 6:15

Yeah, so, as you mentioned just now, you and we've talked about this, we talk about this our patients. You've worked across nearly every inpatient unit. I think you have definitely worked on every inpatient unit?

Dr. Mike McClam: 6:24

Yeah, I've worked on all of them so far.

Dr. Kerry Horrell: 6:26

Yeah, and especially having been here now for 12 years I think, know Menninger in a way that few people do, and I wonder if you can tell us a little bit about kind of what you see as like the core aspects of inpatient treatment here. But I think broadly then, of like what it means to get treatment at somewhere like a therapeutic hospital.

Dr. Mike McClam: 6:45

Sure, we talk a lot about treatment Kerry and I, we always talk a lot about the relationships that we build with within each other, also with the team, and also with the patients, and how the patients have relationships within the community of, of the of the unit, or the patient milieu as we call it.

Dr. Mike McClam: 7:04

Milieu is a French word that really means community, loosely translated.

Dr. Mike McClam: 7:08

But when I think of the milieu or like the therapeutic community, I think of all of it, not just the patients and their interactions with each other, which we certainly help them foster, develop, maintain and also be curious about when things go different ways, whether both positively or negatively, but also the milieu of the patients and the staff.

Dr. Mike McClam: 7:29

So that includes, like nursing staff, our mental health associates, our cleaning staff, even down to people who are working like not on the unit but have interaction in the cafeteria, in the cafe, other individuals that work here, that really contribute all to the therapeutic environment. And one of the things I think is really important is that I think we pay a lot of attention or there's an intentionality to our thinking about relationships not just between patient and physician or patient and team, but patients with patients, patients with staff, patients as they interact in all of the places in the hospital where you would find them. So I think that intentionality and that thoughtfulness and that curiosity that we hold within the team and actually in helping the patients be more curious about why do I interact, the way I interact in certain situations and instances, I think helps create this therapeutic environment, or therapeutic curiosity, as I'll put it.

Dr. Bob Boland: 8:35

Yeah, I mean. So talk about milieu therapy. What are the benefits of it and how can it help folks beyond sort of just the usual individual treatment that people expect in psychiatry and psychology?

Dr. Mike McClam: 8:49

Yeah, I think the biggest benefit that I've noticed over the years is the ability for a lot of different perspectives to be at the same place at once. To talk about all of the different feelings that are generated from all the different perspectives that are generated. From all the different perspectives that are generated, all of the relationships that are generated, get a really whole and complete picture of what the patient is going through, what their core struggles are. And, when I think about that, I think about how our social workers interact with the families and how the relationships that they develop with the family and the family liaison really helps with our thinking about how the patient lives in their own family system when they're not in the hospital, right. And also you know when patients come, if you've heard of that expression. Wherever you go there, you are right. So their interactions with others and our curiosity around that can really help us figure out what they struggle with from a psychological perspective and also provide some interventions for having better and more whole and mutually reciprocal relationships.

Dr. Kerry Horrell: 9:54

You know, I think about this is such a common part of our work, like probably doing this at least every other week at a minimum, a minimum.

Dr. Kerry Horrell: 10:04

We have patients come in, we are working with families and we say something along the lines of we think that the milieu component of therapy here, or treatment here, is really critical.

Dr. Kerry Horrell: 10:11

And then, of course, comes the question wait, what is a milieu and what is therapy? And again, I mentioned that even like we've had times where we've gotten this question from outpatient providers like, just like, what the heck is this part of it? And I think that's what I appreciate you talk, you're talking about, and it's why I really wanted to have you go back to my claim, because I think you know this part of the treatment so well is this is an active and I think it really essential part of treatment for so many people that they have not only the support. It was actually only about a month ago, maybe a couple weeks ago, where you you know it was a community meeting. You know, every unit has a community meeting, which is a time where the unit gets together patients and staff and we talk about how we're doing as a community, and we were talking about our milieu. We have a company called State of the Milieu, which is like how we're doing.

Dr. Bob Boland: 11:17

Yeah, about our milieu.

Dr. Kerry Horrell: 11:18

We have a meeting that's called State of the Milieu, which is like how we're doing, and I think you were speaking to this and I wonder if you can share with our listeners and again people might be listening, which would be our listeners like how you would explain to patients how you'd answer this question to them. What is a milieu. And why is this important? Because, as we know, patients will often say things like I'm never going to see these people again. Why would I care about how I feel about them or these relationships?

