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 The Psychiatrist Player's Handbook

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PostSubject: The Psychiatrist Player's Handbook   Fri Jun 22, 2012 1:46 am

THE PSYCHIATRIST PLAYER'S HANDBOOK
_____________________________________
Warning! This is stupid long! If you can't be bothered to read it, you definitely don't want to play a psychiatrist.

So, you would like to play a psychiatrist, (or perhaps you already play one, and would like a little guidance.) This handbook has been penned with a number of years of experience, playing a psychiatrist in this sort of role-playing setting, with many diverse patients and players. In each chapter, I will attempt to help you understand and tackle any obstacles you might come across, and I will teach you about the sorts of extra responsibilities that come with this position, and make this forum run more smoothly and realistically.

I have broken the handbook down into concise chapters, to help you navigate your way through the different subjects. If you have any further questions that are not covered in this handbook, then by all means send me a message, and I will attempt to help you as best I can.
      ~Ghost
_____________________________________
INDEX OF CHAPTERS



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PostSubject: What is Expected of a Psychiatrist Player   Fri Jun 22, 2012 2:11 am

WHAT IS EXPECTED OF A PSYCHIATRIST PLAYER
_____________________________________

In this chapter, I will try to explain the overall expectations and tasks that come along with taking this position. Naturally, everyone has to start somewhere, and we do not expect you to be a walking dictionary of psychiatric terms, procedures and medications. Knowledge takes time to ecru. However, that being said, we do hope that you will have some grasp on the setting, and on general psychiatric procedure.

We hope that you will understand that this is not Bedlam, and that many of the torturous procedures that used to take place in psychiatric care have been eliminated or even outlawed. Hallowsgate does not perform lobotomies, for example, nor does it abuse its patients (where anyone can see it anyway.) ECT, or Electro-Convulsive Therapy, is still in use today, however, the application of it is far more humane (the patient is sedated throughout the procedure) and it is only used for cases of depression, dissociation or catatonia that have not responded to medication.

If you do go the route of making a less... savoury type of character as a psychiatrist (which you are allowed to do too), you should be aware of the restrictions of the law, and that anything you do in character may well result in in-character repercussions. We don't wish to dictate your character to you, but an abusive psychiatrist who cannot hide it well is not going to last long.

In all things, a psychiatrist player should have a grasp of basic common sense. For example, it would not be common sense to corner and yell at a patient who is claustrophobic, or allow a suicidal patient to have an item with which they could harm themselves. It is fairly simple to make this role work well for you, as long as you take the time to assess your situations and make reasonable choices in how to proceed.

The psychiatrist player should be aware of what they are taking on before they commit to this staff position. As a character, a Psychiatrist must run both individual and group therapy sessions, and must afterwards make notes about the session on the file of each patient that attended. Sometimes this can get laborious, I won't lie. But this is part and parcel of getting to play one of Hallowsgate's shrinks, and it is what helps our board run more smoothly and realistically. I will go into more detail on these sessions in the Guide to Therapy chapter.

When it comes to a grasp of the psychiatry and medications involved with the job of playing a Psychiatrist at Hallowsgate, as I said, we don't expect you to be an expert. We would like you to have a basic grasp of the sorts of issues that patients on your roster have, however. As you will have noticed by now, we provide links to each disorder in our character creation thread, so if you are not sure about certain disorders, you may read more about them by following the provided links. I will be providing a small guide to some of the most common medications in this handbook, but I encourage you to research others too if these do not fit your needs.

In short, playing a psychiatrist on a site such as ours is no small undertaking. It's not a position to be taken lightly. We're here to have fun, but the psychiatrists are the cornerstones of an asylum role-play. They need to be active, reliable, and driven. They need to be able to make notes, and they need to be able to react on the fly to whatever in game circumstances come up. If you don't think that you can be active, or if you already struggle to maintain your other characters, you should consider what's required of the position before you request to take it.



