Good morning, Dr. Melsberg.
Good morning. I got to read one of the comments on our most recent videos. It says, this guy sounds so young and bro-ish. I'm glad this is not my psychiatrist.
Well, I mean, who's that referring to? Is it me or you? I think it's me. I think you automatically assumed it was you. Have you ever been accused of being young and bro-ish?
I just thought I sounded younger. And I mean, just give it to me straight. Am I am I too broish?
I figured it was me. So, you know, this is a nice little object lesson on app perception. Have you heard of the thematic app perception test?
Yeah, that's the one where they flash pictures.
That's right. They got those old timey pencil drawings and they tell you to make a little story. But in short, a good example of apperception that you can use as an example is that a rich kid and a poor kid are walking down a sidewalk and they both see a five dollar bill. The poor kid looks at it and goes like, my God, that's a lot of money.
And the rich kid doesn't even think it's worth bending over to pick it up. That's apperception. Same object. So different perception.
So we have to ask the listener who's how old do you think we are? And from one to ten, how broy do you think we are?
I guess I'm getting to the age where I'd rather be seen as mistaken for being young, but I'm also a lifetime curmudgeon. So, you know.
And I'm probably where I can still be offended by being called too young.
Maybe. I feel like it is me. I think I have to be the bro because I got my West Coast styles. You're East Coast man.
That is true. I mean, we got a just classic coast war going on here.
Yeah, exactly. Anyway, sorry, Dr. Malzberg. I was late today.
Yeah. Can you tell me what was going on?
Well, I was hoping you were going to say what you said earlier before we start recording, which was...
Don't worry about it. Yeah.
Well, maybe we should worry about it because today's topic is the therapeutic alliance and the frame. And genuinely, without a uh desire to make this a clickbait title i do think this is the number one most important concept in psychiatry uh clinical treatment mental health or medicine that can be learned and it's a simple enough thing to hear about and to read about but i gotta tell you in my years of teaching this to trainees um I have repeatedly tested them after I've taught them repeatedly over years, and it may not stick as easily as it seems.
So try to revisit this one once you've learned about it, or even if you're already aware of this concept, try to listen with fresh ears and see how you can apply it to your practice.
Yeah, and I'll say to, you know, To back up the people that it didn't stick, I didn't learn anything about therapeutic alliance, therapeutic frame. You know, I kind of want to dive into what we think the role of the psychiatrist is, what the role of medications, what the role of treatment. In my training, which was heavily focused on just doing work, I received very little guidance or education on this stuff.
Yeah, it really seems like the classical way of doing this is to... kind of assume that people working in a therapeutic profession are going to pick this up automatically. And we take that for granted. And I do think it's actually more effective to be conscious about this, you know, kind of like deliberate practice as a concept in psychotherapy training. But, you know, if you think, well, this is a therapy concept, you know, I do medication management or I'm an ER doc.
I don't really need this. Not so. This is applicable to every part of your practice, no matter what setting you're in. And I'm also going to say this. If you are feeling burnt out these days, and I think everybody is, I do also think that focusing in on this is going to help you feel and do better as a clinician.
Yeah, I totally agree. This is so applicable to every role in psychiatry, in medicine. So, you know, I think to get started, why don't you, do you want me to ask questions or do you want to just, why don't you give us a prior?
I think how I like to open things and I'm going to ask you as always to play the role of the, you know, learner person, even though you're a very good psychiatrist of your own right. And I don't want the last videos to give any other impression because we basically fake these roles for the purposes of a dialectic. But what would you say that Your impression of what therapeutic alliance meant in training or what was if someone had said therapeutic alliance when you were in training, what do you think most people would have thought they were talking about?
How would most trainees or people in the field define it?
Yeah, and I think what you said earlier stuck of like, oh, I'm not doing therapy. It's medication management. That would be my initial expectation for what most people would say. Going one step further, assuming they understand the question. For medication management, I would say, oh, I prescribe medications and monitor. Make sure there's no problems, no medical issues. It's really most of my job.
Yeah. Yeah. And in terms of what the alliance actually is or a therapeutic alliance, I would say that when most people think and feel about it off the cuff, they're thinking of emotions. They're thinking, oh, does this patient like me? Do I feel positively towards this patient? You know, and that's where they leave it. But the concept of the therapeutic alliance that I'm going to define here.
And by the way, this is not something I made up. This is in the literature. This is has been researched and established. Therapeutic alliance has three necessary and sufficient parts. OK, you need all three for this to work. So the first is the emotional bond between the patient. and the clinician okay that includes trust in that treatment process and there's two more parts so most people are like wait there's two more parts what could those be okay this is where it gets really important it's it's both something that is done between the patient and the clinician and also something cognitive that is formed again between the patient and the clinician it's not just something that can be one-sided it has to be a shared issue so part two is a shared understanding of what the problem is the clinical problem or problems and what to do with it the goal okay and then part three is a shared understanding of how to get that problem fixed or how to get to that goal okay so the treatment target basically and also the treatment modality So if you don't have all three of these things, you are going to be spinning your wheels.
You're going to be, you know, going to visits with a patient or talking to somebody and you're not going to be getting very far at all.
OK, so you say there's there's three aspects. There's only one part is really like the relationship between the two people. Then it's the treatment target and the treatment modality. So now how. How does this play out? What is the psychiatrist's role in establishing these three things, what sort of things are done to best enhance these things?
Yeah. So I would say that therapeutic brain has, I wouldn't say has been done to death, but there are people who do it better. And we don't have to get into all the details today. But as I mentioned earlier, you know, timing, lateness, availability, and seeing people when you're saying that you're going to see them, that stuff matters. So keeping appointments, keeping a plan, and letting people know in advance how long you're going to be seeing them for, when you're not going to be seeing them, and when you're available is a huge part of establishing a treatment frame and making sure people feel safe in the treatment.
