I got a quote for us today.
Oh, yeah? Go ahead.
The tendency to avoid problems and the emotional suffering inherent in them is the primary basis of all human mental illness.
Avoid avoidance. That's what I like to say.
And then I went on the Wikipedia for this guy, and apparently he had extramarital affairs and didn't talk to two of his children. Who is this? M. Scott Peck or something.
So he's not a professional of some sort. He's just some guy?
No, he's a psychiatrist.
Oh, he's a psychiatrist. Well, then that's just normal, isn't it?
Psychiatrists specialize in their defects. We're the best at seeing our own problems. It's not we're the best at seeing our own problems. It's almost like you specialize in your defensive areas.
Well, I think that to me, I see that more as Fairburn's concept about the exciting object. You get something that activates your almonds, so to speak, as a child. And that's what you want to specialize in. But it also means that you're not going to be able to turn it, you know, turn that high power focus back on yourself. I can't do accents. I'm trying to do Jodie Foster from, you know, science of labs.
So they can't treat themselves. You can't treat yourself. Yes, yes. Treat myself, physician.
I agree. There's an emotional salience to the problems that you have. And usually there's a huge blind spot. I made it sound like psychiatrists see the thing. I'm saying the opposite. Like we can't see the... our own problems.
Well, I don't think this has really... The discussion we just had, I'm not sure how it relates to our topic today, and I think that points to the fact that this is very early for me this morning, and I think you're between meetings. So I don't know how this one's going to go, but let's see what happens.
Well, we'll make it work. This one, in terms of what I want the focus to be, so last podcast we talked about intakes, and this one we asked for questions after the intakes and got a few things that we kind of want to touch on. And I think I want to group them all together by... This podcast can be about difficult situations that kind of come up in psychiatry.
Off air, I was giving you compliments. I think this is where you shine. You rejected the compliment.
Yeah, I'm rejected on air. I think this is false. Don't get me wrong. I haven't given presentations on this. But you've got to understand that anyone can give a presentation. You just apply for it. If you want to give a presentation with the APA, you've just got to pay the fee and do the work. They want the presentations. It's nothing special.
Humble, humble Dr. Fu. So in terms of how I want to structure this, I want to give a small... This is how I'm thinking about it. Feel free. I don't think we ever agree on anything. We'll do a small, super brief primer on what Alliance is, then give kind of an overall approach We were talking about something and the way you described it really resonated with me that you can apply it to different situations.
Then I want to do role plays that you're acting as a psychiatrist and I'm acting as the difficult situation. So I want to touch on, you know, patients who are saying, like, evaluate me for ADHD, patients who are in an involuntary situation, patients who are talkative or off topic, patients who are controlled substance shopping, disability paperwork. We'll see how much we get to. But those are the role plays I want to do.
Yeah. Well, I don't know if we'll go the way you plan it. And I'm sure we won't get through all of it, but let's give it a try.
So to start, I'm just going to define therapeutic alliance. So therapeutic alliance has two core components. The first one is purposeful collaboration. So as simple as agreeing on the tasks and goals of whatever endeavor that is that you're doing, whether you're doing therapy, management, just agreeing on the tasks and the goals. The second part is the affect bond. So just a mutual trust and respect. So those two core elements are what the therapeutic alliance is.
And I think an underlying theme in a lot of the, I expect the role plays is kind of going back to the therapeutic alliance.
Yes. And I would encourage people to really break this down. You know, you call it two core elements. You can break this down whenever you want. I think for the purposeful collaboration element, you really need to understand that tasks and goals are different elements that physician and patient can use. easily disagree on without knowing it at all. You can think you're working together and aren't together on either how to treat the problem or what the problem is.
And this is something that you really have to pay attention to.
Yeah. And that's why I think what you just said is why it's going to come up in all these difficult situations, because the core component is going to be trying to make sure that there is some agreement. I think a lot of providers have a tendency to let things go unsaid. And it mucks up the treatment. So, you know, we focus on psychiatric appointments, medication management. And so I want to, you know, I've heard you define it a few ways, but what do you feel like is the goal of psychiatric medication management?
Well, you know, it all stems from the medical model. It stems from the idea that we are really only experts in detecting pathology, illness. And so what we're trying to do is we're trying to identify what sets someone apart in some fashion that is a problem for their mental health, for their mental life, right? What is unusual? What is a malfunctioning in some sense compared to an average reasonable person?
And it doesn't mean that the person in front of you is unreasonable. The reason why we do this is because it's the only hope we have in short, non-psychoanalytic treatment to make things reasonably better in any sense. And so once we get that, that's what we're trying to do. We're trying to give medical advice. We're trying to give a treatment plan, treatment recommendations, changes that will actually help that problem.
Yeah, you know, the way I think about what you're kind of saying is a core component of the work I do is I'm trying to develop a diagnosis or at least a formulation if I can't get a specific diagnosis and get on the same page with the patient. And I think a lot of difficult situations arise when that isn't explicitly a part of the treatment in that the provider and the patient aren't working under the same operation, under the same formulation.
So there's miscommunications or misunderstandings as to what's going on.
Yeah. And, you know, to be honest, I don't think it's all that different in a therapy either. I think if you let your therapy meander and say that it's going to be this healing process alone, you're not going to get very far. Even in a therapy of any kind, I think formulating and sharing that formulation of the patient is absolutely key. And it's just that formulations tend to be quite a lot more complicated and not just problem focused compared to diagnosis.
Yeah, we have the benefit of in medication giving, you know, one or two labels in therapy. Often it's a much deeper formulation and understanding. Now, the overall approach, I'm going to make it too simple. And I think you'll, you know, think it's more complex than this. But I heard you, we were talking about challenging a delusional patient's, you know, core approach. very strongly valued, overvalued idea. And I really, really like how you put it in that for the patient, it generally avoid challenging overvalued ideas head on.