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PostSubject: Therapist Behaviours   Fri Jun 22, 2012 2:25 am

THERAPIST BEHAVIOURS
_____________________________________

Sometimes, playing a psychiatrist can be extremely taxing, and can ruffle a few feathers. Therapy sessions will not always go the way you want them to, and there are always troublemakers around that will attempt to make the psychiatrist's job as hard as possible. There are also some players that will cause you a lot of frustration, which I will cover in a later chapter. In order to keep your sanity and be successful in the position, here are some basic guidelines for dos and dont's. You may choose to follow these or not, of course, but remember the golden rule of in character actions having in character consequences.

A Good Therapist:
  • Understands that they are caring for patients with psychiatric illnesses.
  • Does not take things personally when a patient insults or otherwise ruffles them.
  • Does not lower themselves to the level of insulting, violent, or petty patients.
  • Is organised.
  • Plans for the worst but hopes for the best.
  • Reads their patient's files before meeting with them.
  • Can think outside the box and change their plans if their original plans do not work out.
  • Does not resort to punishing patients who might aggravate them.
  • Does not keep favourite patients while neglecting others.
  • Is confident.
  • Does not get flustered easily.
  • Is not afraid to ask for help.
  • Listens more than they talk.


A Bad Therapist:
  • Is petty and childish.
  • Takes things personally and becomes easily insulted or upset.
  • Forgets that they are dealing with psychiatric patients, not peers.
  • Loses control easily, or gives up.
  • Never has a plan to follow.
  • Favours some patients over others.
  • Uses seclusion or sedation as a punishment for bad behaviour.
  • Engages in physical altercations with patients.
  • Is unsociable to their peers.
  • Is disorganised and gets lost easily.
  • Never bothers to research their patients.
  • Is only in the job for the money.


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PostSubject: A Guide to Therapy   Fri Jun 22, 2012 3:10 am

A GUIDE TO THERAPY
_____________________________________

There are two different types of therapy at Hallowsgate; Group and Individual. Group therapy is conducted by a psychiatrist or another member of staff, and is conducted with multiple patients in the live chat therapy box. Individual therapy is conducted only between the therapist and his or her patients, as a one-on-one session either in the live chat box, or in a thread. Each of these methods has its benefits.

As a new player of a psychiatrist, you may find it beneficial to begin your individual therapy session in threads. Threads allow the player more time to consider their reactions to the patients' words or actions, and takes a good deal of stress off of the player. Threads also force the patient's player to give more details about what the patient is doing and how they are acting or reacting, which can help you in formulating your replies and understanding the patient.

Conducting individual therapy sessions in the live chat box can be more taxing, though they are certainly much quicker, and connections can be made with the patients much more quickly. In a chat box session, you will not have as much time to consider your responses, and you will not get as much input from the patient's player. However, they can be just as beneficial, and are certainly a lot of fun.

And now we come to group therapy, which is a subject that bears further explanation than the others. Group Therapy can and often will be utter chaos. Never feel personally responsible if your group therapy session does not go the way it was planned, or someone got hurt or upset. What makes group therapy half the fun for many players is the utter shenanigans that go on in them. There will always be certain players or characters that seek to initiate anarchy in a session, and it is up to you, as the player of the psychiatrist, to try to control that chaos. It IS possible to do that most of the time, as I will cover below in my top tips for a successful group session.

First I will explain how the therapy boxes work for you, and what the proper protocol is. Firstly, if you would like to use the box for a session, you must ask one of the forum staff to put it up for you, and they MUST be online and present for the duration of the session. When you are finished with the box, they will put it away for you again. To initiate your session, the psychiatrist should always post their intro first. And individual session should run no more than two hours, and a group session should run no more than three hours unless permission for more time is given. You do not have to use this entire time slot. You may run an individual session for only and hour if you feel you are both posting quickly enough to make some progress. Likewise, you may terminate your group session early if it is not turning out as planned, and the patients should be sent out. It is YOUR session. You determine who stays and who goes, and how long it lasts for.