So that's one part. And of course, naturally, telling people honestly and accurately about whether things are confidential or not, and why you're asking certain things that seem uncomfortable to talk about, also very important, right? So that's the first part. But how does it look in the second part and the third part? Agreement about the goals and also the modality of treatment. Well, that comes down to Do both the patient and you agree on what you guys are supposed to be doing when you meet?
And I think a lot of people take that for granted, right? But how many times have you been butting heads with the patient about the treatment plan? Everyone's had this, right?
Absolutely, yeah.
Yeah. And I think a lot of that comes from misunderstandings about what your role is. So another important thing is to make your role clear from day one and to remind people about your role and the limits of your powers as needed. So what is a psychiatrist anyway? Or what is a medication prescriber in mental health? What's that role and how does it differ from other roles in the mental health field?
I would love to hear your answer.
Well, I'd like to hear first from you. Any thoughts or how would you personally say we differ? Or do we differ? Because there's arguments either way. We could say that actually we're not different at all, right? You could say that, well, anyone could do this job. Are we different in any meaningful sense from therapists, counselors, social workers, anything?
Yeah, and it's tough because the question of how do psychiatrists differ, my answer is different in a global sense and what I communicate to the patient. In terms of what I communicate to the patient, I usually on my consultation call will say, you know, I work with medication management and lifestyle changes. Um, it's not a replacement for therapy. I think therapy is often what I recommend first line for, for most treatments because usually average console call would be depression or anxiety.
Um, so I, I really work with medication management and lifestyle changes. Um, And throughout the process, usually we have come to an understanding of a diagnosis and what we feel like is the main problems. But the modalities that I use to treat are going to be medications and lifestyle changes.
Right. So you're being very clear about what your role is there. And the problem is if you assume that that kind of thing is clear before you start to work with a patient, they might, for example, think that you're what they think is a therapist, right? That instead of trying to figure out what is medically going on and to recommend treatments and to lead them through those treatments, that you're there to listen, for example.
And this can even be a problem in psychotherapy because a role of a psychotherapist is not just to listen and give support, right? Even in an ostensibly supportive psychotherapy. It's different and it's more technical. And so as we talk about this concept, you know, where you can talk most accurately about the psychiatrist role, whatever you happen to be, you can think about your role in a treatment patient, counselor, therapist, anything.
Um, But basically, you have to know what your job is and what your limits are, and you have to communicate what to expect to the patient. Now, for me, I would say that what differentiates a psychiatrist or any prescribing clinician from others is that we operate within the medical model. And in short, it means that we look for pathology. We look for a problem that might be defined medically or has been defined medically.
that has specific treatment recommendations, okay? So our fundamental job is to look at the patient, where they came from, what is going on, and to tell them what is a problem rather than what might be better or worse or what in their lives could be this or that. That might be pertinent to the medical problem, but the first job is to determine what is medically wrong and Or what is medically not right?
And how do we get that a little better? So that's how it is. And that's diagnosis and formulation.
Yeah, and that's really helpful because at least, you know, a lot of the patients I work with come in and... without a specific problem, they kind of just want to optimize their mental health. And I don't know if – I don't believe a psychiatrist is the optimal way to do that for someone who wants to optimize their mental health. And the way that you're defining things, which is – I use the same model.
The psychiatrist is used to finding pretty discrete pathologies often and fixing them. And for people who want to optimize or don't have specific pathologies – psychiatrists and the role of medication management and all that entails might not it's not the best treatment for everyone and that's okay exactly yeah and by the
way i'm not saying that as a psychiatrist you're not allowed to function in some more ambitious manner of optimization of mental health or something like that you know i think we do have some special knowledge as far as that goes it's more that broadly regardless of what knowledge one person has we can say that the field of objectively agreeable facts does not support that any particular person is an expert in optimization right we don't we don't have optimization studies that have been rigorously tested across different populations so that we can say this is probably going to work for you this is probably not going to work for you everything's very nebulous even more so for optimization than for treatment of pathology We can say as medical doctors or anyone trained under the medical model that, hey, we do have studies and evidence and clinical experience and a lot of training in finding these problems and treating them.
And if I can't find a problem for you, we can work together to see if there's other things that we can find. But you got to know that that's actually a little bit more ambitious and outside of general human knowledge.
So can you, you know, you're talking a lot about setting the frame and communicate, like what is your general spiel, either before the first appointment or during the first appointment to help establish these things?
Well, mine's very simple because currently my clinical work is in a setting where they very much do want me to only do medication management and medical treatment. So at least for me, I say coming in today, what would you say are the major mental health problems or issues that you've been having or that you had in the past that you think medications can help you with? This would be a different thing that I would be saying.
I would say something very different if I was a general outpatient psychiatrist who was giving both therapy and medications or if I was one of these more lifestyle optimization guys. I would be saying different things depending on my role. So no matter who you are, I want you to think deeply about your role, your limitations, and what you generally do with people and make that clear. But that's just one sentence.
And really, even though it gives you kind of a foundation, it's not a guarantee that you're going to have a good alliance moving forward. Alliance is something that's built over time and that you are going to have to revisit. And, you know, when I say it's the most important concept, it's because if you ever notice yourself feeling like you're not getting much progress, or if you notice yourself butting heads with a patient or anything, even just randomly, maybe audit your own cases just twice a year, specifically ask yourself, how is the quality of the alliance with this patient right now?
Okay, do we agree on what the problem is and where we're going to take it? Do we agree on how we're going to address that problem and how we're going to get it to the goal, right? And you may find that by explicitly asking yourself about that and even talking about this with the patient directly, you're going to uncover areas of disagreement or uncertainty that have been slowing down the treatment.
