Quick list What to say to patients

“the medication is not the treatment. It's part of the treatment. And how do these work? You're not just going to start feeling happier. This is not a happy pill. What this medication probably does is that it makes it easier for you to change”

“a lot of people are already trained to expect that you're there to throw a medication at them. That's why they're seeing you. Right. And if therefore, if you don't take active steps to show that the treatment process is more than the medication, then that's the natural assumption”

“If you're prescribing these things from a stance of, I am a gatekeeper, I give you the meds and this treats your thing, you're going to have so much worse outcomes”

“the biggest difficulty in treating psychotic disorder, the meds work. The meds work really well. The problem is that they're not fun and they have really bad side effects. And the challenge in treating psychotic illness is to develop a relationship with the patient that they trust you and that they trust your recommendations”

“we know medically that these medications are going to help with things like fear stress level sleep and thinking process okay the thinking process will be more organized and less disrupted and therefore you'll be able to concentrate better and live your life better”

“I tell them it's antipsychotic, but I also tell them the truth. And the truth is that second generation and first generation antipsychotics are indicated and used in a variety of different conditions, right”

“Sometimes some people are OK with having more hallucinations. if they're less sedated. And it doesn't mean that they're going to get hospitalized. You have to assess the patient”

“you can say, listen, I know you disagree, but we've talked about the risks and benefits of this medication, and I think it's indicated. It'll be there at the pharmacy waiting for you”

“I'd rather a patient safely taper off and safely be monitored than tell a patient they need to be on a medication and have them not follow up. Autonomy is one of our guiding principles”

“You have to explain to the patient, like, I'm hurting you if I were to prescribe these things long term. I'm preventing you from getting better”

“You're going to be on a controlled substance that causes addiction, withdrawal, executive functioning problems, memory problems, sedation, and it probably slows your ability to improve yourself in the psychotherapy as well. And I might be happy to give this to you, but I can't say that if you have to change doctors”

“A certain personality type that tends to have an anxiety disorder is probably the lowest risk for addiction habituation with benzodiazepines. It's the medication hater. It's the person who does have strong placebo effect and negative emotional relationship with medications, right”

“The patient who says, I don't have schizophrenia, but I take my clozapine every day has better outcomes than the patient who says, I have schizophrenia, I hate those meds, I'm not taking them”

“there's studies showing that patients subjectively really like clozapine. And we think of it as this messy drug with all these problems, but patients are reporting that they really like it”

“when you pitch it to a patient as the second you get a side effect, we're going to go back down to the lower dose. Whoa, what a difference that makes”

“I literally say to the patients, like the way I think about it is we don't do labs because this medication is unsafe. It's because we're doing this labs, this medication is extra safe”

“even if you have guaranteed decline in renal function, that is not the same as renal failure, okay? And if you told me that over the next 20 years, I had the choice between 30% worse kidney function and 30% less brain function, I'll tell you this. I'm going to take the better brain function every single time”

“You kind of just counsel patients, try to keep your hydration levels stable. Don't let yourself get too dehydrated”

“I made a little page sheet that I share with the patient. And what I would do the first few times I prescribed lithium, and I still do this with patients that I feel like need to hear it. I share my screen and I walk through the, it's a Google Doc”

“I do think there's enough evidence so far to at least mention that this seems to be something that is a positive effect of lithium in preventing dementia. Especially in bipolar disorders”

“You need to be open to updating your formulation. And like I said, working with the patient and describing what you're seeing and then giving them the options within certain parameters”

“the onset of effect of lithium takes at least two weeks most of the time. So that's the problem with the mood stabilizers. I think that's why a lot of people don't use them today, because they want instant gratification as a clinician and a patient. You have to set expectations”

“The mood stabilizers decrease the number of episodes. Yes, it helps with depression but it's very slow. Yes, it helps with mania but it's pretty slow. The reason why I find treating bipolar so fun is because you say we're playing the long game”

“if you don't tell people that, then it's very normal for them to say, wow, I'm taking this mood stabilizer. I feel tired and depressed. I should stop it”

“But I say to people with bipolar disorder and to the clinicians, please give the mood stabilizers a fighting chance. You may find that things go better for you body health wise, mind health wise in the long term”

“If they think about a leather car seat, it's been sitting out in the sun, they never oil it, it's going to get all crackly and crusty and broken. And that's what the brain looks like without the proper oils”

“it's essentially treating the perception of physiological arousal as a threat. If you can perceive physiological arousal as non-threatening, relatively speaking, or even as excitement instead, you will be able to modulate your body response. It's not something you can do overnight”

“The side effects are going to be certain side effects are going to be as bad as they're going to be when you first start the medication. And it takes about three days for it to kind of level out. And usually about one week until you start to feel a little bit normal”

“You want to process those emotions and reorient towards the major purpose of the mindfulness practice, which is long term change. Just like the way we counsel patients on that, you know, this SSRI is not supposed to make you feel happy right away”

“they just want the problem to be better fundamentally. And if you can orient towards that, regardless of what you're going to call it, even if you and the patient end up calling it two different things”

“I have to tell you, though, after just this one evaluation, I'm still not really exactly sure what you have. OK, I am hearing some evidence of possible ADHD type symptoms”

“I understand you really think that the medication is going to help you, but I don't really see any medical indication today. And so unfortunately, I'm not going to prescribe you anything”

“I'm not going to give any medications to anybody that are not clearly medically indicated. I don't want to give anyone anything inappropriate. And I think the best thing to do is if we can keep working together”

“stimulants are not something that it's not just a very safe medication that anyone can take. And I know you can go to another psychiatrist whenever you want, but I'd like to try to find out what this is instead”

“I know that you can go to another provider and get this diagnosis and get put on Adderall if you wanted to, but I'm worried about you. And I'm worried that, yes, maybe the Adderall will help you today and tomorrow, but these things have consequences”

