Key moments, in order
The alliance is not just whether the patient likes you. It has three necessary parts: an emotional bond, including trust in the treatment process; a shared understanding of the problem and the goal; and a shared understanding of how to get there, meaning the treatment target and modality.
Doctor and patient can easily disagree on the tasks or goals without knowing it, thinking they are working together on how to treat the problem or on what the problem is when they are not. A mismatch in conceptualization has to be addressed directly and specifically.
Many providers let things go unsaid, and it mucks up the treatment.
We are experts in detecting pathology. The work is identifying what sets someone apart in a way that is a problem for their mental health.
The crux of the work is developing a diagnosis, or at least a formulation if a specific diagnosis is not possible, communicating it and getting on the same page with the patient, then giving treatments that fit.
In therapy of any kind, formulating and sharing the formulation with the patient is absolutely key.
Do not argue with overvalued ideas or delusions, or challenge them head on. Some ways of framing a belief keep you stuck and others give you a chance to progress, so choose the frame that lets you keep working. This applies broadly, including to how patients understand themselves.
The core of any difficult encounter is finding something you can work on together, and for that you have to agree that something exists.
Having a framework stops you projecting your ideas about all the problems of the world onto the patient and lets you work in a way that works for both of you.
You are going to make mistakes; that is human. Then you repair it or the patient leaves and finds somebody else, and a repair is a chance to understand more and end up with a closer working relationship.
Orient toward the shared wish for the problem to get better, even if you and the patient end up calling it two different things.
If you resent certain types of patients, you will create the difficult situation, not the patient. Feel the resentment about that type of experience outside the sessions so it does not land on the patient in front of you.
Explain what diagnosis is for: guiding specific treatments under medical evidence. Then say you do not have a diagnosis for them at this time.
When you will not prescribe, say it plainly: you do not see a medical indication today, you will not give medication that is not clearly indicated, and you want to keep working together. If after a few more visits ADHD is the best explanation, you can go that way.
Checklists and disorder-specific interviews confirm whatever you asked about. A motivated patient can answer yes to every structured question, which makes the criteria almost useless used that way.
Say why: you know they could get Adderall elsewhere, but you are worried about them, and stimulants are not a medication anyone can safely take. You would rather find out what this is.
The wider differential: substances, the sleep-wake cycle, depressive, anxiety and trauma disorders, OCD, personality traits and disorders, and social stress, including the situation at work and how someone handles stress.
Rather than just throwing a medication at the patient, work on getting them the skills and habits they were not able to have.
Personality is not about being a jerk. It is what you have learned and who you are based on how you were raised and what you have been through.
Usually it devolves into yelling and firing well before that, and then you simply do not prescribe. It is probably the number one reason new patients fire their psychiatrist.
Even under the urgency of apparent withdrawal, do not agree to be one stop in a series of doctors giving urgent benzodiazepine prescriptions.
Benzodiazepine and alcohol withdrawal is medically dangerous. People can become delirious or have life-threatening seizures.
Confirm on your state's controlled substance record that they really have been getting it.
Ask them to commit today to treatment with you and to a medically safe tapering plan.
Long-term prescribing needs at least a minimally adequate psychiatric evaluation that reaches a diagnosis, and a medical indication for a benzodiazepine in that diagnosis long term.
A rule of thumb for tapering, not evidence-based: reduce or stop over a period equal to the total time on the benzodiazepine, or two years if they have been on it longer than that.
One compromise: pick a date together in the next few weeks to get to a medical detox center, and give enough medication to last until then.
Tell them everyone can see the controlled substance record, so if they do not come back and you see the pattern, you will know they did not agree with the plan.
Know the rules, follow the rules, and do a medical assessment. Each kind of disability has a rule set for deciding whether someone is medically disabled.
Disability means a lot of different things, so question one is which rule set you are judging it under. Figure out what kind of disability it is, then read the rules, then apply them to this patient.
Advise patients about the risks and benefits of disability paperwork the same way you do with medications.
For temporary disability the question is: do I have enough medical evidence that the patient is impaired to this degree, and that the impairment requires time off to bring them back to health?
Ask how the time off will be used to get the patient better and to keep the problem from happening again.
A common mistake: a therapist or psychiatrist puts a patient on disability and then adds no further treatment.
Work is a really stabilizing force in people's lives.
Act like a non-depressed person as much as you can handle, even if it feels bad and you do not enjoy it, on top of medication, to speed recovery. That is the core of behavioral activation, or fake it till you make it.
Tell the truth: your responsibility is a thorough assessment of what happened and whether it is safe to leave, and there is no way to do that unless you can talk to each other.
Do not argue risk. Some patients genuinely believe, and it is true at the time of the interview, that they are not dangerous, and then kill themselves or hurt someone within 24 hours of release.
With a sufficiently oppositional patient, you can only go on the interview, and that generally prolongs the detention.
Triangulate: arrange the encounter as two people looking at a third party rather than at each other, even by turning your body slightly so you both face some imaginary object or person.
In psychiatry, as in pediatrics, the patient is not always the agent of treatment. The agent can be the state, for safety or to treat someone who lacks insight, a parent on behalf of a child, a family member, or the law.
Name your role under the rules: if I do not do my due diligence I could lose my license and you could be in danger, so help me out here. The same works for competency restoration, where you can refer to the courts or the competency rules.
In medication management it can look like this: you keep offering solutions, and the patient either does not follow through after agreeing, or has outsized, unusual negative reactions to the plans, over and over.
If giving solutions gets nowhere, reverse the dynamic: become the receiver rather than the giver, listen for the patient's ideas about what will help, and stop explaining.
With some patients, do not give a medication unless they are almost begging for it, absolutely certain it is what they want and need.
Become more passive: ask what is important to talk about today and what the patient thinks should be done. You do not interpret the pattern out loud, since even in analysis that takes many repetitions.
You are getting information, not giving it: pulling information and values out. Ambivalence in treatment often comes from a lack of clarity about the underlying conflicts.
Come from who you are in an appropriate way: suppress the parts of yourself that are clinically inappropriate rather than putting on someone else's style.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.