Key moments, in order
Address any mismatch in the alliance, rupture, boundary crossing or frame violation explicitly and fairly quickly, if not right away.
Your frame does not have to match anyone else's style. What matters is that it is the same for every patient you see in that setting.
Keep to the date and time and start on time. If more than about half the session has gone by and a meaningful visit is not possible, say you missed the time today rather than attempt the full visit.
Be extremely clear about two things: why you are meeting (the modality) and the diagnosis with its treatment recommendations.
For patients who really push boundaries, the boundaries are not nuisances that get in the way; they are the treatment. Being too flexible or too forgiving, or not acknowledging your own boundaries and resentment, misses that.
When a patient is late, do not just say no worries and carry on. Focus on it and talk about it.
A clinic is not an emergency room or urgent care. It is a place where you have to, and get to, learn to wait and sit with yourself.
Knowing pop culture, media, art and general culture is important to doing psychiatry correctly. Stay in contact with many other clinicians and keep a finger on the pulse of the community: trends, memes, current events, current and old art.
Part of the treatment frame is that you and the patient are on the same page about what the diagnosis is and how confident you are in it.
If it is important enough to be your primary treatment diagnosis, or to go on a bill somewhere, you should at least explain it.
Agreement is not required. Better a patient who says "I don't have schizophrenia, but I take my clozapine" than one who accepts schizophrenia but refuses antipsychotics.
The purpose of a diagnosis is to further the treatment. If disclosing even a confirmed diagnosis would definitely hurt the treatment or the patient, or interrupt it in a way that cannot be repaired, that is a reason to withhold it, at least for now.
Patient and providers pretend the treatment is for major depressive disorder while everyone knows, in the back of their mind, that there is a personality disorder nobody says out loud. That sets up bad treatment outcomes.
People want to apply personality disorder diagnoses only to people they dislike, and some clinicians use it to mean "unpleasant person." That is not what it means.
Escalating or allowing more and more physical contact is, in many cases, a road to hell paved with good intentions.
Especially when you are starting out, follow the rules relatively strictly. Something like a hug should be done only once you have a lot of experience.
Get comfortable being socially unusual. The whole endeavor of mental health treatment is socially unusual.
At baseline, unstressed, people in the borderline range can usually reality-test; that connection is intermittent.
Ask how often in someone's life another person has carefully attended to their inner experience and communicated it back in a way they could accept. That is where the capacity comes from.
If you cannot understand what is going on inside yourself, there is no way you will understand what may be going on inside someone else.
With unhealthy personality functioning, tighten your boundaries and make them very strict. A basic formulation of healthy versus unhealthy functioning is enough to guide this.
A doorknob comment will throw you off. Weigh how much you need to deal with it right now, do the assessment that requires, and also protect the boundary that the session is over. You will sometimes fail, but try to keep your composure and keep things warm, interested and connected to the next session.
If the patient says the relationship is special, be concrete: thank them, ask what they mean by special, and describe the typical good working alliance you try to have with all your patients.
Many patients act out conflicts they are unable to think about because they are so overwhelming.
Beware the rescue fantasy that you can do everything for this person. If you cannot do this work well and responsibly, refer out, or rely on a very strict, concrete agreement about what you will do.
Making dreams a regular part of medication management is doubtful, because it is such a personal intrapsychic process that it really requires therapy and regular meetings.
If a patient brings a dream, remember that the meaning is up to the patient, not the clinician. Ask what they think it could relate to in their life that has been stressing them out.
When a patient shares something like a sexual dream about you, normalize it: it is very common to develop feelings that might not make sense about a treatment provider, it does not mean they are real, and treating them as anything other than a sign of underlying thoughts and feelings would interfere with treatment.
You do not have to intervene every time. If it is important, it will come back.
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.