And I think that applies to patients, you know, understanding of themselves, if they have delusions, it applies to a broad range of topics. Then you clarify your role in the treatment and you look for common ground. You look for problems that both you and the patient can agree on and then you review the recommended solutions together and you actively elicit the patient's feelings and opinions. So, you're trying to find common ground and trying to find something that you both agree that you guys could work on.
So it's really that part of the alliance of goals and treatment.
Yeah, you know, it's kind of like you can't apply a set of roles to every situation, but that is basically more or less true of every difficult interview or encounter in psychiatry that this is the core, that you want to find something you can work on together. And in order to do that, you have to agree that something exists. So you really have to get a good sense of the patient's values, what is important to them, what they are bringing.
can be unlikely to let go of and try to at least work alongside it if you can't work on that together.
Yeah. And for some reason, you know, just having this very basic framework, I think just applies to so many situations and helps me understand kind of the problem that's occurring in, you know, like a lot of times I've felt completely helpless, you know, when it comes to like, you know, the patients who think they have ADHD and want a stimulant and, you know, I'm not quite sure what's going on.
And understanding this approach really helps me to think through what the actual problem is and not feel like a helpless, like, Oh, you know, because when you do feel helpless, I start saying like, oh, society is like this. And, you know, kids need to blah, blah, blah, blah. And there's an overreliance of medications. And really, the problem is that I don't know how to think through it.
And by having this framework, you know, I stopped projecting my ideas of all the problems of the world and work with the patient in a way that works for both of us.
It doesn't always go so nicely. It's not like I'm having a great time if these kinds of situations are having a lot of success, by the way. Don't imagine that. You're going to make mistakes. There's going to be ruptures in the relationship, and then you'll have to repair it or the patient will leave and find somebody else. That's just life.
So, yeah, let's jump right to it. For the first one, I'm talking about... patient who comes in and says, you know, evaluate me for ADHD. And they have a very strongly held belief that ADHD is their core problem. You know, let's kind of think of a specific patient. So a patient who you don't see a developmental pattern consistent with ADHD. You see a lot of externalizing personality traits, but it's not like there's some clearly identifiable, like this is clearly a borderline personality disorder or something.
You know, there's, there's, maladaptive personality things going on, but there's not a clear bucket that they fit into. And this patient strongly believes, attributes all their problems to ADHD and is seeking treatment for ADHD and stimulants more specifically. Yeah.
Yeah, I think we should emphasize in this scenario, we are using the example of a patient who clearly does not have evidence for having ADHD. We're not talking about patients who present similarly but do have evidence for ADHD. There are both of them in the clinical population.
So, yeah, walk me through... How do you think about this? What is it that you're trying to get across to the patient? How do you navigate it? And then let's do a role play on that patient.
Yeah, I think I'm a little bit lucky. I see this a lot. However, my... Patient population, I think, is maybe a little nicer than people who are accustomed to or have to treat higher SES patients. My patients are coming in for help most of the time, and it's really more of a psych of education issue most of the time, not all the time. The more that somebody is coming in with a very specific outcome that they're looking for, which a lot of people feel either for real reasons that they need a stimulant or know that even if it's not medical treatment the stimulant will help them perform well in their career that's going to be a little harder to actually get to some ground common ground with so that's just a caveat i want to put it forward but i would say that lots of patients who come in and they have some clear idea of what their problem is already yet that clear idea does not actually correspond to medical evidence Patients like that, they just want the problem to be better fundamentally.
And if you can orient towards that, regardless of what you're going to call it, even if you and the patient end up calling it two different things, that does make things difficult. You're going to get further than if you just kind of sit there and say, well, you know, I'm the doctor and you're wrong, which you may be right, but you're not going to have in lines.
Yeah, and you touched on a huge thing. As a provider, you can't resent certain types of patients because you'll actually manifest the difficult situation, not the patient. Because as you say, I've had so many patients come in for requesting ADHD. eval. I calmly explain to them, you know, I kind of evaluate life history and I don't do specific ADHD. And we walk through it and then, you know, I see like an underlying depression rather than ADHD.
And I explain to them that I see the problem and they're totally on board. Like you said, they just want to feel better. There's not this like vicious, you know, like societal, you know, all kids or blah, blah, blah, blah, blah. They just want quick fixes. All they know is that they're not able to do the things they are normally able to do and they want to feel better.
Um, yeah. So if you have developed resentments towards, you know, specific patients that, you know, this is kind of like, it's really helpful to kind of process and understand it because the patients will pick up on those resentments and it'll hurt treatment.
Yeah, said in the other way, if you don't want to resent the patient in front of you, you are going to have to feel the resentment about the type or the experience that you've been having outside of those sessions. You're going to have to talk about and feel those feelings, communicate them, and work them out in some way. That way, you can set them aside, good old mature defense suppression, for the purposes of evaluation and really try to orient in this is the person and they're communicating something and i'm here to understand the underlying meaning and to turn it into something more intelligible or differently intelligible for the purposes of medical treatment now the patient that
i want to focus on here though is the patient that is not open to hearing alternatives and is relatively fixed in their belief that it's just this and not anything else. And so, you know, for some patients, you know, practicing good psychiatric management where you hold the borderline personality disorder diagnosis and explain those things and, you know, you... kind of keep the treatment focused on that is helpful.
But I struggle with those patients where there's not some clearly identifiable label that I can use. You know, like we talk a lot about like, you know, assessing for personality pathology, but how do you go about it when it's not a clear, you know, it's not a clear diagnosis. It's not like I can say, I think this is borderline personality disorder or this is narcissistic personality disorder.
When it doesn't fit into a clear bucket, how do you go about explaining to a patient who's very rigid in their belief that it's something like ADHD?