“I think you need to dial back people who are in this situation and ask, what is important to me? What do I value? And what do I want my life to look like outside of work or outside of whatever I think these stimulants are going to do for me”

“you have to be okay with losing a few patients. And the way I formulated it, I was being considerate. It's not that I missed the diagnosis or I made a mistake. I wanted to make sure that I had the right diagnosis and I didn't just give a treatment to make it so that the patient kept with me”

“I pretty much say, hey, this works great for a lot of people. And for some people, it doesn't work at all and might even make the sleep worse. We don't know. Why don't you just try it out”

“they just want the problem to be better fundamentally. And if you can orient towards that, regardless of what you're going to call it, even if you and the patient end up calling it two different things”

“I have to tell you, though, after just this one evaluation, I'm still not really exactly sure what you have. OK, I am hearing some evidence of possible ADHD type symptoms”

“I understand you really think that the medication is going to help you, but I don't really see any medical indication today. And so unfortunately, I'm not going to prescribe you anything”

“I basically explain what diagnosis is for. Diagnosis is really for us to guide specific treatments under medical evidence. And I don't have a diagnosis for you at this time”

“I know that you can go to another provider and get this diagnosis and get put on Adderall if you wanted to, but I'm worried about you. And I'm worried that, yes, maybe the Adderall will help you today and tomorrow, but these things have consequences”

“you have to be okay with losing a few patients. And the way I formulated it, I was being considerate. It's not that I missed the diagnosis or I made a mistake. I wanted to make sure that I had the right diagnosis and I didn't just give a treatment to make it so that the patient kept with me”

“I pull up the criteria. And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma”

“if you're starting between the clinician and patient with a mismatch in conceptualization and understanding, then you'll have to get to a shared understanding of it more directly and specifically”

“I don't think through all the things that you've been through, you had the opportunity to do that. So rather than just throwing a medication at you, I think what's important is we work on getting you those skills and habits that you weren't able to have”

“It is, let's stipulate that someone has ADHD, okay? It is a neurobiological problem. It is a neurodevelopmental disorder. And you should also keep a calendar”

“The former is taking responsibility. It's recognizing that there's 10 things that have to go wrong to make that mistake. And maybe the disorder is a part of it, but it is not the entire thing”

“when I talk to people, adults that I see have ADHD and were never diagnosed, it's so common to see a history of being criticized when they were children because they weren't listening. They have a history of being yelled at by teachers, by parents”

“Recognize that, again, we're talking about a continuous trait and that for a lot of people, they're going to have ADHD symptoms that are going to impact them. So I think it'll be helpful to remove the idea that there's two categories of people with ADHD and people without ADHD”

“patients, I would recommend you try to come into your visits just talking about what your problems are. Don't come in with a diagnosis in mind. The process of diagnosis is so complex and fuzzy”

“It's like, well, what are the problems that you're having? And it took like four times to be like, no, no, no, let's slow down. Just tell me about the specific problems you're having”

“focusing on the cycling as the treatment goal and not the particular symptoms. I hope that's the one thing you take away. And I say this with every patient with bipolar, we're focusing on less ups and downs, not on a particular how you're feeling that day”

“The mood stabilizers decrease the number of episodes. Yes, it helps with depression but it's very slow. Yes, it helps with mania but it's pretty slow. The reason why I find treating bipolar so fun is because you say we're playing the long game”

“if you don't tell people that, then it's very normal for them to say, wow, I'm taking this mood stabilizer. I feel tired and depressed. I should stop it”

“We're not going to judge that as like laziness is part of the consequence of this shifted rhythm. We're going to help people cope with that”

“This problem you're having with concentration, these issues that you're having with sleep, that's what I'm medically calling a bipolar 2 disorder. And I'm expecting that with this medication, we're going to see improvements on both of those major issues”

“I take the approach that the diagnosis ought to be communicated to the patient, that we should not withhold the diagnosis or mentioning the diagnosis. First off, I mean, it's hard to comment sort of broadly about this because I do”

“every single time I've had this conversation of whether I say you have borderline personality disorder or I say there absolutely are traits, the conversation has gone really well. Most patients really just want help”

“I think that the conversation going well or good is not about so much the specific words you use. It's about what you feel inside. If you truly feel care and that you want to help, patients”

“it's persistent problems in thinking and feeling about yourself and other people in relationships that comes from a combination of inadequate parenting for any reason combined with very strong tendency towards internal negative emotions”

“it surely was not your fault that you developed this condition. Now, there may be certain things about your biology that contributed. And most certainly there were certain things about what you experienced in life that contributed to developing this condition”

“The heritability of borderline is 40 to 60 percent. Just for comparison, major depressive disorder is in like the 35 to 40 percent range. Generalized anxiety disorder is 30 percent. Schizophrenia, which I think of as one of the more biological conditions, is 75 to 80 percent”

“the natural course of personality disorders, even without treatment, is to get better. The problem is that not all of it is going to get better. And the way it gets better seems more like the behaviors change more so than the underlying condition gets better”

“once you have the assessment that you feel like it's more of a borderline personality disorder than, say, ADHD or depression, And framing those symptoms in the context that they are secondary to interpersonal dysfunction is crucial”

“I ask, what's your understanding of what this means? Because... It's very interesting that it's very possible you and the patient will be in agreement with a diagnosis, but then you hear what they think that actually means”

“calling a personality disorder is a wild thing for some patients. And we can't cram them in a box. And I feel like the borderline concept would give us a vocabulary for talking to patients that would allow us to say, this isn't a mood disorder”

“Instead of telling someone, hey, you have a personality disorder, sucks to suck, you can say this is one way to think about your problem. And the good news is calibration can change. You can engage in the process”

“they try to find and form an exclusive relationship with someone that meets all their needs. And this inevitably creates tension. The other person feels like they're going to get swallowed up, like they're going to get, I don't know”

