Key moments, in order
How well you ready and guide the patient is the key to getting any diagnostic data. It is like the resolution of an MRI: poor interviewing and therapy technique gives a very low-resolution picture.
Do not think about the levels of intervention during a session. They are for looking back afterward only.
We all have baggage, patients and clinicians alike. We bring it into the room and it alters what we perceive, notice and do clinically. If we are not aware of that, we are in trouble.
If you stay on the surface of the crazy situations you get put in and do not take time to reflect, you can miss what is underlying them.
It runs both ways: a paranoid patient may attribute their fear and aggression to you and become dicey, oppositional or even overtly aggressive.
Walking up and opening with any thoughts of hurting yourself or others puts patients on the defensive. Coming at it less directly lets you see how they think, unguided by their defenses.
We thought together that maybe something else was going on other than OCD-type symptoms, and that the patient was putting us in a crazy situation of making a really complicated medication switch.
Clinician and patient can both hyper-focus on one problem in a way that obscures another, deeper or parallel problem.
Make links between causes and effects and put them together under a name you can refer to with the patient. For example: this trouble concentrating and getting schoolwork done may not be ADHD; it looks like your high level of obsessions, compulsions and anxiety.
It is the fundamental work of mental health treatment: putting things into words in a way that makes sense and produces causes and effects, and therefore solutions.
Name the problem and link it to the treatment: these concentration and sleep problems are what I am medically calling bipolar II disorder, and I expect this medication to improve both.
Stay close to the material. If concentration has been bad for a few weeks, jumping to childhood attention problems goes far afield. And if you are focused on a med change or a billable diagnosis, you can miss a lot of what the person is bringing in.
'Does that remind you of someone from the past?' sounds like staying close to the material, but it skips the person's internal experience. Start with their own thoughts and feelings first.
Ask for a free-form narrative and steer away from clinical terms, which mean different things to different people. When someone says depression, anhedonia or increased anxiety, ask what they actually experienced.
Labels and symptoms can be a way for patient and provider to collude in not getting into the material.
Act stupider. If you assume you know what the patient means by anxiety, or go straight to an intellectual framework, you close off the opportunity to learn more.
Do not be afraid to ask obvious, even stupid-sounding questions, and simply apologize if it feels awkward.
Feigned ignorance and curiosity help the patient stay undefensive. It fosters trust and encourages self-reflection.
Let go of your sense of mastery of the patient's material. This matters even more for experienced clinicians, who begin to see the same case over and over.
If you can explain the patient's problems so that a completely uneducated person would understand, that is better, because you should formulate with the patient in plain language.
Rewind the tape. Do not be afraid to interrupt and go back to something important the patient slid past. A manic patient can give two hours of history in one; if you do not interrupt, you get no closer to a diagnosis or plan.
You cannot just be a passive, perfectly supportive listener. Practice the things that do not come naturally to you.
Venting by itself is not helpful, and it should not be documented as a psychotherapy intervention. What helps is the reflections you do.
A manic patient can tell you two hours of history in one hour. If you do not interrupt, you will get no closer to a diagnosis or a treatment plan.
Observe and confront: when you notice a pattern or a problem, it is your job to stop the narrative, at least for a moment, and make the observation out loud.
A confrontation is any intervention that points out a pattern, a discrepancy, an inconsistency or a change in the narrative, between different parts of the patient, or between the patient's values and behaviors.
A patient may push back or fight you in the moment, and then the next month you see the positive change. Have some faith that what you are doing is right.
Be non outcome focused. Hold yourself to a standard of practice and do it, because you never know when something you do will bear fruit later.
It is not the first or the fifth time you point something out that it lands. It is the tenth time, a year and a half into treatment.
Expect things to get worse before they get better. Without the old coping skill, the person has to face everything it covered, and it takes a period of destabilization to rebuild something new.
When someone is better, tell them not to be surprised if things get worse again; that is life. But they have picked themselves up and know what to do next time.
If you do the job right, regardless of the outcome, you have done the right thing. That should be the ultimate guideline.
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.