What we’ve said about Medication management

“Your job is to give your formulation, give your treatment recommendations, and explain the benefits and the risks. And risks include not taking the medication”

“I don't view my role as fix the problem, make the person happy, and everything's great with medications. I view my role as, in a sense, I'm communicating to them their options, the options I'm willing to prescribe because I don't think that, I think that the benefits outweigh the negatives”

“we are really only experts in detecting pathology, illness. And so what we're trying to do is we're trying to identify what sets someone apart in some fashion that is a problem for their mental health”

“We're there to try to get as accurate as possible of a picture diagnostically and formulation wise of the patient in order to recommend them certain treatments, medications or other”

“A psychiatric treatment shouldn't be one medication and then you're done. That works for about 4% of patients. But the 96% of patients, they need something more”

“When I do medication management, I'm not trying to get you into remission forever. It's unrealistic. Okay. I want you to engage in a lifestyle and a process that gets you closer to the things that you want and further away from the things that you don't”

“I do recommend that medication management actually take place separately from psychotherapy, even if you're capable of doing both”

“how do you establish trust and safety in a treatment as a clinician? It's about regularity and a really solid and unwavering understanding of what you're there to do”

“if the time into the session has elapsed enough, let's say over 50%, so that you cannot have a meaningful visit, I'm not going to attempt to give the full visit. I'm going to tell the patient, we missed the time today”

“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 appreciate that. At the same time, I want to use the time productively. I want to talk about the things that help me figure out what to do with medications for you”

“I'd like you to schedule breaks. OK, I want you to work in 30 or 35 minute chunks and I want you to schedule another chunk with five or ten minutes. And I don't want you on TikTok or watching clips during that time”

“I'm trying to pair in ACT processes and skills and point people and be very clear, this is not therapy. You need to engage in actual psychotherapy”

“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”

“look at the diagnosis first and treat the diagnosis. Don't treat the symptom. You can't treat anxiety as this thing that we're supposed to manage with medications regardless of the cause”

“it's so much easier uh to just identify a cluster of symptoms and then prescribe a medication and talk about that medication. You can do that until the cows come home and you don't have to do any difficult work in terms of diagnostic assessment”

“The depression occurs after a breakup. The shutting down occurs after fights with parents. And they last shorter. They're not these things that last for three weeks. So that if I keep trying to throw different medications, I'm not fixing the underlying problem”

“we thought together of maybe it's something else going on other than OCD type symptoms and that this patient is putting us in this crazy situation of making this really complicated. Unlocated psychopharmacological switch”

“What needs to happen is oftentimes bringing in family, talking about the pros and cons of medications, talking to other people, hearing what other people say”

“don't give a medication unless the patient is almost begging for it absolutely certain that it's what they want and what they need”

“But I don't think you can do that at an initial evaluation necessarily. Now, of course, if you're doing med management and you're treating patients from a psychopharm perspective, you have to deliver that rather quickly because it's going to have implications with medicine and the patient's going to say, why are you taking off my stimulant and my benzodiazepine”

“we want to find the right clinical treatments for people. And if it's not a medication, that's important to prevent harm and to prevent wasting time with trying to treat a personality problem with a medication”

“Most people use vague heuristics to diagnose just a few of the major personality disorders, and then from there feel as though medications won't work”

“medications are secondary they're adjunctive we know that none of the medications are FDA approved for borderline personality disorder and none of the medications get to the core issues now you need to frame anytime you use a medication that we're treating a secondary symptom”

“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”

“if you're so focused on making a med change or getting a billable diagnosis, you can miss a lot by not paying very close attention to what somebody is bringing in”

“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”

“To me, it's the most practical training. And I feel like I approach, I use the skills so much in medication management in not just therapy”

“you're coming in here and we're talking about medications and it seems like you want to get better. At the same time, I can't help but notice that when we discuss the side effects of medications, you seem quite anxious about it”

“whenever they were mad at me, they wanted to taper off all their medications, and there was... multiple sessions that they would be in acute distress and would be essentially decompensated”

“you do see people play-acting psychoanalysts in once-every-three-months therapy, or once-every-three-months medication management, and I think that does more harm than good”

“don't try the trauma process when you're doing medication management. It's not appropriate. You don't want to teach patients to be afraid of the trauma memories”

“a lot of people think that dream analysis is the clinician interpreting the dream, but really it's up to the patient, right? So I just try to lead the patient and reflect on what do you think this could relate to in your life that's been stressing you out”

“if making dreams a regular part of medication management is, is helpful. Um, just because I feel like it's such a personal intrapsychic process, um, that really requires, in my opinion, uh, like therapy, regular meetings”

“for patients that are really pushing boundaries, the boundaries aren't nuisances that get in the way. They are the treatment. So when I'm too flexible on boundaries, when I'm too forgiving, when I'm too like I don't acknowledge my own boundaries, I don't acknowledge my own resentment towards patients”

“there's not a clear literature that provides instructions on what to do in the monthly medication management visit”

“exploring sexual fantasies is not a normal part of medication management right and if you are starting to do something in the medication management that is markedly different from what you do with other patients that's a red flag”

“you're acknowledging what's going on without encouraging enactment at all. You're recognizing the feelings, but not colluding, not reciprocating. You're not reinforcing the fantasy”

“I appreciate you telling me that. I'm curious by what you mean by special. As I see it, we have the typical special. doctor-patient relationship that I try to have with all my patients, you know, a good working alliance”

“If we can't move forward together without this getting in the way of focusing on your treatment, it's the best thing for you if we can find you a new doctor”

“we can be curious about treatment and treatment theory and treatment recommendations, but I think in the end, we should be practical too. And we need to consider what's reasonable for a patient's values, goals, and their functioning”

“OCD medications are expected to reduce symptoms somewhere in the range of 30 to 40 percent. We're not curing OCD. We're not getting rid of their symptoms. We're reducing them so they can better engage in therapeutic interventions”

“workbooks do work for highly motivated and particular subset of OCD patients. And I also think... For that subset of patients that I identify, I do walk through and explain ERP and then give them the workbooks”

“I say, what do you think you spend the most time on? Or what's causing the most problems right now in your life? Is it hand washing? Is it the checking in on your family not being dead? Is it your thoughts of jumping in front of a train”

“the tier list that you use for medication should really be tailored to your patient population. Patient populations are different, and your diagnostic pool is going to be different, and so your treatment response is going to be different, too”

“formative early experiences are. I had a few early experiences where patients couldn't tolerate Lexapro, so I go slower. You had a formative experience with an SNRI. Those things, for good and for bad, change different clinicians' approaches”