And so rather than simply saying this first thing, the next part is important. You got to get an idea first, not of your ideas, but of the patient's ideas of how do you feel like this is going to go and what's a problem for you? So that's what I start with. So what's been a problem for you? Right. You see, that's in my first sentence I asked about.
I put in all that stuff about medications because they have a separate therapist. But I want to know what you see as a problem. And then I'm going to be reflecting on what I see as a problem. And then I want to know if those things match.
Okay.
Now, what else do you feel like you... So then, yeah, I'm assuming you continue with the assessment. You develop an assessment. What are the other aspects that you think are important to communicate in... early initial visits or pre-visits. So you mentioned making your role clear as to what you view as your role. You mentioned trying to elicit from the patient what they feel like the problems are that they think that your role can fit.
So if your role is medication management, what are the problems you feel medication management can fit? And the third thing being making sure, in a sense, the two assessments align that, you know, the way the provider... views what treatment's going to look like and the patient views what treatment's going to look like is somewhat aligned. What are other aspects that you feel are important to communicate in initial early visits?
Well, I mean, they're all surrounding that, I would say. And it sounds too simple, but it's really not. If you think that you're aligned, I want you to make sure you're aligned, for example. So what's important to elicit, actually, I would say is information that gets you to a explanation of the patient's problem in a way that makes sense to both of you, in a way that the patient will accept, and that leads you towards a meaningful treatment change.
I know that's very vague, but let's take the example of psychosis. Most of the time, people with a serious primary psychotic disorder, like schizophrenia, they have a degree of low insight or no insight that is baked into the condition itself. I believe we talked about this in the previous episode on psychosis. That's almost where a condition itself has set up a huge wall for a therapeutic alliance.
So if you come in and then it's clear as day to you that someone has schizophrenia, right? And it's clear as day to you that how to get them thinking and feeling better within a few weeks is an antipsychotic medication. Well, explaining that to the patient is not going to make them say, oh yeah, totally. I have schizophrenia and I should take Haldol, right? I mean, how many times does that work for you?
It doesn't work, right? And so instead, it's more important to say, OK, what's a problem for you? What do you see as a problem? And ask yourself, what can I refer to that I can actually help with medication that the patient can agree is a problem? And at least for most psychotic disorders, if you're experiencing issues like thought disorganization, paranoia, hallucinations, delusions, your life is full of stress.
full of anxiety, you got problems sleeping most of the time, and you don't feel so good mood-wise, right? It's a stressful way to live when you're in acute or subacute psychosis. So when I say it's less about what you specifically elicit and more about paying attention to what both of you can agree on as a problem. And being aware if your formulation of the patient is something very abstract out there and really accessible only to experts, that it's going to be less useful to lay a foundation for the alliance.
So for this hypothetical psychotic patient, I would say, look, so you come in today and you told me about a few different problems. Your neighbors have been hacking your computer and spying on you. It sounds like that's causing you a ton of stress. You've mentioned that you have problems with sleep and you're anxious all the time, okay? I think that the best treatment for that is, let's say, Abilify.
This is a medication that we use to treat pretty much a bunch of different conditions. And in my opinion, I'm fairly confident that the other medications will not work as well as this medication for you in order to lower your stress levels, help you think straight, and help you sleep better at night. It's true. And it's focused on an explanation of the problem that both parties can agree on, hopefully.
And don't just say that. Go like, what do you think? What do you see as causing this problem? And a lot of people will refer to external factors as the main causes of a problem when really you can't do anything about external factors, right, as a psychiatrist. You know, I can't stop your neighbors from harassing you, whether or not they really are. And if you could do it, maybe you have done that already.
Let's not do anything illegal. Yeah. But I'm here. The limits of my power, this is where we go back to how it's important to talk about what your limits are. I can't help you if your external circumstances any appreciable way. What I can help with is medication and or psychotherapy and how you feel and think about things. So that's where we go to the third prong of the therapeutic alliance in terms of, you know, getting to some agreement on how to accomplish the goal, how to solve the problem.
This has opened up a huge can of worms because I think we're in tricky areas when we're talking about choosing carefully the things that we communicate to patients. As you mentioned in your description of Abilify, you didn't describe it as an antipsychotic. I'll still tell them it's an antipsychotic.
I'm just saying in terms of focusing on what the treatment effects are, there's no need to talk about hallucinations and delusions. Why? Because It won't land. There's no point talking about a pathology or a problem that someone doesn't think exists. Right. It will be exactly the same as talking to someone that is convinced that their problem is not their personality, but is instead, let's say, I don't know, anxiety.
Right. Right. People come in with all kinds of preconceived notions about what the problem is. And you being a psychiatrist is not enough authority to budge them on that. It's the time that you spend with them and the things that you can both agree are true being brought to the fore that will eventually get you there. So I'm not saying lie to the patients. I'm saying there's no point discussing things that aren't going to land.
Yeah, and I'm reminded of a case I had in residency. I actually enjoy working with patients who come in with preconceived notions about negative views. I had one patient who had been hospitalized three times in the past year, and they came into the appointment hating me. They came into the appointment saying... everyone's making stuff up about me. This is all bullshit. The medications kill me. All these psychiatrists are lying about me.
And I think she expected me to be that same psychiatrist and say, you have schizophrenia, you need the medications. And I took a totally different route. I said, listen, I can't speak to... what happened in the hospitals. I can't speak to how the other psychiatrists treated you. It sounds like you had a miserable time. I can't speak to your diagnosis even. I've known you for 15 minutes.
There's one thing that I can speak to. It seems as though when you take the medications, you stay out of the hospital. When you're off the medications, you end up in the hospital. I think we should just make our treatment goal keeping you out of the hospital.