“if you communicate to a patient like, oh, this is going to fix your depression, they're going to get really, they're going to have hope and then they're going to get really disappointed when, you know, after a month and the idealization of the medication wears off and they're right back to where they were”

“I found that patients really appreciate this psychoeducation in that like, uh it goes really really well and they actually appreciate that they have a psychiatrist that is considering underlying problems um and considering the whole picture rather than being told okay let's try the next one”

“What I say to trainees is, I don't care what you call it. Give the right treatment. And that's my approach. And so whatever a patient prefers to call something, we're going to go ahead and call it that”

“worry less about what you call something in terms of a single label worry more about your overall understanding of yourself and how your clinician understands you and whether you guys agree on that and whether you agree on the treatment plan”

“I ask, what's your understanding of what this means? Because... It's very interesting that it's very possible you and the patient will be in agreement with a diagnosis, but then you hear what they think that actually means”

“for complex PTSD, the book I very commonly recommend is Complex PTSD from Surviving to Thriving by Pete Walker. It's written by a person who has complex PTSD”

“really slowing down and explaining what's going on and why it's not, oh, you have depression, that's why you feel bad now. You have anxiety. That's why you feel bad now. But this is what's the process that's going on. It helps patients. It helps families understand better”

“I do think there's enough evidence so far to at least mention that this seems to be something that is a positive effect of lithium in preventing dementia. Especially in bipolar disorders”

“I'd rather a patient safely taper off and safely be monitored than tell a patient they need to be on a medication and have them not follow up. Autonomy is one of our guiding principles”

“we what I recommend is trying for silver metal where you're in your bed, your eyes are closed. You're not asleep, but you're in a restful state, which is productive. So shoot for silver. Don't shoot for gold and fail and just fight sleep”

“do not use any technology invented after 1980 after 10 p.m. or maybe even 9 p.m. depends on your schedule”

“I see almost every single time you see this crazy REM rebound that they're having these crazy dreams that are causing them to wake up. I tell them that their brain has had dream sleep suppressed for a really long time and their brain is now exploding with dreams”

“there's no way you can, some people are like, oh, I want more REM sleep or, oh, I want more deep sleep. It's not like that. It's not like more REM is good or more deep is good. You're really trying to get a balance”

“I just described like it's 4am um I've been sleeping for six hours and it actually worked really well. It helped me calm down, which is not the purpose of it, but it did work”

“diagnosis is for medical purposes. It's just a very small way to capture a certain specific problem in your life. It doesn't explain everything about you as a person, and it still doesn't even explain your problem fully”

“If you can begin to conceptualize a problem that you have as something that isn't fundamentally part of who you are, Isn't fundamentally something that you have to have or do, then you stand to have more hope of changing and improving”

“I think it's important to think of, how do you relate to your diagnosis? When you say, I have depression, what do you mean by it”

“what's important is that these zippers on the inside, you know, that you get to control. Who it is that you tell, what you tell, and how vulnerable you want to be with that person”

“our minds are meaning making machines and our minds automatically find things to cling to to make sense of our experiences”

“if you are the it guy and you never talk to anybody in person and you work from home You might not be as impaired by your lack of showering. But if you're in sales, that's a real impairment”

“the concept of intrusive thoughts provides a container for their experience to help understand what's going on so it doesn't feel like all these wild, called unexplainable thoughts, and in a sense, contains them and makes them feel much better”

“the motivation is not to stop or remove the intrusive thoughts or the feelings. ERP doesn't remove the thoughts or the feelings. So I teach patients they shouldn't be doing it with the hope that they'll be cured or that they'll stop having the thoughts”

“telling patients that OCD is a chronic condition. It's not something that is cured. So, you know, patients who have successful rounds of ERP, it's expected to have setbacks. It's expected when there's a stressful period, you know, death of a loved one, hard loss of a job or something”

“This problem of concentration you have, this problem focusing and not being able to get the schoolwork done, I'm not so sure it's ADHD. It really does seem like that it's your high level of obsessions, compulsions and related anxiety”

“if they don't understand why we're doing the exposures and why would they... willingly subject themselves to that pain, right? It doesn't make sense. So we got to give them some kind of understanding of the disease and a hope”

“I use my hands to show feedback loops because I think something visual is helpful. And I shake my one hand and I say, what happens is you experience a little bit of anxiety and then you start having thoughts of, oh God, I'm having a panic attack”

“there is a minimum level of anxiety, panic, and distress that everyone has to have. Okay. Life is hard. Life has a lot of scary and bad things about it. There's a minimum level of suffering”

“Your personality is the way that you are used to dealing with yourself and other people and how you think and feel about yourself and other people. And where does that come from? It comes from the things that you went through growing up and who you are as a person”

“personality is not about you being a jerk. Basically, it's what you've learned and who you are based on how you've been raised and the things that you've been through”

“Telling someone they have a personality disorder is about the most invalidating thing you can do. Right. I mean, it's it's it's it's frankly insulting. And, you know, a lot of patients aren't going to engage in that”

“I think the DSM writes its personality disorders in a way that makes it extremely difficult to communicate to patients because it's as if each diagnostic category has been written by someone quite mad at a patient”

“You're telling me that to understand myself, I need a diagnosis that 80% of practitioners are going to negatively judge me and interpret my thoughts, behaviors through this pretty hurtful lens”

“be very careful about the possibility of any diagnosis, but particularly culturally laden or emotionally invested diagnoses in functioning as a form of resistance to appropriate treatment, consciously or unconsciously for patients”

“Don't be afraid to diagnose personality. You're not doing it. You shouldn't be doing it to punish patients. You're doing it because you want to be a good clinician and you want to correctly identify which things should be treated with psychotherapy and which things should be treated with medications”