Well, I suppose I don't try to explain that it's not something exactly. In that situation, which in my opinion is actually kind of rare, at least for me, I think you're going to run into it a lot more than I do. I basically explain what diagnosis is for. Diagnosis is really for us to guide specific treatments under medical evidence. And I don't have a diagnosis for you at this time.
I agree that you're experiencing all these different things, but it's not clearly being caused by identifiable medical condition. Based on that, I would recommend XYZ instead.
Well, let's, let's give it a shot. Um, let's, let's just jump into the role play. Um, so, um, yeah, I'll, the patient, you're at the stage now where you're given the formulation and recommendation and it doesn't include stimulants. So, um, I'll just jump this off on the patient. So, so, you know, is it possible that I can kind of just get that Adderall scripts for this next month?
You know, unfortunately, I wish I could just get you whatever medication you'd like. However, I'm not really getting enough so far to say that you do have ADHD. Now, I've been hearing all throughout this that you're having some problems at work, you know, you're having problems paying attention, but I'm just not so convinced that that's simply a problem with a longstanding neurodevelopmental process. You know, this is something that I think has more to do with other factors in your life.
It might be the job that you're at, It might be your mood, your anxiety, or your coping skills. But unfortunately, I'm not going to give any medications to anybody that are not clearly medically indicated. I don't want to give anyone anything inappropriate. And I think the best thing to do is if we can keep working together so I can get a clearer idea of what's going on with you and I can make sure that the treatments we give you are safe and effective.
I guess that doesn't really make sense to me. I clearly have ADHD. I'm not able to focus. I wasn't able to focus in school. I could have done so much better in school. I'm not able to focus at work. My relationships, I have the rejection sensitivity that comes with ADHD. And I literally fit every single question. Me and my therapist went through the checklist. I am ADHD.
Yeah.
Yeah. In reality, diagnosis and medical conditions are really complicated. And you can't conclude something just based off of a checklist. You can get a little bit of television that way. And I don't know if we're going to come to agreement on that today, but I'd love to keep working with you if you're willing to find out more.
What else could it be? To see if there's any other choices. There's 20 checklist questions and every single one. How is it not... Do you have training in this?
Yes, I have a lot of training. I have a lot of experience in this. I don't know if that's really going to help, though, because it does sound like you're pretty sure that it is ADHD.
I've done a thorough... I've done every single checklist. Literally, whenever anyone describes ADHD, there's no other explanation.
Yeah. Can you explain to me why you think I don't have it? Yes, I can hear that you're very... I can hear that you're very convinced about this. And the fact is that not everybody, and in fact, many, many people who get those checklists, who have all the situations that you've talked about, not all those people and many of those people don't have what's called ADHD. And what is it?
We are in a situation now where we have a lot of people get diagnosed with this. You know, but stimulants are not something that it's not just a very safe medication that anyone can take. And I know you can go to another psychiatrist whenever you want, but I'd like to try to find out what this is instead. And that's going to take some time because we're going to find out things that are accurate about you.
that are real, that isn't going to take time.
Well, I've taken, you know, in college I took stimulus and it was literally a lifesaver. Like, I'm a different person who can finally function. And you say you want to find out what it is. What are the possibilities?
Well, there's a broad range of things. This could be that it's a matter of your situation. It could be what you're doing in your life on top of the situation, how you respond to the stress in your life. It could be a matter of also something to do with anxiety or mood. There could be a number of things, even down to the way that your sleep is going, your sleep and wake cycle.
I'm just saying that for today, I'm not able to come to a conclusion just yet. And I'll tell you something else, you know, after we do a few more visits, if I start to see that the best explanation is ADHD, we can go in that direction. But it's not, it's just simply not something that we can do.
I literally cannot function without medications. Like these things are life-saving and doctors like you are just, it's like you're scared to prescribe these medications that are going to literally save my life.
I am scared. I've seen all the bad things that can happen. What are the bad things? I can see that people can really not go anywhere in their lives because they're using what's essentially a drug. And these are drugs as well. That's the danger of them. One of the big dangers of them. So, again, I can't stop you from finding someone who will simply say, yes, you have ADHD and give you a stimulant.
And I'm sorry if it feels like you've wasted your time today. But I don't think you're wasting your time if you stay in treatment with me. And I'd like to keep working on this together. But this is the time we have. And I see you back in about four weeks. Awesome. That was fun. I don't think most people will be very happy about that. And also, I suppose the problem, the weakness with this is I'm probably more willing to call personality, even on the first visit.
I don't call it personality disorder, but I'll point specifically to elements that I've elicited. in the first contact and that interview as to what I think are possibly causing it. And that's kind of a different topic than how you're going to interpersonally handle this because that's really about the differential diagnosis of inattention. And, you know, we've talked about that before. But substances, sleep-wake cycle, mood disorders, anxiety disorders, trauma disorders...
personality traits and disorders. And of course, saifu social stress are all possible contributors to a parent and attention. So yeah, I try, I try to be more specific in reality.
I'm so curious. I really want you to answer this. Give me an example of how you talk about, you know, personality traits without, because to me, I find it very easy if I can, you know, put it in a bucket and explain that thing to them, like, you know, borderline personality disorder. How do you do it if you pick up particular traits? Give me an example script of a patient with ADHD that you might have this conversation.
We don't want to be all that specific, but I will say things like, you know, we learn a lot from the way we grow up. And the way we grow up tells us how to respond to situations and stress. Or on the other hand, you might say, You know, a lot of people throughout their development were supposed to be learning certain habits and skills. And I don't think through all the things that you've been through, you had the opportunity to do that.
So rather than just throwing a medication at you, I think what's important is we work on getting you those skills and habits that you weren't able to have. I like that a lot. Yeah, that's if there's no diagnosis. If there's a diagnosis, I'm going to the whole spiel about how, you know, personality is not about you being a jerk. Basically, it's what you've learned and who you are based on how you've been raised and the things that you've been through.