Yeah.
with this particular patient that landed because we were working on the same goal. Exactly. And the alliance wasn't, you know, me in the white coat in a high chair saying, you have schizophrenia, you need medications. We started the treatment saying, let's figure out what our... first goal that i agree with that you agree with and start there yeah i mean that's
a beautiful story an excellent example of why you're such a great psychiatrist right um that's perfect alliance and there's nothing that is untrue that's being said right and what you're focused on is your humility as a clinician right and also what the patient is coming to you with that they want help with those are the important parts and you know i'm not advocating by the way for false humility here you know if you think that you're a psychiatrist you can do anything for a patient and make them do anything then i don't know what to say to you but we really do need to be genuine in how little power we have uh to help people and then that's where we can actually start helping people if we can say to them You know, this is basically what I can do for you.
You got a lot going on in your life, and this is a medication I can offer. I hope you try it. I do think strongly that you will get better, but let's find out together. If it doesn't get better, we're going to find something else for you, hopefully.
Yeah, and I want to move this conversation to... You know, I think something like schizophrenia where it's a little bit, to me, clear-cut whether medications will help and what they're helping on. And move towards what I see a lot. You know, I supervise a decent amount of cases and providers who think that their role is to keep trying medications until the patient feels that their problem is fixed.
Whereas, you know, a lot of what I have to communicate to them is part of your role is to explain medications. what the role of medications are, where we think they'll help, and what their limitations are. I don't view, when I'm doing medication management, I don't view my role as fix the problem, make the person happy, and everything's great with medications. I view my role as, in a sense, I'm communicating to them their options, the options I'm willing to prescribe because I don't think that, I think that the benefits outweigh the negatives, and how much I think the medications will help with you know i have i have error bars on all this there's some patients i go i have no idea if the medication will help there are patients that i hear certain things i go you sound like the kind of person that i am very confident that this will make a big difference in your life um you know my my role isn't fix everything my role is to communicate to the patient the options and let them choose exactly
yeah you know i would say that it's Yeah, we've been using schizophrenia as a clear example, but this happens so much more often in neurotic conditions, let's say. People who are pretty sure that they have ADHD, anxiety disorder, depressive disorder, any kind of disorder, and they've heard certain things about certain medications. And then I think a lot of clinicians will get upset. It's like, this patient isn't going to take what I give them.
You're not going to get better. Why am I doing this? And that comes from An understandable view that the patient-clinician relationship is one where the patient comes in with a lack, okay? There's something that they're lacking or they don't have and that your job as a clinician is to find that thing and give it to them. You know, I think this feeling is worsened because that's how insurance treats us as pill dispensing machines or machines that give a diagnosis, for example.
But instead of thinking that relationship is one where someone comes in missing something and you have to give them something. I totally hope people can try the other thing instead. The patient comes in and you build the alliance. You build a alliance by trying to figure out together what you can both agree is a problem and that you both can agree is a meaningful solution. And the way you talked about your case here, that's exactly that.
What you sound sounds really important, and I want you to expand on it. So you mentioned it's not that the patient comes in with a lack and the provider fulfills that. And then you mentioned the alliance is an important part. Then what is communicated to the patient? What is actually supposed to be going on?
Well, I mean, that's exactly the thing. If it was simply giving them something that was missing, I could tell you what to give them. But it doesn't work that way, right? It's just a two-party minimum process where you have to discover together what you can both agree on. That is a problem and that is treatment, right? And so there's no prescriptions, pun intended, that I can give clinicians about how to approach that.
It's a process that you have to Learn together anew with most patients. If you want to read more about it, actually, the literature that is closest to this that covers this topic the best is probably the motivational interviewing literature. And that's the funny thing about motivational interviewing, because I feel like in the way that's trained and talked about, most people encounter motivational interviewing, I think, in the context of smoking and drug cessation.
Right. And then there, they are still unfortunately conceptualizing the process as one where this person comes in and they lack motivation. OK. And what I'm going to do is I'm going to give them motivation by talking to them in a very particular way. Whereas if you read in detail the motivational interviewing and, of course, the Rogerian psychotherapy literature, what you are doing is that you're engaging the patient in the process where you mutually discover the what is important to the patient, what they want, and what they see is or is not a problem.
And then relying on that process, you also come to some mutual agreement about what might be done about it.
So now let's say, you know, and we all have this, I have a patient that I've been working with for a long time. And We don't have that shared understanding. What is a way to open the door to trying to work on it or opening the door to the conversation of the misunderstanding you two are having?
Yeah, I mean, that's where the framing comes in again. And what I do is I'll say, hey, you know, next time I really want to talk about X, Y, Z. And that can be next time I'd like to focus our efforts on getting a little bit more clarity on your diagnosis. I'm going to do more assessment that day. And then maybe on that day, I'll spend less time, a lot less time on medication management unless there's something pressing or urgent.
And then I'll do a diagnosis visit at that point. And then for the therapeutic alliance, I will either scheduled or unscheduled say, hey, you know, I'd like to talk about how the treatment is going. OK. And then, of course, what's more important is how they feel. So I say, how do you feel about how things are going, your treatment progress? How do you feel about how I'm doing?
OK. Now, I want to know just overall, what do you see as the main problem that we're trying to get better, that we're trying to work on? And what do you see as the best way to do that? And then literally being that explicit, that's why I recommend you can just open up discussion rapidly about the elements of the therapeutic alliance. For some reason, everyone, including me, feels awkward about doing that.
But get over it. It's like learning to talk about sex or dreams in psychoanalysis or something. You know, once you get used to it, you will find that That it speeds up treatment and treatment progress. You know, we got to remember that what we do fundamentally is not a socially normal thing. Right. It is not normal to sit in a room or over Zoom with somebody and talk about all these extremely intimate, embarrassing and painful details about one's life.