Dr. Kerry Horrell: 11:41

So how do you explain this to?

Dr. Kerry Horrell: 11:41

patients and families of why this is so important. What is this thing we do?

Dr. Mike McClam: 11:46

Yeah, yeah, I think that's a good question and my response to that is when you were talking about that, I was thinking about the times that I was on the professionals unit and the way we preambled or opened our community meeting was something like you know, we welcome people into the community, we say hello, we say goodbye to individuals as they come and they go. We have, we share, our highs and our lows and basically we're all in this together, right? And so you know the idea of individuals, both patients and staff, coming together and talking about how we relate to each other in a community. That may not necessarily be, yes, for some patients. They'll say, well, this is not my home community, but yes, but you bring from your home and your other personal experiences, your thoughts about relationships, reactions to relationships within this community, and we can use that. We can use those relationships and use the feelings and thoughts and all the other kind of reactions that are generated in these relationships to actually have something to say about how we can help you have better relationships when you go back home, right?

Dr. Mike McClam: 12:57

So I think in the context of that meeting, we were talking about how individuals were making some comments, statements within the milieu that were, I think, causing other people to have some conflicts and thoughts about what was being said, and I think that was the time in which we tried to remind ourselves that, yeah, our relationships or what we say in the milieu, what we say to each other, really do matter, and it matters in lots of different ways.

Dr. Mike McClam: 13:24

It can be as innocuous as yes, I have said something to you or I've communicated something to you that really makes me feel that I'm not in this alone, and so that's one of the things that's really helpful in the community.

Dr. Mike McClam: 13:35

Or you have, someone has said something in the community that's caused a reaction, either positive or sometimes negative, right? And so even reactions that are negative can be used in a way, with curiosity and with empathy, to say something about both individuals or the community in general, how we're functioning right, and I do think there's some way in which we can use that in order to translate to I want to have better relationships, I want to be closer to the individuals that are in my local community or in my family that I'm not having the relationship that I want, or I just want to function better in society, and so we create this intentional society that is curious and that looks at the relationships and that you know, tries to have something to say about why these things happen, when they happen, to give you know the people that are involved, including staff. You know, critical insights about how they function in the world and how they function with each other.

Dr. Bob Boland: 14:34

Yeah, I mean, you know, I think milieu therapy is just is one of those kind of terms of it does get bandied around and then it becomes a bit generic. I'm sure you know, if we ask most places if they do, they say yes, because in the most general sense, yes, I suppose they do.

Dr. Kerry Horrell: 14:51

There are patients and peers around, yeah right.

Dr. Bob Boland: 14:53

We have a community; we have a milieu. It's an environment. Yeah, I mean, how would you advise, like your patients or families if they were kind of looking to a place that took it seriously, what they should look for, what they should ask?

Dr. Mike McClam: 15:05

Yeah, so the one word that I think keep coming back to is intentionality, like the intentional curiosity around looking at the relationships within the milieu. Yes, it's one thing to have a community of individuals, but I think it's another thing to be intentional about using the relationships within the milieu to say something about relationships within the patient and also relationships between the patients and the team. So I'm really sure that other places have communities and think about communities, but I think the way we think about the relationships within the community not just as, um, as people just happen to be at the same place, at the same time you need to just manage.

Dr. Mike McClam: 15:46

Yeah, but like but actually having some real curiosity and also having some real reflection within the team, within the staff community, about how we influence the therapeutic relationship right or the therapeutic community.

Dr. Kerry Horrell: 16:01

I'm going to come back to this in another question that I have in mind, but I do just want to say now I think that you model that so well, Dr. McClam.

Dr. Kerry Horrell: 16:08

I think that your vulnerability, your humility and how you modeled the team like. Reflecting on this is what this patient brought up for me, or this is how I'm responding to this conflict. I want support around that. I want to think it's really I think it's been really influential to me in regard to working in a milieu. One thing I want to ask I want to get more into that in a second. One thing, as we're on this topic, I want to say I make this joke sometimes and I know this is a little, maybe this is a little bit hyperbolic, but we take a lot of patients who have personality disorders, trauma.