“I think you always have to start with what's the problem for the patient. What is the patient able to see as a problem? And sometimes they see zero mental health problems. So then you'll have to externalize”

“i don't think i would ever say um not purposefully to one particular patient that's not real or that isn't reality i might suggest it even strongly uh most of the time it would be to ask them if they're willing to consider an alternative interpretation as reality”

“I know we don't disagree. I know we don't agree that it's an appropriate treatment for you. But medically, as your doctor, I am recommending it. I think you should continue it because I think it is going to help you”

“I strongly believe that psychotic disorders are not a matter of personality or development and are a matter of just something that happens to the brain, like epilepsy”

“I tell every patient, this medication is not going to solve your problems. This medication is not going to take over, take over, take away the fact that you had these traumas, but it'll help”

“just because you have a white coat and a stethoscope, you do not deserve the trust of these patients. And it really needs to be earned. It needs to be acknowledged that it's okay to not trust me”

“I try to make it fairly clear that this is something that has happened to them both because of the traumas that they've had and also because of the response. That it's a rational but also perpetuating response to keep avoiding danger”

“The people who... develop the chronic ptsd it's not because they you know are little brats who refuse to expose themselves or weak people or something like that right”

“Don't be afraid. Just telling people that is not going to convince them. Right. But be afraid and nonetheless act in the direction that will get you to where you want to be”

“I pull up the criteria. And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma”

“I'd rather have a patient who says, doc, I don't have schizophrenia, but I take my clozapine than a patient who says I have schizophrenia, but I hate antipsychotics and refuse to take them”

“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”

“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”

“we know medically that these medications are going to help with things like fear stress level sleep and thinking process okay the thinking process will be more organized and less disrupted and therefore you'll be able to concentrate better and live your life better”

“So you really have to come to a shared agreement for what it is that you're targeting and the reasons that you're making these changes”

“don't sugarcoat things um and also like allow like empathize with patients for how annoying these medications can be. I think it's helpful. I think you have to stay hopeful but also stay realistic”

“you need to make sure to establish from the outset and to maintain that the patient is the primary agent in the treatment, even if they're conserved, okay? even if they're concerned, because ultimately we do want people to take medications voluntarily and knowingly”

“I think in the majority of cases, they simply learn to go along socially. And you can actually test this. You can say, so do you have schizophrenia? And they go like, yes. Why do you believe that? Well, that's what the doctors tell me”

“I try to take a non... authoritative stance and that like, I'm not wagging my finger and saying this is, I don't have a moral problem with you going and doing these things. But you're saying you have a problem and I can see the problem”

“Don't argue with the delusions, but also don't agree with the delusions. Right. You have to keep in mind that when you live in the world of the patient, you're not. agreeing with the delusions necessarily”

“i don't think i would ever say um not purposefully to one particular patient that's not real or that isn't reality i might suggest it even strongly uh most of the time it would be to ask them if they're willing to consider an alternative interpretation as reality”

“unless it's directly interfering with a very key or emergent part of the treatment plan, you shouldn't work too much on it. Acknowledge that it's there. If the patient is distressed by it, you can talk a little bit about that”

“i notice you're getting a little different there it seems like maybe you're being bothered or this is a lot for you uh let's just go over some things right now can you tell me your name okay where are you right now who am i What's the color of the chair that you're on”

“I probably advise against fighting it. Part of that fighting response seems to pull people into a generalized fear or anxiety response that might make things work”

“a lot of people are also afraid that they're completely out of control. or can't do anything at all, or are almost unconscious during dissociation, which is not generally true”

“And don't tell patients if you're starting Abilify that they're not going to have weight gain because it's on the lower end. You will run into problems. Your patient will not trust you”

“it is, as you say, it's the most well-tolerated mood stabilizer by a long shot. And frankly, I like to phrase the SJS risk because of its rarity as an allergic reaction”

“The real point of this is to set goals however small and accomplish them. And if you find that you're not accomplishing them, make the goals even smaller because we don't want to produce even more stress over not setting goals”

“i also encourage patients to act anticipating failure. I want you to plan these goals with the understanding that you may not follow through with them, and that's okay. Simply putting the goal down is the first step”

“it probably helps with 50%. So if we keep trying different, different things, eventually you're going to be in one of the 50%. It might not be the amber glasses. It might be the sun simulator”

“in my clinical experience, people's attention is held very strongly by this story. So when you want to tell a story to facilitate a behavior change, this is a story that really actually is worth telling”

“It's really worth it for you as a clinician to go ahead and buy 10 pairs of the amber lenses that you want people to try and have them in your front office and then sell them back at your cost”

“Instead of telling someone, hey, you have a personality disorder, sucks to suck, you can say this is one way to think about your problem. And the good news is calibration can change. You can engage in the process”

“I don't think we're going to find the right medication that's going to make you feel that's going to fix the problems that you're experiencing”

“The biggest resistance for most people is the fear around memory and memory concerns. Having explicit conversations around what those risks are is really important as far as an informed consent is concerned”

“often it's their support, the support around them, husband, wife, parents, that has the most resistance to the idea of doing ECT because they've heard that it's going to wipe out their memory, it's going to turn my loved one into somebody completely different”

“it's critical for people to know that doing nothing is a treatment option. They can choose not to treat their disease, but doing nothing and allowing a disease process to run rampant or run its course can have profound impacts”

“Oftentimes when somebody is getting referred to me for ECT, the average number of medication trials is greater than 12. By the time they show up, they're feeling hopeless. They're feeling like this is the last stop on their journey”

“I have had to have some creative conversations around informed consent for individuals who had depression and were actively suicidal and they hear that under general anesthesia there's a chance of dying and that's their indication that they want to sign up”

“the motivation is not to stop or remove the intrusive thoughts or the feelings. ERP doesn't remove the thoughts or the feelings. So I teach patients they shouldn't be doing it with the hope that they'll be cured or that they'll stop having the thoughts”