Right. So don't be afraid to do things that are a little bit socially unusual if they're serving a very important treatment function.
Unfortunately, it seems to be more normal to trauma dump, but that's for another day.
I guess that's the other thing, right? People do come in and they think how this works is I'm going to tell my doctor all my traumas. I'm going to trauma dump on the doctor or I'm going to tell my doctor about my crisis of the day or I'm going to tell my doctor about my past and my story. And all those things might actually be important to the treatment, but they might not.
And so you, the doctor, Or you, the clinician, you have to have a very clear idea of how this treatment process works. And then you need to prioritize the topics and the discussions that are going to get you towards that alliance.
Now, what do you communicate to patients, you know, that do come in, do the trauma dump? You know, I'm actually reminded, when I got my hand off from residency, the provider said, you know, you're just going to be a giant container that's going to get dumped in. Yeah. So, yeah. Yeah. Oh, don't get me wrong. It's a huge problem. Yeah. So what, you know, when you do have patients doing that, what is it?
Do you have things that you try to communicate to them in terms of letting them know what you find is helpful and not helpful? Do you have any tips?
I mean, that's a great question, right? I mean, first and foremost, be warm. Yeah. Be kind and be understanding. Let me tell you, OK, you can't expect that you can't say I'm I'm the doctor. I'm going to start working this way and you have to come along with me because the majority of patients have not had any experience of working with a clinician who actively and explicitly considers the treatment alliance and the frame.
and orients towards it in a conscious fashion. Most people do not do that, I would say, except for the excellent clinicians who just they're naturals. They've been doing that anyway. And then so in a way, patients have come to expect a certain way of interacting with their doctor, their therapist, whoever. And in fact, if you try to make this shift way too fast or without explaining yourself, people will rightfully get angry at you.
They're going to leave treatment with you. They're going to say, what are you doing to me? OK, I'm used to this. Why are we doing this now? Change is hard. We got to appreciate that. And so what do I do? Well, I tell them, now, let me tell you a little bit about how I work and why. And everything I talk about, I try to point towards treatment progress or making their lives better as the ultimate goal.
Because it's true. I'm not doing this just for me to have an easy time or to feel good as a doctor. Don't get me wrong. It's nice to feel that way. But I... stick to thinking about and building the therapeutic alliance because I know that that is going to be the fastest way to get patients better or at least to keep them from getting worse. And so I tell them that.
I say, I strongly believe that XYZ way is going to be how we're going to get you better. And so I want to make sure that we spend the little time we have together talking about that, for example. That's just an example of how you direct the one thing to another. And you might say, that sounds like very important thing and i'm glad that you reflected on your life to build the story about all the awful things that you've been through now let me tell you about what i think i can help you with i think i can help you by figuring out how those things are impacting you today in your sleep and your energy and what you're doing in your life and so in our visits i want to really focus on those things Does that sound okay to you?
And there are going to be times where if you explicitly visit this, the patient will just disagree with you. Say, no, I don't think this is what I need. And that's going to save you a lot of headache because if it's not something that you can do for the patient and they feel like they need it, then you can tell them that. You can say, actually, what you're talking about doesn't sound like it should come from a psychiatrist.
I think you can get that best from social worker, therapist, a friend. social organization, whatever it might be. Make sure that you're actually able to do what the patient wants you to do.
Yeah, and that's such a great point. I think I struggled with this in residency thinking that I had to fix all the problems and I'm responsible for all these things. And it's such a helpful thing to realize, to know your limitations and to be, in a sense, confident and humble in your limitations. And that you can say, the things you're bringing up, they're important. I don't know.
acknowledging to the person that you alone are not a person who can fix all the problems and that there are therapists that are better equipped that should be dealing with the problems they're bringing up. I even had my friend one time text me saying, hey, I want to see a psychiatrist because I think I should be exercising more. And I texted him. you need to go you need a trainer i'm not like psychiatrists uh like um the psychiatrists have a pretty narrow range of skills and abilities um and it's okay to acknowledge that there are you know referring out is totally acceptable yeah um Now, I do want to talk about, and I think this is an important aspect of the therapeutic clients, and that's diagnosis.
I have an idea of where I want this to go, but a lot of patients come in wanting a diagnosis. Dr. Fu, can you work me up for ADHD? Expecting at the end of the first appointment, like, what's wrong with me? Can you talk a little bit about that?
I mean, that's a particularly challenging area today, right? It's an increasingly challenging area. You can look at social media for mental health professionals to get an idea of that because the idea of diagnosis is barely understood, in my opinion, by many professionals and definitely misunderstood because of misinformation from social media. So, yeah, a lot of people come in with a very specific idea about what's already wrong with them and why.
And so that means that they have already a sort of idea that that can be very opposed to what you think is going on. So what can you do? Well, I try to slowly and gradually get to a situation where we can get some agreement. It's the same process as we're talking about with the psychosis and medications, but I will say Okay, tell me about, and I say this, I say, let's not use any diagnostic labels.
That's just a way we organize our ideas so we know if we're talking about the same thing. So I want you to tell me without using any jargon, without any big terms, what's been going on in your life and what are you noticing and what do you want to be different? And having heard that, if I agree that it's a diagnosis, I'll say, hey, I agree with that.
And then I'll say, if not, Well, you know, what you've described so far, it sounds actually a little closer to what I would call XYZ. And then I explain what I mean by that diagnosis. Let's say it's OCD, for example. This is actually kind of an often neglected one. A lot of young people in college... They come in with kind of seemingly new onset, quote, ADHD because they're having all this problem completing their work.
They're having all of these problems paying attention in class. And they think they have ADHD when really what it is is that their baseline obsessions and compulsions have worsened over time without treatment and are really getting in the way now that they're in college. For example, reading and rereading. A common obsession for OCD in some people obviously is going to make it really hard for you to complete your assignments on time.