And if it's causing you some problems, we have an opportunity here to change that.
Um, why don't we move to our next one? Um, why don't we do a similar one that, you know, patient who wants a particular controlled substance, um, with a confirmed history of being treated with that thing. So I, I think I want to talk about a patient who let's say they're on Xanax three milligrams, um, and they're coming in for a how to walk through and think through.
You know, I think we should say at the outset that this is probably the number one cause of me being fired as a psychiatrist for new patients. So, you know, maybe I'm not the one. But, you know, just between you and I, from a liability standpoint, it may be better for you to be fired by some of these patients. And not all of them fire me. Some of them will sign on board and we'll get them a healthier regimen.
But let's hear it. Let's go.
Well, yeah. So let's say the patient is coming in on. Should we just jump into the role play or do you want to talk about it first?
I think, yeah, let's talk a little bit.
So, yeah, patient comes in and says, you know, Xanax three milligrams is the only thing that's ever worked for my anxiety. I'm actually running out tomorrow.
Okay. So for this situation, I actually recommend that clinicians first worry about their own license. Sorry. You should work. Edit, edit, edit. Okay. I think you got to worry about your own license first for this one. You should not, even under the urgency of apparent medical withdrawal, agree to be the stopover in a series of doctors that a patient is going to for urgent benzodiazepine prescriptions. Okay.
If you cannot confirm after conducting a appropriate medical evaluation that the controlled substance is medically necessary, that patient needs to go to a detox. And yes, the DEA does send fake patients to you. Okay, not to you specifically, but to clinicians to present in this exact scenario so they can build an evidence base to pull your license. Okay, I am seeing these cases. So please worry about your own license first.
First, determine whether there is a medical emergency or urgency. Yes, benzodiazepine and alcohol withdrawal is medically dangerous, right? People can, you know, delirium, they can have life-threatening seizures as a result of withdrawal. And so you need to give medical advice to these patients that even if you can't give the medication, they need to go essentially to detox or to emergency room for medically observed withdrawal process. Okay.
Once you've given that warning, then I'll talk to them basically about the rules. First of all, I will want to confirm in some fashion that they have been getting the controlled substance on my state record. I think every state now has a record of controlled substance prescriptions that you can look at. Now, it's not a perfect record, by the way. I've run to situations where pharmacies are not reporting it correctly for some reason.
So that's one thing. And then sometimes you run to the situation where a patient is genuinely seeking some help with you and you're trying to do a benzodiazepine taper based on street benzodiazepines. But fundamentally, what I need to do is I need to tell the patient, You need to commit today to treatment with me and we need to commit to a with a tapering plan, basically a withdrawal plan that is medically safe.
And we're going to agree at the outset here that if we deviate from this for any reason, you will have to go to a detox. Otherwise, we won't be able to work together.
So, yeah, I guess the part I'm struggling with is you mentioned, like, if it's medically necessary. And we know that there is medical necessity for benzo withdrawal. So, I guess, when do you willingly write the script that's a taper plan? And when do you tell them to go to an outpatient detox? Like, what if a patient says, like, I can't go to an outpatient.
So, when I say medically necessary, what I mean is that you've done a... at least minimally adequate psychiatric evaluation to reach a diagnosis and that there's a medical indication to prescribe that benzodiazepine for that diagnosis in the long term. You're not urging period. You're outpatient. We're talking about outpatient or a single encounter. And then if it depends on the plan, it depends on what is the plan for this patient.
Is this a patient with bipolar disorder, history of catatonia? I'm continually dependent. We don't even have to have this talk. Okay. Is this a patient that essentially has some kind of iatrogenic benzodiazepine dependence. Then we're going to talk about the plan to see how we can reduce or stop the dosage over a period of time that's equivalent to the total time that they've been on the benzodiazepine or two years if they've been longer than two years.
That's my general rule. It's not evidence-based. And then is this a patient that I believe is essentially seeking medications in a knowing way then uh well i'm not going to give you the benzodiazepine and if you are taking benzodiazepines i want to start giving advice about again detox and substance use disorder treatment so i don't know if that answers yeah let's let's have this
scenario so let's i guess let's play out a scenario okay all right do you want to give a shot Sure. All right. So, yeah, I've been on the Xanax, the Xanax four milligrams for the last four years. It's really the only thing that works. And my family member just died. So I do need to like I'm going to the funeral tomorrow. So something like detox really just is not an option.
You know, can we kind of just prescribe the Xanax for the next month?
Well, I don't think I can do a month. You know, as we discussed earlier, I'm not going to give any medications that are not medically necessary and also a safe thing for you in the long run. What do you mean medically necessary? My opinion is that if you'd let me finish, I'm sorry, if you'd let me finish, my opinion is that we can't be giving you this long term.
If you really have a funeral that you have to get to, if you really can't handle it today, let's pick a date together in the next few weeks where we can get you to a medical detox center. And I'm going to give enough medication to last until then. But if we don't have you in that detox center by then, unfortunately, I'll be able to give you this medication.
Because I want to get a plan together with you about what we're going to do about this. And I'm telling you, this is not a good medication for you, Longman.
So I guess I'm confused. You say it's medically not necessary and I'll die if I don't take it. And it's the only thing that works for my anxiety. So it's literally the most medical necessary thing I could think of.
Well, he'll die because you don't take it. You can see how that's bad for you. I don't think that's a good treatment plan. And I don't think that it's actually treating your underlying problem. I'm going to die because of the benzo withdrawal. The benzodiazepine withdrawal is a short term thing. That's exactly the problem that we're trying to address here.
So I need it for my anxiety.
I simply don't agree with that. I don't think it's a good treat.
Okay, so it's the only thing that's ever worked. I've been on 30 medications and the Xanax is the only medication that worked out. You met me for 30 minutes. How do you disagree with it?