“Don't be afraid. Just telling people that is not going to convince them. Right. But be afraid and nonetheless act in the direction that will get you to where you want to be”

“I probably advise against fighting it. Part of that fighting response seems to pull people into a generalized fear or anxiety response that might make things work”

“the purpose of the frame is not only to intellectually tell the patient what is actually going to happen, but also to try to establish some common ground between you and the patient”

“When I explain things to patients, it needs to be super duper simple. You don't want to add all these other layers of Buddhist thought and your own experiences of mindfulness because it can be too confusing and complicated”

“people should get a general idea of what it is, hear about the perils and pitfalls, hear about why it's going to be helpful and what ways it might not be helpful and what the goals are”

“I think this is a practice that's really going to help you. The medications might help you somewhat, but I think this is really going to help you in the long run in terms of getting better”

“There are a lot of different ways you can do this. You can be active about it. You can not be active about it. All I need is something like five minutes once a week”

“Don't expect it to make you feel good, because if you do, that's putting pressure on yourself. And don't expect yourself to try it in a way and do it perfectly. Expect to fail”

“Judging yourself for judging yourself is a type of judgment too. Just notice that you're doing it and try to put your attention back on whatever it is that you're trying to pay attention to. That's all you have to do”

“It's practicing so that you can start to understand the nature of your mind and understand how it works. And then when you practice in just short bursts a little bit every day, you have a little bit more space to react to the stuff that comes up”

“is to practice when things are calm and easy so that it helps during the more stressful periods. If you only practice during the stressful periods, you're going to be too ramped up to really kind of get the benefits or see it work”

“before I check in on it, I always go like, and by the way, often most patients don't follow up my recommendation. So no worries at all”

“if somebody tells you that they did try it, I think it's very important for you to take a neutral and inquisitive stance to get their genuine experience of it, right? We want to review with the patient and make sure That there isn't some kind of a false sense that they had to have enjoyed it”

“There's no use giving a diagnosis to a patient that they don't understand. OK, or that they can't explain in their own words based on what's happened in their lives”

“worry less about what you call something in terms of a single label worry more about your overall understanding of yourself and how your clinician understands you and whether you guys agree on that and whether you agree on the treatment plan”

“A lot of people come in with a very, very strong, almost culturally embedded idea of what they have. And sometimes that's wrong”

“I think denigrating your formulation is not helpful to the patient. What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it”

“I think we can and should give direct education advice on matters that are beyond the normal awareness of a layperson. So anything that is specific to the practice of mental health sciences”

“the medication is not the treatment. It's part of the treatment. And how do these work? You're not just going to start feeling happier. This is not a happy pill. What this medication probably does is that it makes it easier for you to change”

“if you don't tell people that, then it's very normal for them to say, wow, I'm taking this mood stabilizer. I feel tired and depressed. I should stop it”

“The mood stabilizers decrease the number of episodes. Yes, it helps with depression but it's very slow. Yes, it helps with mania but it's pretty slow. The reason why I find treating bipolar so fun is because you say we're playing the long game”

“we know medically that these medications are going to help with things like fear stress level sleep and thinking process okay the thinking process will be more organized and less disrupted and therefore you'll be able to concentrate better and live your life better”

“I don't assume that the patient remembers the side effects and the problems and all those things. So for medications, what do you start with? Start with an SSRI. I prefer Zoloft or Lexapro. More recently, I usually pick Zoloft first”

“It's always a balance of giving patients information about the medications and then causing a potential nocebo effect where if you say, oh, the nausea is going to be awful, then the nausea will be awful”

“the patient is seeing that there's more neuro connections after treatment. And then I'll talk about how lifestyle interventions, which I let them choose from, I give them a menu and I don't want to overwhelm them. So I have them really just do one intervention”

“We don't plan on feelings. They really come and go. There's not a lot of really control you have over the flow of your feelings. If someone says, just get up, feel better, let's go to a movie, you can't just make yourself feel something differently”

“I'll just move on up. This is the midbrain. This is where affect comes from. These are where your ancestral inheritance, these are where your emotional experiences, this is where this information comes up. And as we move up, there's a primacy on the influence of information”

“Extinction really is growing new inhibitory connections. So it's all about growth. We don't delete old memories. We don't delete things. You just grow new ones”

“people should get a general idea of what it is, hear about the perils and pitfalls, hear about why it's going to be helpful and what ways it might not be helpful and what the goals are”

“a lot of people are already trained to expect that you're there to throw a medication at them. That's why they're seeing you. Right. And if therefore, if you don't take active steps to show that the treatment process is more than the medication, then that's the natural assumption”

“I think therapist skill has enormous variability. And when a patient says, you know, the therapy didn't work, the analogy I like to work is if someone says like, oh, I read a book and it didn't help. Well, what book did you read”

“the easiest way to tell if you are in a good therapy or not is how your therapist responds to you bringing up issues about being in the therapy itself”

“we want to teach patients explicitly that emotions, while they're unpleasant, are not in themselves dangerous”

“Don't talk to them. Listen to them. Why is it that you are going to bed at two in the morning? How did you get there? And acknowledge because they certainly recognize it would be a good idea not to be doing that”

“I think it's best to just get a good sense of what they're actually going through and doing at night and then asking them what they're willing to change by the next visit. Small steps, even if it's one small thing, even if they're going to try it once”

“You'll hear all the time like, oh, no, my sleep's good. I sleep five hours a night. Trust your heart. Yes, there are some people who can sleep five hours and function great. Those are rare, rare, rare, rare exceptions”

“Don't talk to them. Listen to them. Why is it that you are going to bed at two in the morning? How did you get there? And acknowledge because they certainly recognize it would be a good idea not to be doing that”