It's going to make you really stressed out and have difficulty paying attention. And obsessions about having heard the right thing or having done the right thing in class, right, would make it extremely difficult for you to pay attention appropriately. And it can be hard to tell the difference for a clinician or a patient. If it's ADHD or it's OCD. But if you have a clinical suspicion, I say, you know, I'm actually a little concerned that the problem may be something else.
Now, you don't have to believe me and I have to be sure, too. So I'd like us to work together on this over time and over the next few visits to see if we can come to some kind of agreement on it, even as explicit as that. Right. Just acknowledging that you don't agree that there are reasons why and that you also need more information. I think can at least get you on the right foot to start with.
Yeah. And actually you, you nailed exactly what the point I wanted to make by asking the question. And that's that, um, you never feel a pressure to make a diagnosis. And I think, and something that was really helpful in, in, my treating of patients was not feeling a pressure to make a diagnosis at the end of a first appointment and, and communicating to the patient, you know, like these things are on my differential.
But the truth is I need, I need to observe you over time. I need to see month to month. It's not, this isn't, it's not that it's something that I can't know right now. And just, it's been so helpful in regards to, you know, I, I, i don't feel a pressure to make a diagnosis when i'm not sure and that's because it's impossible to talk to someone for 45 minutes and know exactly what their
problem is yeah or unless it's extremely obvious but even then you only know one problem and not all the problems
Yeah. Yeah. Sorry. I should say with all patients, sometimes it is clear cut. The patient has a very obvious pathology and everything comes across it. But, you know, a lot of the time it's things are more complicated than that. And patients generally don't give me a tough time about it. They appreciate that I'm careful and thoughtful and I'm, you know, I don't just throw out a label just because, yeah, like patients generally appreciate it.
Yeah. You know, I'm going to say forensic work helps with this. And it's because you can't, the court is not going, the court and attorneys are not going to accept your opinions just because you're a doctor. OK, on the contrary, your opinions are only accepted if you can lay out the database that you used and your reasoning to connect the evidence that you reviewed to get to your conclusion.
And in the same way, you can't expect patients to simply believe you because you've got a diploma on the wall. OK, you need to set out what evidence you're using and why that leads you to your conclusion that's different from their conclusions. Right. Of course, assuming that the patient does not have a fundamental neurological problem of reality testing as seen in psychotic disorders. I wanted to go back to something you mentioned about the patient that you inherited where you were told this person is just a big container.
And you're going to have to dump into them. Right. No, no, no.
Sorry. It's the other way around.
You're a big container. You're going to receive what this patient has to give you. Right. I find that very interesting as an anecdote because a lot of patients can put a... They're not doing this on purpose. A lot of clinicians can feel a sort of human pressure to provide. And that's normal, right, given our rules. But we have to be very vigilant about when that happens and we have to be...
careful that we're not just doing that because we feel like we have to we're doing that because it serves some treatment purpose because the whole concept of containment I feel like people don't necessarily understand how it works it's a weird and complicated concept and topic and they can fall into a trap of just being the dumping ground in that case that's conceptualizing that the patient lacks someone to dump on and that you're going to give them someone to dump on, right?
Versus technical containment would be that you're there to receive the disorganized thoughts and feelings of the patient. And you're going to use your mind to clarify them towards the patient so that they can organize their understanding of themselves in the long term. Both containing in some sense, but one of them serving a long term goal. And one of them kind of staying in place. You know, I don't know how clear that example is, but I hope it came across in some level.
No, absolutely. And I think it really speaks to the therapeutic alliance, you know, because there are a ton of patients that I feel used by and I feel dumped on by. And then there are patients that will have almost the exact same session, but in the context of my relationship with the patient, I find it's something that is necessary for them and helpful for them and therapeutic for them that in this session because of XYZ, you they're going to be need containment.
Um, so, so the context is super important. And I think in the beginning you mentioned like, it's hard to be prescriptive about these things because what we're doing is so complex and that kind of speaks to it. And that sometimes, you know, containment is absolutely what the patient needs and being dumped on is a helpful therapeutic thing. And then for some patients it's spinning wheels. Uh, it's done as a way to spin wheels and not actually make change.
Yeah, basically, I would say the simple version is if you're doing something in a clinical session, it needs to be serving the greater goal. That's basically the short version. And the greater goal has to be the building of the therapeutic alliance, because the therapeutic alliance is more of a frame concept that applies to any therapeutic process, whether that's surgery, diabetes treatment or mental health. And so I guess that's going to be the take home there.
Yeah. You know, one thing I want to touch on today in regards to therapeutic alliance and the role of psychiatrists, I kind of want to talk about things that our role aren't, like things that is not part of our role and how that actually can be helpful with therapeutic alliance. I'm thinking, and I probably have talked about this on previous podcasts, sometimes I'll have patients that are hesitant about medications or who have had negative experiences with providers.
And how helpful it can be for them to hear. I have no... I have no motivations in regards to prescribing medications. other than to help you and and make your mental health better um and it's you know i communicate them autonomy that like we're we're working together to figure out what is best for you and that works within your values and if medications don't work for you or you like you know we have to work with that um and i'm speaking more towards the depression anxiety it's a little different with something like psychosis or bipolar.
I actually don't think it is different.
I don't think it is different. I think you've got to do the same thing. But go on.
Yeah, actually, as you say that, what's different is my explanation of what medications provide and their role in the treatment.
Yeah, how key they are. Exactly.
Exactly. And I say, you know, my role is not to make you have medications. My role is to communicate to you the role of medications and what they can do to help you and work together to see if it's something that works for you. It's a totally different paradigm than, you know, what I kind of learned in, because first year residency is inpatient, where it feels like your entire job is get patient to take medication.