It's my opinion. You know, other doctors will have other opinions and I'm sorry to disappoint. I can't do anything that I don't believe in for you. You don't believe in it? I've given you the options and I hope you take them.
Well, so what are the options? You're willing to write me a script for a short period?
Only if we decide today and we agree together on what we're going to do about this in the long run. And if you want, we can try to taper you off over the next few months. I'll give you other medications. I'm going to treat you for the underlying condition. We're going to work on that both with medications and with other ways of managing anxiety. And then hopefully we'll be able to reduce it or get it down or change it in some way that's a little healthier.
Or we can get you to a detox facility in the next couple of weeks.
I'm on board. I'm on board for that, whatever. But I have to go to a funeral tomorrow. I can't be messing things around. So I guess let's walk. What is the plan going to be? I need this in the short term. So I guess can you prescribe it to me for a week? And then... Yeah. Would a week work?
I need you to agree. I need to agree about when you're going to, which of these paths you're going to take and when we're going to do it.
Sure. So if you can prescribe for a week, then I'll do the detox after a week.
One week. Okay, well, just keep in mind because we all have access to this controlled substance record. And so if I see this happening and you don't come back, then I'm going to know that you're not really agreeing with me about how we're supposed to treat this. And you're just trying to get about seven days out of me. And I know this can make you very angry, but I'm telling you, I'm doing this because I really want you to be better in the long run.
And I will be sending a message to whoever the next doctors are. If I notice that you're not coming back and you're just going around from doctor to doctor, it's no way to live. So please think about what we talked about today. It's going to be seven days. And we have a plan here that you're going to detox facility. And I'm giving you the information. But I do hope that you follow.
How long is this detox? How long does it take? It depends. Depends on the person. You know, you've been on this for a few months. I think that you might be able to get, you know, after a week or two. I have work. I have work. There's no way. They'll be able to sign disability paperwork for you.
Okay, so you'll sign disability. And I really, I just don't think I can get off of work for this. In the long run, we have to take time to get there. I'm a lawyer. There's like, this isn't the kind of thing where you just, I can just take a week off. I'm not like you.
Well, I can't take a week off either, but if I had a medical necessary condition, I would do it.
Oh, boy. All right. Well, for the interest of time, let's keep going. It doesn't really go this way, usually.
Usually, it devolves into yelling and firing. way before that, you know, and it's what you do. And then you just essentially don't prescribe it. Don't prescribe it, folks. If there's not good faith discussion and work on a treatment plan, Don't risk going.
All right, next one.
Refer and give instructions.
Disability paperwork. So a patient who is requesting disability and you don't quite think it's warranted. Maybe they do have a history of depression, but... you know, it's not severe enough that they shouldn't be working. How do you sort of think through whether a patient deserves, I mean, even the word deserves is crazy, whether to provide disability?
That's interesting. Some countertransference poke through there, deserve. Yeah, that was a problem. You know, I've noticed that different people are extremely different when it comes to disability. And that's a little bit of a problem. I think you just got to follow the rules. Okay. If you look at each particular kind of disability, there is going to be some kind of a rule set for how you determine whether someone is medically disabled.
Sometimes it's extremely vague. It just says... can't do the same work as before to the same level. And then when it's that vague, yeah, you just kind of have to make a judgment call on your end. But I would first be aware of the rules of whatever specific disability that you're signing for. Sometimes, for my area, it can be Not able to do a welfare to work program for 28 hours a week.
It can be cannot sit on a jury. It can be never can be employed in the whole economy ever. OK, disability means a lot of different things. So you need to figure out what kind of disability it is first, and only then can you read the rules, and then you can apply it to the specific patient. On top of that, you should make some clinical judgment. What clinical judgment are we making?
Everything that we're doing is supposed to be, in theory, for the good of the patient. So you need to ask yourself, by giving this disability uh for whatever duration is this going to be for the long-term good of the patient or not and to know that you got to know the patient's current values and what they might be interested in the long run you know even if someone is going to medically qualify for let's say three months off uh from some demanding job Is that going to keep that patient employable in the future?
Or is this employer going to probably do some shady stuff to get the patient fired? And, you know, the patient will either have to find a different job that maybe they don't like or is off their career or have to wrap themselves in a lawsuit for years and years. You know, you got to I think. When we give disability paperwork, you should also advise the patient in the same way that you do with medications about the risks to the benefits.
That's what I'm thinking. So clinical consideration and legal considerations, you got to consider both.
How do you do the assessment of whether the depression is so bad they shouldn't be working?
I think that's an entirely different episode. But what you have to ask, generally speaking, is based on what I've heard and what I can see, do I have enough medical evidence to say that they are impaired to X degree and that this impairment requires time off in order to bring them back to health? That's basically the question. This is for temporary disability.
How do you talk, let's say you feel like it does,
you know,
the patient does meet, you know, that criteria. How do you talk about what they should be doing during that time off?
It's very similar to the Benzo thing. I say, look, I'm hearing that you don't think you can work at all because of these panic attacks. Now, I'm also hearing that you want to be working along and that you just kind of feel like you can't do it right now. And I'm sympathetic to that, right? It's very hard to have these panic attacks. Nonetheless, I don't think simply being off of work will actually help you with your problem.
You'll certainly have less panic attacks for a little while. But what we want to really do together here, what I'm hoping to do with you is that you can be going to work or to be in stressful situations without basically getting disabled the same way that you are right now. So let's kind of plan together. How are we going to use the time that we're going to have you off at work to get you better, to make sure that this kind of problem doesn't happen again for you?
And then you discuss your treatment plan. For depression, you know, it might be if they have the resources of partial hospitalization, intensive outpatient. Otherwise, it would be talk therapy, you know, medication management, workbooks, just a whole range of treatments that we have available. Right. If someone is so symptomatic that they become substantially impaired from their baseline, that does imply that there is a significant problem and that they need more intensive treatment.
