Key moments, in order
It applies to every part of practice, in every setting, and focusing on it can help a burnt-out clinician feel and do better.
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.
Keep appointments, keep a plan, and say in advance how long visits are, when you will be away and when you are available. That is a huge part of patients feeling safe.
Make your role clear from day one and remind people of it and of the limits of your powers as needed. Many clashes over the plan come from misunderstanding the role.
Patients may think you are a therapist who is there to listen, rather than someone figuring out what is medically going on, recommending treatments and leading them through those treatments.
We operate within the medical model: we look for a problem that has been, or might be, defined medically and that has specific treatment recommendations.
Psychiatrists are used to finding and fixing fairly discrete pathologies. For people who want to optimize, or who do not have a specific pathology, medication management may not be the best treatment, and that is okay; there are no rigorously tested optimization studies to tell them what will work.
Audit your own cases about twice a year: how is the alliance with this patient right now, and do we agree on the problem and where we are taking it?
Start with the patient's ideas, not yours: what has been a problem for you, and how do you feel this is going to go?
Telling the patient they have schizophrenia and should take Haldol does not work. Ask what is a problem for them, and tie the medication to that.
Find common ground in concentration, sleep, fear or stress. You are not lying when you say the medication helps those, and there is no point talking about a pathology someone does not think exists.
With a patient who keeps getting hospitalized: when you take the medications you stay out of the hospital, so let us make our goal keeping you out of the hospital.
Be genuine about how little power you have to help. That is where you can actually start helping: this is basically what I can do for you.
The role is not to fix the problem and make the person happy with medications. It is to communicate their options: the ones you are willing to prescribe because you think the benefits outweigh the negatives.
Clinicians get frustrated when they see the relationship as the patient arriving with a lack that the clinician must find and supply.
It is a process where you and the patient mutually discover what is important to them, what they want, and what they do or do not see as a problem.
To repair a stuck treatment, name it: how do you feel about how things are going, and how I am doing? What do you see as the main problem we are trying to work on?
Treatment is not a socially normal act, so do not be afraid of socially unusual moves that serve an important treatment function.
Patients come in thinking they will trauma dump, tell the crisis of the day or tell their story. That may or may not serve treatment, so you need a clear idea of how treatment works.
When shifting a patient used to another style, go slowly and explain yourself. Shift too fast or without explanation and they will rightfully get angry and leave.
If what they want should not come from a psychiatrist, say so and point them to a social worker, therapist, friend or organization.
Be confident and humble in your limitations. You can tell a patient that what they are bringing up is important even when it is not something you treat.
When a patient arrives with a diagnosis in mind, ask them to describe what is going on without labels or jargon, what they are noticing and what they want to be different.
Do not feel pressure to make a diagnosis at the end of a first appointment. Tell the patient what is on your differential; with experience, uncertainty goes up, and one 45-minute conversation cannot name all of someone's problems.
Have a basis for any clinical conclusion that you could explain to a neutral audience. Opinions are accepted only when you lay out your data and reasoning, and patients should not have to believe you because of the diploma on the wall.
Technical containment is perceiving the inner emotional experience of another person, receiving it, digesting it yourself and communicating back that you have perceived them. That is all: you are not giving information or changing anything. You use your mind to clarify the patient's disorganized thoughts and feelings so that over time they can organize their understanding of themselves.
Almost the same session can feel like being used and dumped on with one patient and be necessary and therapeutic with another. The relationship decides which it is.
Anything you do in a session needs to serve the greater goal, and that goal is building the alliance. It is a frame concept that applies to any therapeutic process.
Tell them plainly: my role is not to make you take medications, it is to explain what they can do and work out together whether they fit. You do not have to take them, but say when you are concerned.
Inpatient training can make it feel like the whole job is getting the patient to take medication, and that can spill into outpatient work. That is not our role.
Because we reviewed her history and went through her past, even parts that did not feel directly connected to what she was experiencing now, she trusted me more because she felt understood as a person.
Show your work: what you found and why. Our terms are loaded and lay understandings are often wrong, and patients trust a diagnosis far more when you show your reasoning and what you reviewed.
With political stress, skip which event upset them and ask how it comes into their life and affects the rest of it. A patient intensely focused on this is showing a clinical problem, whether or not they are right.
Reflect on what you are doing and why. Supervisors and your own therapist give you a place to do that.
Avoid self-disclosure for one reason: it interferes with treatment, taking time and shifting the focus. Say that reason and you will not seem cagey.
A strict rule that sometimes gets broken is better than a wobbly one, because clinicians unconsciously get narcissistic and connection enjoyment from self-disclosure.
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.