“When I say mood stabilizers, I'm not saying lithium and Depakote. I'm saying things like sleep. I'm saying things like diet. And framing it that way is so helpful”

“Then you exercise, you run around, and then around 5 to 6 p.m., the sunlight slowly goes down, and then you have no light whatsoever from 7 to 10. You fall asleep naturally at 10, and then you wake up to the slowly rising sun, and that's the perfect idealized rhythm”

“You need to explain why this is important. You can't just say like, okay, let's get you sunglasses. Let's get you waking up at the same time because they'll be like, why? I've woken up early. I hate it. So first you have to build motivation and explain why we're doing this”

“We're not going to judge that as like laziness is part of the consequence of this shifted rhythm. We're going to help people cope with that”

“And if I were to just, you know, be paternalistic and be like, no, you can't do that. The patient's just they're not going to listen like they're, you know”

“A doctor can't talk to you for 45 minutes and know with 100% confidence what your diagnoses are. And you essentially can't rule out conditions by meeting and talking to someone with 45 minutes”

“a good clinician, their motto should be never say never, right? It's not, you absolutely don't have this. It's that my working theory is currently this, but we're going to continue to screen, monitor, and watch out for XYZ”

“work actually provides a structure that's very protective for a lot of conditions. So when you're doing these disability assessments, you need to be talking to the person about the downsides of disability”

“When we give disability paperwork, you should also advise the patient in the same way that you do with medications about the risks to the benefits”

“Human beings fundamentally do not like to do nothing. They like to create things. They like to connect with each other and they like to generate”

“Asking about self-harm is standard. It should be standard in every single encounter with a patient”

“being transparent as to how you're thinking about the case can help the patient understand why you want the information. Not just that if he says you sent the text, then you're going to be locked away forever”

“being honest with a healthcare provider of any kind is key for you to actually get better”

“You should be advising patients about risk of suicidal ideation and agitation from SSRIs. Again, this is really primarily probably in bipolarity, but it is a risk”

“I'll just move on up. This is the midbrain. This is where affect comes from. These are where your ancestral inheritance, these are where your emotional experiences, this is where this information comes up. And as we move up, there's a primacy on the influence of information”

“Extinction really is growing new inhibitory connections. So it's all about growth. We don't delete old memories. We don't delete things. You just grow new ones”

“it surely was not your fault that you developed this condition. Now, there may be certain things about your biology that contributed. And most certainly there were certain things about what you experienced in life that contributed to developing this condition”

“Important for me not to lose therapeutic alliance by being like, you're wrong. They're terrible for sleep. I explained to them, it's like, you're right. So it does help you fall asleep”

“Other things, alcohol and marijuana massively negatively impact sleep architecture. It's worth telling patients, why don't you try going off of it for a little bit”

“I'd like you to get used to accepting suffering. There's a minimum level of suffering and anxiety that you have to live with. And if you accept that, you won't make it worse”

“telling yourself I'm having a panic attack is very different than telling, and we'll get to that in a second, but I'm having an adrenaline release. Like how you frame these things is really going to change how you respond to them”

“it's essentially treating the perception of physiological arousal as a threat. If you can perceive physiological arousal as non-threatening, relatively speaking, or even as excitement instead, you will be able to modulate your body response. It's not something you can do overnight”

“The side effects are going to be certain side effects are going to be as bad as they're going to be when you first start the medication. And it takes about three days for it to kind of level out. And usually about one week until you start to feel a little bit normal”

“I try to make it fairly clear that this is something that has happened to them both because of the traumas that they've had and also because of the response. That it's a rational but also perpetuating response to keep avoiding danger”

“I'll have to insist this is still a medical relationship. The reason why we're meeting is for your good. I'm not just here to be friends. I'm your doctor too”

“I'm not feeling those feelings. And what I feel is care for your well-being as a patient. That's my job here. And that's always going to be my job as long as we're working together”

“it's actually very common to develop feelings that might not make sense about your treatment provider, including myself, doesn't mean that it's real. And certainly it would interfere with your treatment if we take it as anything other than a sign of your underlying thoughts and feelings”

“in any situation like this in the doorknob common you're going to be thrown off kilter as a clinician So you better try your best. You're going to fail sometimes to keep your composure and try to keep it warm, interested, and connected to the next session”

“Important for me not to lose therapeutic alliance by being like, you're wrong. They're terrible for sleep. I explained to them, it's like, you're right. So it does help you fall asleep”

“I see almost every single time you see this crazy REM rebound that they're having these crazy dreams that are causing them to wake up. I tell them that their brain has had dream sleep suppressed for a really long time and their brain is now exploding with dreams”

“I always save the last like 15 minutes for discussing my case formulation. And patients at the end are like, oh, you're definitely not a reductionistic kind of doctor”

“if you can explain this patient's problems in a way that a completely uneducated person will understand, that's better because that's how you should formulate with the patient in plain language”

“you need to gather enough information together with the patient to string it together into a story that they're going to accept”

“I think a lot of providers have a tendency to let things go unsaid. And it mucks up the treatment”

“with bipolar, you're teaching about the long game. I think he had a quote. I think he said I got it from a mentor of you're not trying to treat the symptoms. You're trying to stop the cycling”

“our body loves, like, we evolved in rhythms. We evolved in that there's a night and a day. There's seasons. The, you know, the tides. Like, everything has rhythms and regularity”

“Then you exercise, you run around, and then around 5 to 6 p.m., the sunlight slowly goes down, and then you have no light whatsoever from 7 to 10. You fall asleep naturally at 10, and then you wake up to the slowly rising sun, and that's the perfect idealized rhythm”

“You can say, this is what's on my differential. This is why I think that. And time is the only thing that's going to tell us what the actual diagnosis is”

“as I get more and more experienced, the amount of uncertainty I have goes up and up. And the amount of times that I communicate to patients, I say almost at the end of every intake, I wish I could talk to someone for 45 minutes and tell them all their problems”