Top Tips for Therapy Success:
  • A) Number One. Most Important. Know your patients! This is just as important for group therapy as it is for individual therapy. Even if the characters in your group session aren't on your therapist's roster, I promise you that making the mistake of not familiarising yourself with them first will be a move you will regret. The worst thing you can do is going into a GT blind, and then have it break down into chaos because you let the sociopath sadist sit next to the PTSD, quivering wreck. Always at least get a gist for the patients in the group first.

  • Have a plan! Once you have figured out who is in your group, you can usually come up with some kind of common theme that works for most or all of them. For example, maybe they all seem to have parent issues, or drug issues, or unhealthy relationship pasts. You can then plot out a sort of theme you want to stick to. For example, if they all have parent issues, you can composed the session around how they feel about their family, what they think a real family should be, how they would fix particular issues, etc. If someone tries to derail your session with another topic, it's up to you whether you allow them or not. Usually, the safer bet is not to veer off topic. It is the first horseman of the GT apocalypse when a patient takes control of the group.

  • Derail the trouble makers before they derail you! If you have a character in your session that you just know is up to something, or that keeps somehow trying to derail the situation, derail them first. Confront them verbally if need be. A popular tactic of many of my psychiatrists is to ask them why they are disrespecting the other patients by talking over them or ignoring or making fun of their issues. This gets the rest of the group on the psychiatrist's side, rather than on the side of the trouble maker, and usually allows you to deflate the chaos before it begins. If they continue to act out, you could send them out of the group. Either make them sit away from everyone else, or send them out of the session entirely. If they resist, call upon your magical NPC orderlies to assist you.

  • Take your notes as you go along! After any session, you will have to make notes on the files. This is so much easier if you take notes while you go along, so you don't have to rely on patchy memory afterwards. Makes notes of their behaviours and body language, how their emotions seem to you, what questions they were asked and how they answered and reacted, how they were with other patients. Anything pertinent that you would want to put on their file. I always keep a notepad file up on my screen during sessions, to take running commentary as I go along. I put the name of each attending patient there, and then make notes under each name.

  • Deny the attention seekers! Just like trouble makers, attention seekers want to derail the session and turn the focus on to them. Sometimes they try to get a rise out of you or the other patients, because even negative attention is attention. The very best way to handle attention seekers who try to derail the conversation is to ignore them entirely and stay on track of the topic you already planned. If they make a snarky comment to you, ignore it, and call out another patient, by name, and ask them a question. This will put the attention (hopefully) back on another patient and on the topic at hand. If another patient gets angry with them and starts reacting to their bad behaviour, direct a question quickly at the patient who is getting angry, in an attempt to derail them. If you deprive the attention seeker and the trouble maker of their attention and fun, most often they will get bored and simply sulk.

  • Be careful with the meltdowns! Now and then, patients will have meltdowns in group therapy. Sometimes certain players will be renowned for this sort of thing, which I'll cover later in the handbook. Sometimes, frankly, there is nothing you can actually do about it than let it run its course or have those magic orderlies come to take the patient away. If the player is reasonable, however, you may be able to talk them down. Perhaps they're having a PTSD freak-out or flashback, or a panic attack. Try talking them down first. Don't crowd them or allow other patients to crowd them. Use common sense with these cases. If it is a lost cause, it is a lost cause, and unfortunately, you will just have to put up with it or have them leave the session.

  • Make an order and stick to it! When you take names for a group session, make an order out of them so that when you begin asking questions, if your group is a standard type of group, you can go around and ask each name in turn. This will keep you from losing your place, and it will make it much easier for you to try and keep the group on track. You will know who to ask next, if there's a disturbance, and it will be easier to take notes in order.