So to me, those things do go hand to hand.
You know, I totally agree. I think I see a lot of patients be put on disability with like, you know, a therapist or a psychiatrist will put them on and then not have any sort of additional treatment that they're providing. And that's, you know, just intuitively, that's wild. It's like something about their current treatment is leading them to be this level of depressed. There needs to be a bigger focus on treatment or a different type of treatment.
So I always emphasize, you know, like... What are we going to be changing that's going to make things different so that we can use this time to get you back to work? I think a really helpful thing to understand is that work is a really stabilizing force in people's life.
It can be stabilizing or destabilizing. Everyone thinks it's destabilizing, but it is stabilizing.
Yeah. And like, you know, you mentioned the risks of not working and a lot of people aren't privy to it in that structure is a really helpful thing in and having purpose. So, you know, a lot of people, when they think of work, they think it's like, you know, they have a boss they don't like and the grind of having to wake up. But there's also a lot of purpose to be found in work.
So someone not working, like you really need to think through these risks of like having, removing all structure for someone's life is a,
potentially dangerous thing you know focusing on depression it's going to sound strange but unless we are in the realm of no even in the realm of psychotic depression really part of the treatment is getting the patient as much as possible to behave like the person who is not depressed That sounds crazy, right? It sounds crazy that that's the treatment plan because you're pretty much, most people feel unable to do that.
But when I'm talking about the small steps, right, if your depression is essentially biologically causing you to ruminate at night, fall asleep really late, and then wake up too early and then just stay in bed all day, that's part of the illness, right? Yet, if you don't make efforts, even small efforts, to use a combination of medication behaviors to get more activities during the day and sunlight, sleep better at night, start doing some of the things that you used to do, even if you don't enjoy them, you're not going to have as quick of a recovery.
You know, you have to essentially act like a non-depressed person, even if it feels bad, even if you don't enjoy it, to the extent that you can handle it, on top of the medications to really speed the recovery from a depressive episode.
And these are kind of the core principles of behavioral activation or, said in a quote, fake it till you make it. All right, why don't we move on to... involuntary situations. That was one that people asked about in regards to our intake episode. Patients developing or thinking through the alliance in a patient who doesn't want treatment or how to collect information from a patient who is oppositional or doesn't want to be talking to you or just wants to get the heck out of the hospital.
Okay, I think you had formulated kind of a more personality type of involuntary and oppositional. We can talk about that, but I just want to note that there is a basically psychotic variety of involuntary and oppositional, and there's also a mixed variety, and they can handle it a little differently. But we'll start with the plan vignette, I think. It's inpatient. It's admission. Patients brought in by police after some kind of a suicide attempt or behavior.
And also has text messages that describe suicidal intent and the patient is demanding discharge. I wasn't suicidal. Everyone overreacted. Right.
Mm hmm. So how do you set the frame? And, you know, let's say you're coming up to talk to the person in their room after they were just
admitted on a Friday. I mean, I'm not going to start right from the beginning. I think I'll start in the middle. And I'm going to assume that they're saying, I don't want to talk to you. This is pointless. Something like that, which is pretty typical and understandable. And I'll say, hey, you know, I can see that you don't really want to talk to me right now. But this is an important part to getting you out of here.
I can see you don't want to be here. And frankly, I don't want to keep anybody here who doesn't need to be here and isn't really benefiting from being here. Unfortunately, it's just not so easy for me to snap my fingers and get you out of here. Essentially, if I did that, I wouldn't be practicing medicine tomorrow. And there's a lot of laws around this kind of thing, even though they're not written in stone.
So my responsibility here is to really do a thorough assessment of you and what happened. and to figure out whether it's safe for you to leave and there's really no way for me to do that unless we can talk to each other about what happened and i can figure out more about you as a person the alternative is you don't talk to me and we're just gonna have to observe you for longer it's really going to keep you here longer and that doesn't sound like anything that either of us wants what do you say can we talk a little
I'll just jump into the role play. Well, if you can't be the one to discharge me, I need to be able to talk to the person who can.
This is what I'm saying. I will be the one to discharge you if we find out that it's medically appropriate.
Well, I need to be like, it's the weekend. I was told that I'm not going to be able to talk to someone until Monday on the weekends. There's just no, I'm not here through the weekend. Like I, this weekend I was supposed to make plans with my kid. Like this is the most important. I need this weekend.
Unfortunately, I think you're in the situation that we're in it together. And I hate to break it to you. I don't think it's very likely that you'll be leaving this weekend at all. And best case scenario, maybe you'll be out the door tomorrow night if everything is going well. And that's not a promise. That's a minimum amount of time that we're going to need to observe you.
If if I'm not discharged tonight, then I actually will be suicidal.
Well, if that's true, I'm just going to have to post up somebody to watch you all the time. And that's really going to be prolonging how long you're going to be here. I don't think it's helping you out.
Being here is the reason that I'm having trouble with my mental health. Like being here is the problem. You can't keep me here when it is the problem. I need like, I'm telling you right now, I'm home tomorrow morning.
I get that. I don't want you here if you don't want to be here, but the rules are the rules. There are laws. There are things that I have to do. I got to do my job and I wish I could do it. But if we don't talk, if we don't get some more information on you, we can't let you go.
What are the rules and laws?
I got to do a medical assessment. We got to observe you. We got to make sure you're safe.
Okay. So if I tell you all those things that I'll be discharged tomorrow.
Well, if you participate with the interview correctly, yeah. If you talk to me and we find out what's going on. I don't know if you'll be discharged tomorrow, but it's definitely going to speed things up. You just said I would be discharged tomorrow. Well, I didn't say that, but I'll say it again. It's not a guarantee, but the minimum, the minimum that I'm seeing for your case right now is tomorrow night.