“I think patients always know when you're documenting and I think we've got to be open about it. In fact, I'll even sometimes say, give me a moment. I don't want to write that down. I don't think people mind if you document. I think what they mind is if you're doing things that really aren't about their treatment”

“you, the patient, are the only... Single person who can coordinate the care and report everything to everybody”

“I'm going to define it as getting the patient to talk more to continue their narrative without changing the trajectory or content of the narrative”

“you may find that you get a richer narrative or more information that you would not have gotten if you prompt people to continue talking on one line of thought one line of narrative rather than asking specific questions”

“it's important for psychiatrists, clinicians, psychologists, therapists to have a wide variety of hmms and hmms in their You know, in their back pocket to try out nonverbal acknowledgement sounds very important, right”

“You can say, you know, I can feel how sad you are touching on these memories again right now. Just by saying that, you may cause the patient to continue speaking”

“You basically punctuate by basically emphasizing some particular word or turn of phrase that someone has just said to you. Okay. You're not introducing new content, but you're just sort of highlighting something that they've said”

“I'm not feeling those feelings. And what I feel is care for your well-being as a patient. That's my job here. And that's always going to be my job as long as we're working together”

“it's actually very common to develop feelings that might not make sense about your treatment provider, including myself, doesn't mean that it's real. And certainly it would interfere with your treatment if we take it as anything other than a sign of your underlying thoughts and feelings”

“You're going to be on a controlled substance that causes addiction, withdrawal, executive functioning problems, memory problems, sedation, and it probably slows your ability to improve yourself in the psychotherapy as well. And I might be happy to give this to you, but I can't say that if you have to change doctors”

“The biggest resistance for most people is the fear around memory and memory concerns. Having explicit conversations around what those risks are is really important as far as an informed consent is concerned”

“a part that gets lost in the conversation here is that even if one medication carries the same risk across the population, that risk becomes more salient. when the condition you're treating is either less serious or less responsive to that medication”

“my responsibility here is to really do a thorough assessment of you and what happened. and to figure out whether it's safe for you to leave and there's really no way for me to do that unless we can talk to each other”

“it helps to understand that the law is keeping them hospitalized, the law in society. Right. There is just a system of rules that we've vaguely agreed upon as a system to execute for good reasons”

“With a sufficiently involuntary oppositional patient, you can only make your observations based on that interview. It generally does prolong the time that they have to be involuntarily detained”

“There are patients who will genuinely believe that And it will be true at the time of the interview that they are not dangerous in some fashion. And then they will go kill themselves or hurt somebody else within 24 hours of release”

“It is, let's stipulate that someone has ADHD, okay? It is a neurobiological problem. It is a neurodevelopmental disorder. And you should also keep a calendar”

“True ADHD is not just responsive to medication. It is treatable through medication. Psychotherapy, skills, changes in your life, changes in what you do”

“I think you always have to start with what's the problem for the patient. What is the patient able to see as a problem? And sometimes they see zero mental health problems. So then you'll have to externalize”

“You need to ask, what do you see as the major problem that you're having? And then you need to compare that to your conceptualization of the problem. And then you need to talk openly with the patient about, do we agree on this? Why or why not”

“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”

“I know we don't disagree. I know we don't agree that it's an appropriate treatment for you. But medically, as your doctor, I am recommending it. I think you should continue it because I think it is going to help you”

“your priority is keeping the patient in treatment and monitoring. And in treatment is not on a medication necessarily. In treatment means engaged with monitoring and follow-ups”

“I literally say to the patients, like the way I think about it is we don't do labs because this medication is unsafe. It's because we're doing this labs, this medication is extra safe”

“if they're better, I say, hey, by the way, don't be surprised if things get worse again in the future. That's life. But at this point, you've picked yourself up out of this and you know what to do next time”

“there's a way to frame beliefs that will keep you from progressing. And there's a way to frame them that may give you a chance to progress. And that's why I frame it that way. So, you know, you've heard this before. Don't argue of overvalued beliefs or delusions”

“unless it's directly interfering with a very key or emergent part of the treatment plan, you shouldn't work too much on it. Acknowledge that it's there. If the patient is distressed by it, you can talk a little bit about that”

“And if the patient's sending intrusive emails, I've gotten more and more comfortable with saying like, you know, talking about it. This is not how I really work. Why do we think we're having this? Talk about patients who are sending me emails. Talk about the content of the emails”

“if you give a PRN, you're going to reduce the important teaching point. And I think the important teaching point for improving with anxiety is being able to trust that you'll be okay and trust that you're able to handle something”

“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”

“i said you know i don't know what you have i don't know if you have anything at all you could have something you might not there's definitely some stuff we are seeing here uh in the past from you that suggests there's something but i can't tell you what it is”

“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”

“There's no use giving a diagnosis to a patient that they don't understand. OK, or that they can't explain in their own words based on what's happened in their lives”

“naming a condition can reorganize a person's narrative and that reorganization can reduce stress. So labels can help or harm depending on the accuracy and the fit and the person”

“I basically explain what diagnosis is for. Diagnosis is really for us to guide specific treatments under medical evidence. And I don't have a diagnosis for you at this time”

“every single time I've had this conversation of whether I say you have borderline personality disorder or I say there absolutely are traits, the conversation has gone really well. Most patients really just want help”

“once you have the assessment that you feel like it's more of a borderline personality disorder than, say, ADHD or depression, And framing those symptoms in the context that they are secondary to interpersonal dysfunction is crucial”

“I think denigrating your formulation is not helpful to the patient. What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it”

“the purpose of a diagnosis is to further the treatment. So if disclosing a confirmed diagnosis, even one that you believe, would definitively and you know would hurt the treatment process or the patient or interrupt it in some unrepairable way, that is a reason to at least temporarily withhold it”