  • Don't forget the magic NPC orderlies! If all else fails, bring in the men in white... trousers and shirts. If chaos erupts, have your therapist radio for the orderlies, or if there are players of other staff members in the regular chatbox at the time, you can request for them to come and help your character.
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PostSubject: A Guide to Medications   Fri Jun 22, 2012 3:46 am

A GUIDE TO MEDICATIONS
_____________________________________

Firstly, know that if you do not feel comfortable handling medications, you do not have to. I'm not going to penalise you for it. If you really think a patient needs meds and you're not sure what to do, come and ask me, and I'll help you out with some suggestions. Or you can do this in character too. Your psychiatrist can ask another psychiatrist or the facility administrator for suggestions. In the case of Cyril, the admin, if you ask him because you don't really want to handle medications, he will handle it for you. It's an easy out if you're not comfortable with handling medications yet. You could also leave a suggestion that the patient should be medicated on the file note, and if you direct my attention to it, I will add a prescription note.

Now, I'm no psychiatrist or pharmacist myself, so the medications I'm listing are just those that I have come across in play. This is by no means an extensive list, but if you need a quick fix, so to speak, you can just grab one of these for your prescription note if they fit. I will probably add more to this list as time goes on and I research more medications.

For Insomnia, Anxiety Attacks, PTSD Outbursts, Severe Impulse Control, Severe Anxiety, Severe Restlessness or Ticks Caused by Antipsychotics:
    Diazepam (Valium) - 5mgs basic dose for insomnia and 'spot treatment' as attacks occur. 5mg for insomnia should be given with evening meal, or before lights out. General treatment might consist of something like 2.5mgs given orally, twice a day. Causes slight sedation and sense of well-being. Higher doses can be given for greater effect. This is my go-to prescription for the anxious and insomniacs.

    Lorazepam (Ativan) - Warning, this is the big guns. Same as the above, but stronger by far. 1-2mgs can be given orally as spot treatment or as insomnia treatment. Causes considerable sedation, impairment of motor functions, euphoria, amnesia. Up to 10mgs can be given orally per day (Holy Cow!) Lorazepam is also the IV sedative of choice for hospitals and psychiatric units. If you have to sedate a patient by needle, this is what you would give them. Generally 1-4mgs IV.


For Depression, Anxiety, OCD, PTSD:
There are your SSRIs or Selective Serotonin Re-uptake Inhibitors. They are the standard antidepressant of choice for doctors nowadays, to help with the above mentioned issues. The old class of antideppressants can still be used but have more side effects, and I don't know as much about them.
  • Escitalopram (Lepraxo) - Standard dose is about 10mg a day, once a day. It can be raised incrementally from there.
  • Fluoxetine (Prozac) - Standard starting dose is 20mgs a day, once a day. It can be raised incrementally from there up to a maximum of 80mgs a day, split up into three doses.
  • Paroxetine (Paxil) - Standard starting dose is 20mgs. Can be raised incrementally for there, 10mgs at a time.
  • Sertraline (Zoloft) - Standard treatment for depression and OCD is 50mgs a day. Should be started at 25mgs and raised to 50 gradually.


For Schizophrenia and Psychosis:
This is the first time we've actually had characters with these conditions, since they are usually banned, so my research into antipsychotics is pretty sparing. So for now I'm just going to list a couple that I have come across, and I'll add more as we go along.
  • Risperidone (Risperdal) - Start at 1mg twice a day, and raise incrementally to 3mgs twice a day, or 6mg once daily. Can be raised to 8mg from there if necessary.
  • Clozapine (Clozaril) - Begin at 12.5 mgs twice daily. Raise by 25 to 50mgs per day until a target dosage of 300-600mgs daily is reached. Can be raised up to 900mgs daily if necessary.


This list will likely grow as I research more, and you're welcome to offer suggestions as well, and I'll post them up.



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PostSubject: How to Approach & Handle Problem Patients   Fri Jun 22, 2012 4:52 am

HOW TO APPROACH & HANDLE PROBLEM PATIENTS
_____________________________________

Contrary to the portrayals in Hollywood, psychiatric care is rarely a 'madhouse' any more, if you'll excuse the pun. It is not considered legal to shove the patients around or otherwise abuse them. There are actually some pretty strict protocols in place for how to handle certain situations, and especially at Hallowsgate, Cyril, the facility administrator, makes a big deal out of actually following them. He doesn't condone over-use of sedatives, restraints or seclusion. Granted, his perspective may not always be spot on, so it's down to your judgement about how to proceed with a patient who is proving a danger to themselves or others.