That's the minimum.
So, yeah, I guess jumping out of the role play. What do you think are the main principles that you kind of stick to when you're in those conversations?
So, you know, you have an involuntary oppositional patient. You really have to stick with the truth, I think. And, you know, the fact is we can't just discharge people. Okay. Even if we want to. Sometimes we even feel like we should. And I feel like this is something that a lot of residents struggle with. But you are obligated to act under a professional standard, a responsible standard, a standard under the law, essentially.
Otherwise, you will no longer be practicing and bad things will happen across cases. There are patients who will genuinely believe that And it will be true at the time of the interview that they are not dangerous in some fashion. And then they will go kill themselves or hurt somebody else within 24 hours of release. This happens. And it's impossible for you to tell at the outset. And there's no real point arguing about it with a patient who is in an agitated state.
So all we're going to try to do is convince them to try to tell themselves if they're capable and talk. Engage in the medical process. If you're not able to, then you do have to go to collab. With a sufficiently involuntary oppositional patient, you can only make your observations based on that interview. It generally does prolong the time that they have to be involuntarily detained, and you'll just have to call people, look at records, or simply keep them on the unit and observe what they're doing.
Yeah, this is a messy, difficult situation that we could probably spend a full episode on, but in the sake of time. I do want to talk about, as you said, there's a big difference between this type of patient and the psychotic patient.
Yeah, in terms of the underlying process. And for the psychotic patient, I think it's kind of useful to triangulate a little bit. I think it was Harry Stack Sullivan who wrote about interviewing conversing with the psychotic patient. Rather than looking directly at the patient, imagine that you two are two people looking at a third party. You should try to arrange the dynamic of the encounter instead of two people looking at each other as to two people looking at a third party.
That kind of triangulation can help a little bit with the paranoia And the fear that is inherent to the biological situation of psychosis in many cases. And so that helps you. So in that case, I will try to refer more to basically society's demands, the law itself. um the regulations and i will emphasize that i am not a free actor under that system i cannot just say hey you're discharged okay uh i am under the rules as well we're both under the rules and we're gonna have to operate within them and here are
the options can you expand a little bit more as to what you mean is that the two parties looking outward
Well, there's a general thing I like to think of. An interesting thing about psychiatry compared to other branches of medicine is that in most medicine, other than pediatrics, the patient is also the agent of the treatment. The patient brings themselves and wants the treatment. Right. But in psychiatry, in voluntary psychiatry and also in pediatrics, the patient is not always the agent of the treatment. Sometimes the agent of the treatment is a family member, society at large, the law, anything.
Right. And so you need to know what's keeping the patient in treatment. Is it the patient's own volition? Is it the patient's wishes plus the wishes of another person or is it entirely the wishes of another person, society or the law? You got to have that squared away because that's part of the kind of understanding the patient's motivations and values when you can really have a good idea that this patient doesn't really believe in or want treatment.
But we're all forced to kind of act within the system to give the treatment for whatever reason. So that's a dangerousness and voluntary folds, incompetency at stand trial, you know, people on conservatorships or minors, right? These are all situations where the agent of the treatment is separate from and distinct from the patient themselves.
So when you say two people looking out, can you give me like an example of like sentences that kind of capture that?
No. Why? Because this is literally nonverbal sometimes. This can be not facing the patient head on and staring at the patient. This can be turning your body slightly to the side so that you and the patient are both facing out some imaginary object or person. This is kind of making a reference to and talking about outside forces that are stressors or forces of intervention in the patient's life with the patient rather than aligning yourself with them.
Like, oh, me and your mom really want to make sure that you're doing well and healthy in school, right? That's not what I'm going to say. I'm going to do something more like... You know, it really seems like your mom's concerned about you and it doesn't seem like you feel so much about that. What do you think we can do about it? You know, something like that.
It's not explicit. And I think it's more about the attitude that you bring into the encounter than any specific thing you can say.
Maybe to capture, to repeat what you said, you mentioned there's different agents in treatment. Let's say there's a person who's psychotic and the family member. Here, the family member is a major agent in treatment. You're aligning yourself with the patient. Even though the other agents are clearly influencing treatment, you're not disregarding them, but you're focusing on the bond with the patient and aligning yourself with the patient and thinking with the patient rather than pushing your view on it.
Your mom says you're psychotic. I know you're psychotic. You're focusing on the bond while also aligning with the treatment goals of what you think is the best for the patient.
Yeah. I mean, this even applies to incompetency treatment. You know, if you're on the team that's restoring people to competency, feel free to refer to the courts or to the incompetency rules. Right. Hey, you know, I know you don't really believe in this medication or, you know, you're not really interested in this stuff, but we're not going to be able to get you off of the status unless we work together and get you a set of medications and you learn these facts.
All right, so why don't we try to do one more and then kind of wrap it up? For the last one, I was thinking, I don't know if you, there's a famous paper called The Hateful Patient. Ironically, in residency, the attending that made us read it, I thought was a relatively hateful attending, but... He saw all patients as a hateful patients, but that's a story for another day.
But he classifies there's four different kind of phenotypes of difficult patients. And one of them is, we can kind of talk about other ones later, but the one I want to talk about here is the help-seeking, help-rejecting patient. So, the patient who is dependent and needs you to help, and then anything you kind of throw out there is just rejected. Yeah.
Well, it's interesting. These are two different kinds of patients. You could categorize help seeking, help rejecting under the hateful type. But I do think that help seeking, help rejection, it's not quite the same as the kind of aggressive denigrating type patient.
So, yeah, I guess talk to me about the patient you're thinking of here.
Yeah. You know, seeking help projecting can be pretty subtle. Both the patient and the physician may be completely unaware that this happened. But the most common version that you're going to see in a med management scenario is that you keep giving solutions and the patient either doesn't follow through with them after agreeing to them or has outsized or very unusual negative reactions to the treatment plans in a way that is just repeated and different than your average patient.