And sometimes that can spill over into the future outpatient years. And that's not our role. Our role is not, give treatment and have patient take it yeah our role is to work with the patient to figure out the treatment that works with the best for them absolutely and you
know if these things sound too basic or at least feel too basic or you might feel silly talking about them explicitly i encourage you to do it anyway you know we you can't take for granted that this is going to be Now, in some cases, there is automatic understanding and the therapeutic alliance just kind of goes along right away. I think that's usually more a matter of luck than a matter of what you're doing.
And even if it's not... Even if it's present already, parts of the therapeutic alliance, I think being explicit about it, being clear about it, saying these things are obvious. You don't have to take the medications. You have a choice in this matter. That's really important because parts of everybody are going to feel otherwise. People are going to feel pressured, criticized, guilty for taking or not taking medications.
um based on a doctor's recommendations and if you can be explicit and put yourself out on the playing field and say here's what i'm here's what i'm here to do these are my limits i think it makes it a lot easier for people to work with you yeah and
i you know i love working with patients who are hesitant to take medications um and i you know not intentionally but by not caring if they take medications um They almost always do. And it's not it's not some, you know, that I'm using. It's not a Jedi mind trick. It's, you know, I communicate that I don't care if you don't take medications. That's your prerogative. I, you know, do want to help you.
Yeah, I guess the only thing I do differently there, maybe, which I'm sure you do also, is that I say, you know, you don't have to take medications, but I am concerned. You know, there are some cases where I'm actually not concerned they take the medications or not because I know that psychotherapy and lifestyle changes are an equal treatment. But obviously, for the more biological illnesses, then I will express concern because I really do have concern that their lives will be a lot worse without the medication.
But of course, that requires us to have a good idea diagnostically what's going on and a good idea scientifically of how much we can expect medications to work for a particular condition.
Yeah, another another point a little different I want to talk about is is once you change your goal as a prescriber, you know, when you view it through the therapeutic alliance rather than viewing yourself as a prescriber. I think a good example of this. There was a patient that like on the consultation call, I knew the medication I was going to be. explaining to them that i thought was helpful um within 10 minutes i kind of had enough of information to that i had a good 99 chance i was going to be offering this one medication and i still did a very thorough full history even though i was very confident that i you know where I was going to go.
I did the full history. I talked about their childhood. I talked about their major relationships. I talked about, did a full review of systems. Everything was exactly how I expected it to go. And in the end, I pitched the medication that I had expected within the first three minutes. But what was different is that the patient, and she communicated this to me in the next appointment, was that because she felt understood by me and because we reviewed the her history and i i went through her past even aspects that didn't feel directly connected to what she was experiencing now she trusted me more because she felt like i understood her as a person and because i spent time trying to understand her rather than just oh i know what the treatment is here it is yeah um precisely beautiful and completely changed our relationship and how we work together um And that's why I really want to emphasize the importance of the relationship as the thing that you're providing for the patient, not just a medication algorithm.
And I will say not only the relationship, doing that, right? Staying within that frame, doing your full assessment, that also builds prongs two and three, right? It gives you credibility. It gives you credibility when you give your opinion on what is the problem, what's the treatment. Because even if you were right at the outset, Why would anyone believe you? Right. It might as well be black magic.
You might as well have thrown a dart at a board with different medications for all they know. Right. They can't read your mind. It would be in the forensic world, the equivalent of writing a report with two lines. I am a doctor. I diagnosed schizophrenia, right? But if you show your reasoning, your thought process and all the things you reviewed and why you think this and why you don't think that, and then you say, I diagnosed schizophrenia, people are going to be a lot more willing to trust you and believe you because you did the work and you showed them that you did the
Great. Now, I'm curious, any before I kind of ask my start, you know, final questions, anything else that we haven't talked about that you think is important to bring up?
Well, I mean, it's a huge area, actually, even though it sounds so simple. So I would just reemphasize, please try to apply this explicitly to your work. Um, it's not something that either is or isn't there, um, or that you lay a foundation for and you forget about something that you have to revisit and build over time. Um, and again, I do think this is the number one, most important thing that you can learn in any therapeutic role.
It's super, super important. Your final questions.
Yeah, I have a pretty loaded one. Um, that I think is going to touch on some of these things that we're talking about here. It's always going to be an example of how to think through these things, given the principles you're talking about. Have a lot of patients presenting with worsening mental illness or heightened anxiety in light of all the political stuff going on. What are your thoughts in regards to how to deal with that?
How... How do you deal with patients who come in with those concerns? Yeah.
Yeah. I mean, you know that there's a lot of therapists and psychiatrists who think that their job there is to agree and empathize, right? Yeah. And maybe, maybe, what I would say is the same thing. You can agree and empathize all you want or even not as long as you're pursuing the actual treatment process, the therapeutic alliance. And, you know, as... Sometimes political and social issues are relevant stressors to somebody's mental health, obviously, obviously.
Right. But for us, we have to say this is a stressor and here's what I can do about it. Right. We are not able as psychiatrists to change social events, natural disasters and politics. Right. We might wish we can. I wish I can, but we can't do it. So I try to focus in on what I can change. And that's specific to your mental health, your emotions, your reactions.
Well, I can't even change those, but we can talk about how you might be able to do something a little differently.
So if you have a patient who keeps kind of bringing up these political concerns, how do they change your assessment? What do you feel like is important to communicate to the patient?
Well, it kind of depends. I'm not going to go like, hey, you keep bringing up political things. That's wrong. I think I can say something like, These political events seem really important to you. I noticed that you talk about them a lot when you meet. How is this affecting you throughout the week, day to day? What are you doing? And then they're bringing you something explicitly or not.