Dr. Kerry Horrell: 16:41

We work with all sorts of patients but I would say a fair number come with some relational pain in their life. So we take people who've had these relational struggles and pain and they've experienced things that are going to influence how they engage with other people and we stick about 20 of them together in this small space and especially on our unit, our young adults unit or our adolescent unit. You know, of course, like what did we expect would happen besides there being conflict and there being these things where you know, again, I haven't worked as much on the adult units, so I imagine this happens, but, like on our unit, crushes are happening all the time.

Dr. Kerry Horrell: 17:20

People like having romantic feelings towards each other you know, it's this really intimate yes, it's like these, this really intimate, close-knit space with people who've had all sorts of different kinds of relational experiences that oftentimes are getting reactivated and like of course, it's just so much fodder for their treatment because, like, there's stuff coming up between them.

Dr. Kerry Horrell: 17:41

It's got me thinking about who and again, if people are listening, especially people who maybe aren't treating within an environment where there's groups or a milieu, who is a good fit, like, who benefits the most or benefits at all from a milieu, who would it be? You know, like, hey, they probably could really what clinical presentations kinds of people would really benefit from this. And then, conversely, are there people who really wouldn't benefit from a milieu.

Dr. Mike McClam: 18:08

Yeah, what do you think about that?

Dr. Mike McClam: 18:10

Yeah, that's a really good question and also, I think, in some ways, very complicated in some ways, and also, I think, in some ways, very complicated, in some ways not as complicated as I'd like to think it is.

Dr. Mike McClam: 18:21

I think one of the main things is a willingness, like you were talking about, a willingness to be curious about how things come up for a person in relationships would always be really helped in a milieu-based environment.

Dr. Mike McClam: 18:34

And then, conversely, you know individuals that really struggle in the milieu or individuals that don't have that type of curiosity, not necessarily don't have it at all, meaning if not kind of helped along, but would say I would say you know, in that process of helping them develop curiosity, basically just say I'm not really that curious about it. You know, and particularly around you know certain things around conflicts, conflict avoidance, and also I think one of the things about our milieu that we do have to be sensitive to and thoughtful about is, as you said, Dr. Perl, there are many individuals that come in with broken relationships, with trauma, that have been frankly abused, and so individuals that come into the milieu that are perpetrators or have more of a sense of wanting to not be very curious about how they we can call it what it is like someone who's more antisocial, psychotic in nature.

Dr. Mike McClam: 19:31

Yeah, so yea sociopathy, antisocial persons who kind of want to have their needs met and not really curious about the impact to others. But getting their needs met would probably not be very well received in the milieu-based environment.

Dr. Bob Boland: 19:46

How about people with like reality testing problems like, say, delusion?

Dr. Mike McClam: 19:49

Yeah, that's the other thing. Yeah, it really. It kind of depends. I think that one's a little bit more complicated because we certainly we've had individuals that have had some delusional disorders and some psychosis, that have been able to function reasonably in the milieu. If it gets to the point where they're starting to act on their behaviors or having a lot of difficulty with managing those behaviors and it starts to affect the others in a way that's not really helpful, then those individuals we kind of think about sending to another place I mean when I say another place, maybe to a place where we're not as focused on the milieu and the relationships. Sometimes, for folks that are psychotic, the reality testing is such that it's really hard for them to effectively connect with others and others that are just not in the place to really help them along. They tend to have some difficulties with managing their own triggers sometimes.

Dr. Kerry Horrell: 20:43

And the boundaries. And the boundaries, yea, A milieu only works when there are clear and supportive boundaries, and I think some people, not only who are maybe actively psychotic, but people who are manic- yes. Just where they're not in regard to their illness is such that they can't respect the boundaries of the milieu.

Dr. Bob Boland: 21:01

Yeah, and what does that mean in practical terms? What would be an example of a boundary?

Dr. Mike McClam: 21:06

Yeah. So, for example, we have someone that's manic, that starts to say things that are really sexually explicit to other Appropriate, yeah, sexually appropriate, or other types of things. Appropriate, yeah, sexually appropriate, or other types of things and so what happens is in the milieu, then we become really focused on, uh, that particular, that particular issue within the milieu, and it's hard for us to, you know, to really kind of focus on how do we kind of use that relationship, because at that point people are just so triggered that it's just about we need to have you know, we need to address this problem because I see, yeah, one thing we talk about a lot is that a milieu only functions well when there is emotional safety.