Standard Hallowsgate procedure for a patient who is a danger to themselves or others goes something like this:
  • First, try to diffuse the situation. Do not escalate the situation by panicking or losing your cool. If you can, talk them down. Remember, they're a person too. Find out what's setting them off, and if you can get sense out of them, try and talk to them like a person, try to calm them down and offer to talk about their problems or concerns. If they won't calm down, or they are totally nonsensical, go to:
  • Step two, try to wait it out. If they are in an area where they're not going to hurt themselves or someone else with anything, try to wait out the dramatic response. If they don't show signs of wanting to hurt themselves or others, again, wait it out. Don't leave them alone, but don't interfere either.
  • Step three, if they are threatening themselves or others, and all other forms of communication have failed, you can use mild physical restraint. The aim is to get them to the floor, on their stomach, as quickly as possible without hurting them or obstructing breathing. Do not punch them or kick out their knee or anything like that. Use leverage to get them to the floor and hold them there, whilst being aware to safe guard yourself. Once on the floor, you may choose to pin them there until they calm down, or move to step four.
  • Step four, move them to seclusion. Seclusion rooms are designed in such a way as to allow no items for the patient to seriously harm themselves with. It will take more than one person to move a patient to seclusion. Two people should carry them by their arms, while someone holds their legs to keep them from hitting, scratching or kicking anyone. A patient should never be left in seclusion for days at a time. Usually, mere hours should suffice, and once they are calmed, medications can be given by mouth, if necessary.
  • Step six, restraint. If there is a substantial fear of the patient continuing to harm themselves or others, or seclusion is otherwise not indicated for the patient, soft bed restraints may be used to secure them to a bed until they have calmed down or have been medicated to the point that they no longer pose a risk. This may happen either in seclusion, or in one of the chronic ward rooms where no other patient is present. They should be checked frequently and no other patients should be allowed admission into the room.
  • Step five, the dreaded hypodermic. No-one but accredited nurses and medical professionals This includes psychiatrists) should administer IV sedation to any patient. Medication can be administered either IV (intravenously) if it is safe to do so, or intramuscularly via the buttock or the upper arm. IV sedation works in a matter of seconds, where intramuscular sedation may take up to half an hour to take full effect. Depending on the dose of medication, patient may remain conscious but calm, or may be entirely sedated. The former is preferable.


As with all things, use common sense. Do what you think is best for the situation and the patient in question. If you do not think that a situation is going to be able to be diffused, you can quickly move to secure the patient before they hurt themselves or someone else. If the patient poses no risk to themselves or others, it's often best to wait it out. Don't leave the unattended, but again, don't crowd them either.

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PostSubject: Problem Players & How to handle Them   Fri Jun 22, 2012 5:19 am

THE VARIOUS TYPES OF PROBLEM PLAYERS & HOW TO HANDLE THEM
_____________________________________

One of the greatest challenges when role-playing a psychiatrist is often times nothing to do with psychiatry at all. It's all well and good for us to know the disorders and methods, but often times, players don't, or they otherwise make it impossible for their character to be helped at all. There are lost of different types I've come across over some years and many, many patient characters, and I'm going to list some of the main, recurring ones here, and how I think you can deal with them.