They're bringing you something of clinical interest. So I want to know how it impacts them. That's the important part. I don't want to talk about exactly how upsetting it was or agree that it was upsetting or tell me which specific event made you unhappy. No, I want to know how's this come into your life and how's it impact your ability to do the rest of your life?
The things that matter to everybody, you know, work, play, love. That's what matters. And so that's how I would orient it towards what I have the power to do versus getting caught up in the pleasure or displeasure of discussing recent events and the crisis of the week.
So, yeah, you mentioned talking about like the pleasure of talking about these political things. Let's say, you know, some ridiculous political thing occurred and the patient is looking for your opinion on it. What do you what do you think is important to communicate?
I think it's important to communicate that, you know, my job isn't to tell you about this stuff. Well, OK, that's that's a tricky one, right? If someone asks about your politics, I think it'll be easier if we role play it.
um sure so elon musk is a nazi and this you have to agree correct well yeah i mean
that's pretty worrying to a lot of people isn't it how's it been impacting you um
so you agree he's a nazi correct it's important to you that i agree yeah absolutely
i mean Of course. I wonder how you would feel if I didn't agree. I assume that would be a very difficult thing for you if I had a different opinion. How would you feel?
How would I feel if you sympathize with a Nazi?
How do you think I would feel? I think it'd be pretty awful. So is this something I've been worried about that a lot of people important to you in your life might be with the bad people or against you. Now, you can see it's a little off the cuff, but ultimately, some people will paint you into a corner for your opinion. And if let's say someone is doggedly doing so, I think what I would say at that point is it seems really, really important that you find out about this.
And it seems like we can't work together if I don't answer you. But I want to really emphasize that what we're here to do is not to talk about our beliefs, right? We're here to talk about you. Well, rather my beliefs. We're not here to talk about my beliefs. We're here to talk about you. And I'll tell you what I believe, but I do think it's important that even if you don't want to stay with me because of this, that you have to keep in mind this is not what gets you better mental health-wise.
And that if you focus on this with your clinicians in the future, I think you're going to be doing yourself a disservice. And then I'll give my opinion.
Ooh, that is... That's the juice that we were hoping to squeeze from this podcast.
It's tricky. The problem is this. I think I do. I do genuinely think that if you are that patients who are very, very focused on that, it's a clinical problem, not because they're right or wrong about the political issue. It reminds me of the Lacanian thing, right? The man who's always paranoid that his wife is cheating on him, even if his wife is really cheating on him, his paranoia is still a pathology.
And so the fact that it intrudes so much into the actual therapeutic action of the clinician-patient relationship tells me that it's going to be intruding into the other things in their lives. It's going to be causing them so much distress and dysfunction. And so that's what's interesting to me. I'm not terribly interested in the self-disclosure or talking about politics otherwise. That's my position anyway.
Yeah, and I think you bring up a similar point in that we are not supposed to use our – even if we agree with our patients, even if we are 100% aligned with their views, it's not productive. I mean, I think we kind of talked about therapeutic alliance. Some aspects can be productive in regards – but you're not supposed to use your patient as a chum to discuss the political things and be in agreement with them.
That's not – That's not the purpose of the appointments. Yeah. And don't.
Don't make this mistake. Even if something is true, you can be getting excess enjoyment out of it that may be detrimental to the treatment relationship. It may not feel that way, but even at the minimum level of taking time away from talking about what matters and what's going to progress the treatment, that's an issue. But of course, we have to be flexible about these things. It can be that briefly.
Showing some kind of commiseration or empathy briefly is going to get you the ability to move on to the things that matter for mental health treatment. Not that the politics don't matter. All of our lives are affected by these things deeply. Right. It's a matter of what can I help you with today?
You know, as providers, it's important to really reflect on. what it is that we're doing, the reason for what we're doing. It's important to have supervisors, to have our own therapists, to be able to reflect on... to have outsiders kind of make sure that we're, there's, we don't have blind spots.
Yeah.
Yeah.
It is funny though. I will, let's end on this. I think a lot of trainees hear that they're not supposed to do self-disclosure and they don't really understand why. And then, so when that starts to happen, they get super cagey and go like, what do you want to know? I'm not supposed to talk about that. Okay. And that's very off-putting to a patient. The reason why we don't do self-disclosure is because it interferes with the treatment.
That's why. It's not anything else, really. It interferes with the treatment both from taking time away and also removing the focus, shifting the focus, fuzzing the focus. And so if you can keep that in mind, then you can better explain why you may be a little cagey about it. And really that the purpose of not doing self-disclosure is so that you can focus in on the patient and their problems.
If you start from there, I think you come off a lot more credible to patients who don't understand why you're doing that.
Yeah, and to be a little pedantic, self-disclosure, it's not that it does take away from the treatment, it's that it can take away from the treatment.
Well, that's technical. I do think it always takes away from the treatment. Now, do I never self-disclose? Obviously, you know, everyone does it sometimes, but I think it's a big enough danger. It's an area where clinicians unconsciously get a lot of enjoyment out of it. You know, narcissistic enjoyment, connection enjoyment that I'd rather have a strict rule that gets violated than a wobbly rule that makes people feel they're safe.
Yeah. All right. Well, I don't know. Do you think this one's going to do numbers? It's kind of abstract.
If we were trying to go for numbers, we're doing a terrible job.
Well, I want to do some numbers. Like and subscribe. Like and subscribe. Comment. Share.
Like, please. All right. Let's close it out. Any closing remarks?
Not particularly.
All right. Have a good one.
All right. See you next time.
Also, me and Dr. Fu have been talking about posting on Substack more. Probably going to send out little just practice tidbits every day with occasional longer posts every once in a while. So if you want to check out those, just Google Psychopharm with an F. Substack should come up first. All right.