Don't get me wrong, some people are more sensitive to medications, but I'm telling you, it is a little different than this kind of patient.
So what do you think is going on? And what do you think is kind of being ignored by patient and provider?
It's not being ignored. It's just extremely subtle and hard to notice. I think probably what is happening is that there is a pattern for patients like this to want to ask questions in a manner so that ultimately the person in authority is undermined. It's like a repetition of that kind of dynamic. And I don't think the patient's aware of it at all. And I think it's rooted in both their personality tendencies and probably how they interacted with an important caregiver or parent in development.
Okay. People are not going to like this. This is classically referred to as a hysteric. Okay. The person who basically brings mysteries or questions or problems, puzzles to somebody who is an authority. and ultimately displaces them or humiliates them as an authority or as a provider of help by making that solution not work. Again, fully unconscious, automatic pattern. No one's deciding and purposefully doing this. I mean, if someone is and haven't encountered that, that would probably be categorized under an entirely different configuration of personality.
Why am I emphasizing this formulation of the patient? Because I think that you need to break out of that cycle as the clinician. You're naturally put in the place of the authority or the expert by patients as a matter of your role in society and your expert knowledge. If you find that by giving a bunch of solutions, you're getting nowhere with a patient, I think the time is to reverse the dynamic in a sense.
You need to start becoming the receiver rather than the giver. What are you receiving? You are receiving both information, and the patient's ideas about what will or will not help instead of being the explainer become the listener stop offering anything at all in fact i will advise people don't even prescribe a medication to patients like this obviously unless there's clear medical evidence for it that's different okay talking about where it's not so clear that medication will be helpful don't give a medication unless the patient is almost begging for it absolutely certain that it's what they want and what they need Why?
Because I think there's a lot of unconscious mixed feelings about the treatment plans that this particular kind of patient is not able to access and communicate to you. So by just pressing on and trying to give instead of receive, it's going to be a problem.
So how do you flip things?
Well, instead of saying, hi, this is today's medication visit, I'm going to ask about XYZ, and then I'm going to recommend XYZ, which is the typical way things go, right? You become more passive. You say, okay, what do you think is important to talk about with me today? How can I help you? Tell me more, tell me more, tell me more. Well, what do you suppose should be done about that?
Well, is there anything else that can be done about that? Is there anything else that can be done about that? You really don't get much information in this scenario.
Now, do you make explicit what you think is going on?
No. It's not a psychoanalysis. Even in a psychoanalysis, if you do an interpretation about this kind of thing, you'll probably do it 100 times before it's even marginally accepted. This is more about understanding that your way of interacting, the typical way of interacting, is not working and you need to change the way communications and information are being exchanged.
All right, let's do a quick role play and then call it. So you ask your question when I come in. Doc, I'm still depressed. Like nothing's changed. I feel awful. Awful.
It's a terrible thing to be feeling that way. You know, we've tried a few things so far. I don't think they've worked very well. Where do you see yourself as these days? Where do you think you want to take the treatment?
I'm excited to hear about what medication you think we should try next.
Well, I don't really have any ideas at this point. You know, I'm not sure the medication will work for you. It might. We could try another thing again. But, you know, I'm not confident that it'll work. The last few haven't worked either. What do you feel like doing? Do you feel like one thing is going to be more or less useful for you than the other for the treatment of your depression?
Yeah, that's what I'm curious what you think. If medications aren't what to do, like what, you know, what do you recommend?
You know, I can only give recommendations if we can only understand what's going on. So I suppose I'd like to know more about that. Can you tell me more about the depression so far? We've talked about it before, but I really want to get into the details. How does it really impact your life most of the time?
Oh, we talked about it. I have no interest in doing anything. I wake up, smoke a little bit of weed, kind of just play video games, and I don't get enjoyment in anything. Everything's miserable. I can't motivate to really do anything.
What would you suppose is the reason for that? You know, there's all kinds of reasons that can cause a depression, right? There could be problems with using substances. There could be problems with not having enough stuff in your life. There could be all kinds of causes, even the brain or biological problem. How do you see your problem?
If you could help, like, how do I do more stuff in my life? I've tried and it just doesn't work. What have you tried? You know, making myself food, applying for jobs. What? Yeah, I guess none of those things really stick.
And let's go over that. When was the last time you tried something like this and it didn't stick? Can you walk me through that process and how that felt for you? So you see that you don't really need to give information. And frankly, this is because I've made a clinical determination for the case that giving information is actually not helping the patient for X, Y, Z reasons.
And the technique, if you want to get more training or experience with it, is really Rogerian reflections, which is probably best written in... in motivational interviewing managers okay where basically you try to get information you're not giving information you're pulling information and values out and i think that a lot of the time ambivalent behavior and treatment comes from a lack of clarity into the underlying conflicts of differences in motivation and feelings emotions of patients so just trying to throw
solutions is not going to work awesome um i'm being wary of time i think we're at the hour we don't want to bore people with uh you know two hours of content um any closing remarks i think this is going to be really helpful for people um yeah i
hope so you know um I think what you have to understand, though, is you can try things that you hear other people do or that you see other people do. You can watch all kinds of videos about different interviewers. I think you have to be true to yourself as a person. It's useful to put on certain masks or styles to try them out here and there if you're still developing as a clinician.
But you really have to come from who you are in an appropriate way, right? You're going to suppress the parts of yourself that are clinically inappropriate. You're going to emphasize the parts of yourself that are caring and interested and try to help people along, but you don't have to be a false self and you shouldn't be one to do this kind of work in difficult situations. Be who you are, but appropriately.
Wow, you're such a sappy fellow saying, Dr. Fu, be true to yourself. That's the message we're ending on.