“Nowadays, people come in and they say, I have disorder X, disorder Y, disorder Z, and I heard about it on TikTok and this is exactly who I am. And when you try to take that away from them, you're going to face a lot of resistance”

“ideally, that would be a process that's Done over a course of time, when there's a good working alliance, when the patient feels comfortable with you, when the patient trusts your judgment, when the patient has a sense that you actually know what you're talking about”

“I blame society and the practice of medicine and mental health because we've given sort of an impression to the layperson that they are the expert in their diagnosis. They are the expert in their lives. They are the expert of their experiences, and we need to respect and understand that and get that out of them”

“You seem irritable today. What do you suppose is going on? The way we're interacting now seems to be kind of bringing up a lot of irritability. We're not really on the same page. What do you suppose is going on? Probably much more effective”

“I notice that as we're doing this, it seems like I'm irritating you and I don't blame you for that. These are annoying questions. I'm sure you've been asked about them a lot and might not seem clear right away why I'm asking so much or in this way”

“This problem you're having with concentration, these issues that you're having with sleep, that's what I'm medically calling a bipolar 2 disorder. And I'm expecting that with this medication, we're going to see improvements on both of those major issues”

“i said you know i don't know what you have i don't know if you have anything at all you could have something you might not there's definitely some stuff we are seeing here uh in the past from you that suggests there's something but i can't tell you what it is”

“I'd rather a patient safely taper off and safely be monitored than tell a patient they need to be on a medication and have them not follow up. Autonomy is one of our guiding principles”

“I strongly believe that psychotic disorders are not a matter of personality or development and are a matter of just something that happens to the brain, like epilepsy”

“I pull up the criteria. And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma”

“Instead of telling someone, hey, you have a personality disorder, sucks to suck, you can say this is one way to think about your problem. And the good news is calibration can change. You can engage in the process”

“It's not that the whole system of personality is broken. It's this one thing that's causing much bigger problems than it needs to. And then they're constantly kind of making up for it”

“You have to tell patients how not getting this can result in missing diagnoses or making the wrong diagnosis and therefore getting the wrong treatment and bad effects from it”

“I tell every patient, this medication is not going to solve your problems. This medication is not going to take over, take over, take away the fact that you had these traumas, but it'll help”

“You really got to know what the general effect size of SSRI is. You shouldn't oversell it, right? Because if you oversell it, you're going to give people the false impression that this is a powerful medication that's going to change your problems”

“I like to link the mechanism to things that empower them rather than making the mechanistic explanation sound like something that makes them depend purely on a drug to boost their serotonin”

“even for the most biological mental disorders in psychiatry, treatment is something that really happens on the order of, at minimum, two or three months. OK, if you get a major effect within a few weeks, most of the time, that's a drug, not a medication”

“the onset of effect of lithium takes at least two weeks most of the time. So that's the problem with the mood stabilizers. I think that's why a lot of people don't use them today, because they want instant gratification as a clinician and a patient. You have to set expectations”

“8 out of 10 anger, not 10 out of 10 anger. I don't know. You'll have to tell me what you feel. This might be a good effect. If you have one less big fight with your partner a week where you yell at your kids less, this might be a good medication for you”

“I tell them it's antipsychotic, but I also tell them the truth. And the truth is that second generation and first generation antipsychotics are indicated and used in a variety of different conditions, right”

“You really got to know what the general effect size of SSRI is. You shouldn't oversell it, right? Because if you oversell it, you're going to give people the false impression that this is a powerful medication that's going to change your problems”

“You'll have to tell me if it's something that's helpful for you or not. Mm-hmm. And that's going to be different with every patient”

“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”

“If you're prescribing these things from a stance of, I am a gatekeeper, I give you the meds and this treats your thing, you're going to have so much worse outcomes”

“don't sugarcoat things um and also like allow like empathize with patients for how annoying these medications can be. I think it's helpful. I think you have to stay hopeful but also stay realistic”

“I take them not as trying to manipulate me, not as trying to get this drug. I take them as an innocent person who heard that Xanax is helpful for anxiety and calmly lay out my reasoning as to why I don't think it'll be helpful long term and why we won't be going that route”

“I tell all the patients with trauma disorders that the medication is supporting their treatment but that the primary treatment is the things that they're doing in their lives and the psychotherapy if they're willing to engage with it”

“Important for me not to lose therapeutic alliance by being like, you're wrong. They're terrible for sleep. I explained to them, it's like, you're right. So it does help you fall asleep”

“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”

“a lot of these substances, they can cause effects in the brain, sometimes short term, sometimes long term, that can really make things confusing, both in our treatment of you with medications and in our diagnosis”

“Don't talk to them. Listen to them. Why is it that you are going to bed at two in the morning? How did you get there? And acknowledge because they certainly recognize it would be a good idea not to be doing that”

“it's actually very common to develop feelings that might not make sense about your treatment provider, including myself, doesn't mean that it's real. And certainly it would interfere with your treatment if we take it as anything other than a sign of your underlying thoughts and feelings”

“I try to be extremely clear about two things. Why we're meeting, basically the modality of the treatment, and also diagnosis. Okay, and treatment recommendations”

“a lot of anxiety for anyone is just being untethered, not knowing what to expect. Right. So if you can set and keep expectations, that is how you show that you and the treatment are trustworthy”

“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”

“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”

“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”

“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”

“And if the patient's sending intrusive emails, I've gotten more and more comfortable with saying like, you know, talking about it. This is not how I really work. Why do we think we're having this? Talk about patients who are sending me emails. Talk about the content of the emails”

“If it's important enough to be your primary treatment diagnosis, if it's important enough to go on a bill somewhere, you should at least explain it”

“Have it so that they know that if they do this, this is going to occur. And those expectations are very comforting. They're protective”