Dr. Kerry Horrell: 21:43

Right, this is something where if there's that, if there's pieces that go against that and we kind of have like a pretty discrete list we share with our patients, like you know, being discriminatory or racist, sexist, homophobic, transphobic, able, those are off bounds, like that's not going to contribute to a place where we have emotional safety.

Dr. Kerry Horrell: 22:04

And then it gets a little hairier and I'm kind of curious if you could talk a little bit about this, because we wrestle with this a lot, which is some patients would prefer that in a milieu there's no talk about religion, politics, drugs or alcohol, and these are ones that we don't ban.

Dr. Bob Boland: 22:22

We don't say, hey, you guys can't talk about this. It's kind of hard to avoid if you're living there, right?

Dr. Kerry Horrell: 22:26

And I mean even at the time we're filming this right now, which I think this will come out quite a bit later, but we're approaching a presidential election. These are things that people are thinking about and they care about and to just put sort of is probably not that practical, like I think they're going to talk about it but, I also think it doesn't such a disservice, because these are things in real life and I wonder how?

Dr. Kerry Horrell: 22:48

How do you talk to patients or how do you share with patients when they say we would feel better protected, but in this milieu, if you just said nobody could talk about any of that, how do you respond? Or not that there's an easy answer, but I'm curious where your mind goes.

Dr. Mike McClam: 23:01

Yeah. So again, you know, I think, where we land is. I think, like you said, d Rell, being clear with certain boundaries around emotional safety, you know the homophobia, xenophobia, transphobia, ableist, those kinds of things, but you set these very clear boundaries. And then I think when we talk about more, I think, more gray areas or topics like religion, talking about substances or substance use, I think those things can be very fair game. I'll just say how I'm thinking about it, With the proviso that all of us involved kind of set some clear boundaries on what we're talking about within those subjects and then don't fall into some of these traps. I do think that I think talking about those more sensitive topics or more gray area topics can actually be very helpful in terms of conflict resolution and management about bringing up feelings around certain topics, particularly with substance use. I think one of the things that our substance dependency counselors talk about is we can talk about it but not glorify it and talk about it.

Dr. Mike McClam: 24:04

Yeah, so you know, talking about the use, to be very specific, talking about the use of substances and how they're used to help manage or cope or avoid certain feelings and vulnerabilities, I think it's fair game. And also talking about ways that you can help with managing your feelings independent of substances, I think it's fair game. But when we talk about what we call war stories, where they're just kind of really glorifying that use, then it goes into the realm of probably need to set a boundary there. Same thing with politics and political views. I mean, you know, people come from all walks of life and different stripes, and so it's not, it's unreasonable to think that everyone's going to have that same type of or similar type of political views.

Dr. Mike McClam: 24:45

But I think when it goes, when it strays into the some of the areas that we're talking about where we have clear boundaries, is when we have to set some limits and I think again it goes back to intentionality, like if the staff and all of us have to be intentional about what we consider the boundaries are and kind of talk about it out loud, because I think what happens sometimes is we don't talk about some of these things out loud, and then there's these fantasies and expectations that staff will kind of manage it for us, and sometimes I think these conversations become actually pretty good because it kind of brings these things up that people have been kind of thinking about avoiding, wanting to talk about including staff. I mean, I think there's parallel processes that happen with the staff that we want to avoid certain topics because of certain pitfalls that we think we're going to get into.

Dr. Bob Boland: 25:28

It makes sense, which kind of brings in another challenge, I guess, is that you as a clinician, you're part of the milieu and so you bring yourself into it as well. I sure do. Well, can you say a little about that? How does that work and how is that challenging for you?

Dr. Kerry Horrell: 25:46

How do you manage it?

Dr. Mike McClam: 25:47

Yeah, I mean I think one of the benefits of working in a team is I have folks like Dr. Horrell and I have other individuals around me that can kind of keep me honest, and I think you have to have a certain level of curiosity about yourself.