  • The Unfixable Character: This is by far the most common one. The problem is that when someone makes a character a certain way, often times, they are totally resistant or opposed to change. They might consider it breaking their muse to have to play a character differently from how they wrote them during application, and so they will entirely thwart your efforts by basically ignoring them. I can see where they are coming from, but it's not entirely fair. Characters should be allowed to grow and evolve depending on their circumstances. The unfixable character is one that never changes. Perhaps the character is depressed, and despite all therapy and medications, has not changed at all since the day they were apped. We don't expect them to totally 180 their character, obviously, but there should be a little wiggle room, and sometimes other players just won't allow that. This is incredibly frustrating as a psychiatrist player, and I think the best way to approach it can sometimes be to just sit down and have a chat with the player in a private IM or message. Let them know about your concerns, and discuss the evolution of their character, and how you find it frustrating that they won't allow the character to evolve realistically. If they still resist and it's problematic for you, you may contact a member of staff privately, to intervene on your behalf.

  • The Angsty-Sue: Also known as The Borkening. They seem to start out fine. Sure, they have psychiatric issues, but they were fairly standard either because they were apped that way, or they had to be altered after being pended on their application. But gosh darn it, they just keep running into situations that break them more and more somehow, until they're a gibbering pile of angsty goo and you can't do anything with them. Again, the best course may be to talk to the player and discuss ways in which you can get the character back on their feet together. As with all player problems, if you can't resolve it between the two of you and you find it a problem, let a staff member know. No-one enjoys just bashing their head against a wall repeatedly, and that's sometimes what it feels like when the player's got it in for their character.

  • The Worst of the Worst: Or The Histrionic. Their patient has the worst possible case of ______. So bad, in fact that no-one has ever been able to treat them, and their other psychiatrist for some reason just gave up. You stand no chance at fixing them, because they are the most severe ______ ever, and no-one knows how to handle them. Now... realistically speaking, since this is a real life (ish) site, this simply wouldn't be true. Psychiatrists are trained for worst case scenarios. They study the severe cases. You can go about tackling this in a few ways. Number one is using knowledge as power. Out-fox the fox, so to speak. Research their issue, and let your character use this to their advantage. Let them flaunt their knowledge of the issue in such a meticulous and well-read way that they look like they just wrote the Diagnostic and Statistical Manual themselves. Sometimes, this might intimidate the player into toning it down a bit, and giving you some actual ground to stand on. (This technique also counts for the Holier Than Thou player problem too.) Failing this, you can try to actually just treat them. Medicate if you have to, and let the player know in no uncertain terms that this medication has been proven to work. If they don't give you some wiggle room, refer to point one of this list. And again, if ti persists, contact them to talk, or speak to a staffer.

  • Holier Than Thou: This character knows everything there is to know about psychiatry. They know more than you. They look down on you and scoff at your effort because the player, out of character, knows that it doesn't really matter what you do in game, because they will do whatever they want to do with the character anyway. Perhaps they have a background in psychology or psychiatry and want to flaunt it a bit. This can easily become flustering, and sometimes even insulting. As with the worst of the worst, knowledge is power. No-one on this planet knows anything about psychiatry that you can't learn as well. Since the invention of the internet, all of the accumulated psychiatric knowledge is just a mouse click away. You should never have to feel intimidated, or be made to feel stupid. Out-fox them. Do some reading. Have retorts. Once they realise they can't maintain an air of superiority over the psychiatrist, they may give up. If it persists and it begins to bother you, or you feel in any way intimidated or insulted, contact a staff member. This is a game, you shouldn't be made to feel bad about anything. We're not psychiatrists, after all.


IN CLOSING...
_____________________________________

If you have any problems with anything while you are playing a psychiatrist, you can contact me at any time. Whether it's a question about therapy, a problem with a patient, a complaint about a player, don't hesitate. I have been in your shoes too. I once had to start somewhere, and I am by no means an expert on any of this stuff. I know how taxing it can sometimes be. But remember this above all, despite how much I've written here, and how doom and gloom it may sound, playing a psychiatrist IS actually a lot of fun, especially with the right people (all of you guys!) If at any point you don't feel like you're having fun any more, you're not obligated to keep playing. You should definitely contact me first, as we may be able to fix it, but don't feel chained, and don't feel like it's a chore. Have fun, and happy hunting, fellow Psychiatrist Players!



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