Dr. Mike McClam: 26:06

It's like one of my old supervisors used to tell me right, the very thing that you don't want to talk about to your supervisor is a thing you should talk about to your supervisor. So, yes, just like any person, any human, I have my own reactions to things that happen in the milieu, the relationships that I've developed with the patients, with staff, and we need to talk about that, because the more we talk about that, the more that I can use that as a way to help with the therapy and with the therapeutic support, or with understanding something about how the team is functioning, how the team is reacting to what's going on with the patient, and we can bring that back to the patient and make a consultation about. This is, I think, what's happening, and this, I think, is the intervention that we can use to help you have a better relationship, not just with the team but with anyone else.

Dr. Kerry Horrell: 26:52

I wonder, bob, if you experience this too when you work on the unit. Do patients know that you're the chief of staff? Does that come up ever?

Dr. Bob Boland: 27:07

Well, I think the associate question is do they care? Yeah, yeah, right, or know what it means? Yeah, occasionally, on the units where particularly patients are given, the hierarchies may be interested to know that, like I'm the boss, and then they'll start to give me a list of complaints that they might have about, like the color patterns or something or things like that.

Dr. Kerry Horrell: 27:25

but in general, no, I mean, at the end of the game, it's really about them, you know, and about how am I going to help them with their problems because one thing for both of you that you would have in common that I do think it comes up a lot is that both of you are psychiatrists, so when you're working with a patient on the unit, you're typically the team lead, and I think patients know that the buck stops with you in regards to, like, when we have to make a final call.

Dr. Kerry Horrell: 27:47

Um, you're also both men and you're both in leadership positions at the hospital, and so I'm thinking about this because I know, working closely with you, Dr. McClam, this comes up especially with our young adults and adolescents. You just quickly become a lot of times not always like a lot of times. You become dad, you become parent, you become authority. You know long before they can even get to know you and know that you have such a like, I think, incredibly caring, soft, thoughtful. You know demeanor. They come to you with arms crossed, they're ready to fight.

Dr. Kerry Horrell: 28:21

And again, I wonder if, if you can speak and that's not always the case, you know, we have different patients who have different reactions to us, um, but I think that's one that like that's a common one. Yes, like, how do you manage that? How do you think about that, Bobby?

Dr. Bob Boland: 28:32

I'm curious if you run into those things well, sure, I mean, this isn't exactly answer your question, but it does make me reflect on …

Dr. Bob Boland: 28:37

It does teach you some humility though. Yeah, along the way like I can recall early so I would have been not the old psychiatrist now a younger psychiatrist, but still kind of like a team leader where I think I missed like a meeting with a patient and it came up in a community meeting and I tried to analyze and say like how it was kind of like a good learning experience for everyone. You know that things, mistakes happen, and they called BS on that appropriately and the group like came down to me so hard about like why was I rationalizing? Yes, well, I just apologized for like being late. Yeah, you know that sort of thing and it was like a good, you know, and it made it, um, a good experience for me to kind of like just be honest with the group, totally yeah, and with myself, oh yeah, yeah, yeah, you made me think about, like when I started with this work early on is, um, what, like you said, how I affect other people, like you know to.

Dr. Mike McClam: 29:33

Of course they get jargony, like their feelings toward me, and part of their feelings toward me is who I am and the parts of that that I just can't change, and also then the projections of the fantasy they have about me based on who I am.

Dr. Mike McClam: 29:44

Right, it's a co-created process and we're all trying to kind of figure out what's what. So, yeah, I am aware of that and to some extent, to a large extent, I tend to lean into that a little bit because knowing there's a part of me that I just about myself that just bring me to feeling like a person in authority and parts of it I just can't hide. So I'm going to be very transparent, like, yep, I'm the person you know that that has to make the final call, but that's not to say that I don't take in, like, the inputs of everyone else and in some ways, I think when I came to especially on professionals, because those patients there that I was treating lots of doctors, lawyers and things like that they tended to split me out or wanted to split me out, meaning because I was the authority figure. Well, the other team members don't mean as much.

Dr. Kerry Horrell: 30:29

We're both doctors, we get it.

Dr. Mike McClam: 30:31

Yeah, yeah, exactly, exactly, exactly.

Dr. Mike McClam: 30:34

And so what I learned early on was if I had to collude in a split, to be on the bad side of the split, which is very painful, to be in right, you know you don't want patients to be on the bad side of the split, which is very painful to be in right, you know you don't want patients to be mad at you but at the same time you know patients have a tendency to kind of like split mom and dad out, right.

Dr. Mike McClam: 30:53

My philosophy at that point in the service of the team and again this is another podcast about you know kind of team dynamics and how you manage that was I realized quickly that when it came to like the limit setting and all that, you know all the hard stuff, you know that I need to take that on and I think at some points you know the team would say no, Dr. McClam, we can take some of those points on too. But I thought it was really important as a team lead not to get split out in favor of undermining the whole team, right, team lead not to get split out in favor of undermining the whole team, right. So if I had to, the team had to be colluding in a split, then I would take that in front of it.

Dr. Bob Boland: 31:29

Yeah, and when you refer to yourself as kind of like the dad, that kind of thing, one can't help but go to the family metaphors about this.

Dr. Mike McClam: 31:38

Exactly.

Dr. Bob Boland: 31:39

And I imagine a lot of family issues and dynamics play out in these teams and in the community.

Dr. Kerry Horrell: 31:45

Well, that's why I think something else that you're not mentioning, that I referred to earlier and we'll come back to, is that you take an incredibly humble stance with the patients in a way that's hard to do. Acting on a frustration, you catch that and you apologize in a way that I think, like a lot of people probably and this might be an overgeneralization, but like probably have never experienced from their parents, they're like admitting a mistake. You know I did something and I want to own up to that and I want to appreciate that you probably have reactions to that and like you've modeled that really well.

Dr. Kerry Horrell: 32:25

You know, like when patients come around and they say things like well, the nursing staff, Dr. McClam's kind of lying there and he goes that's, that's, that's my staff, those are my people, who I work with.

Dr. Kerry Horrell: 32:39

So, if somebody wants to say something about them, you're like say it to me.

Dr. Mike McClam: 32:42

You're saying it about me so just say it to me.

Dr. Kerry Horrell: 32:45

I think you balance that really well and I really think and I highlighted that not just to compliment you in your work, but I think that is back to one of your questions, Bob like one of the things that makes milieu treatment really hard I think really beneficial is when people have this intentionality of yeah, we are going to know we're bringing ourselves into it. We're going to have to then know our stuff's going to get stirred up. We're going to have to work on open communication and transparency A lot of the stuff we talk about. Let's look at the core of mentalizing. We're going to mentalize it.

Dr. Bob Boland: 33:16

We're going to talk about it, and you keep saying intentionality, which is like a big word and very fancy, but I mean what you're really saying, I think, is this is a lot of work. It is a lot of work. So, it gets back to kind of, how does this differ? Well, it doesn't just happen because there's a community right, you’re clearly putting a lot of work into what you're doing to make it work properly.

Dr. Mike McClam: 33:34

Right, that’s true. Thank you, Dr. Horrell. I really appreciate that because rounds can be pretty challenging, but I do I own. One of the things that I've learned over the years I've worked here is to own your responsibility in the relationship, because it's not going to be helpful to continue to gaslight a patient if that's what's happening, if you're contributing to what they're experiencing. So that's something that I think I've learned, and I think it's been really helpful and also pretty enriching experience, because it becomes about therapeutic ruptures and repairing Right and getting into correctional emotional experiences to have someone in authority say, look, that's my fault and I own it.

Dr. Bob Boland: 34:15

I know we just scratched the surface, but this was fascinating and we're so glad to have you on. Clearly, we have to come back to talk about some other things.

Dr. Kerry Horrell: 34:22

I know some of the military psychiatrists would be fascinating as well.

Dr. Bob Boland: 34:25

Important. So, yeah, but once again, everyone, you've been listening to Dr. Michael McClam, associate Professor at Baylor College of Medicine, and I'm your host,Bob Boland.

Dr. Kerry Horrell: 34:35

And I'm Kerry Horrell and thanks for diving in the Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

Dr. Bob Boland: 34:49

For more episodes like this, visit www.menningerclinic.org.

Dr. Kerry Horrell: 34:54

To submit a topic for discussion. Send us an email at podcast@menninger.edu.