Monday, January 14, 2008

Fill In The Blanks

This is kind of a How-To post, if that's okay. It's about "How To" start off a therapeutic relationship in such a way that the patient's ability to feel hopeful is optimized, and the patient feels confident about the Shrink's skills. We've talked about people getting to Shrink Rap when they Google "how to manipulate your psychiatrist." This post is going to have a tinge of "how to manipulate your patient." Sort of, not really. This technique works well for psychiatric evaluations and the beginning of psychotherapeutic relationships, but it works just fine for other medical specialties, and probably in any field where a client comes to a professional seeking help solving a problem. There's no science here, just my own observations of patients, and my own feelings when I've seen a doc.

I'll call the technique Fill in the Blanks, but I'm not sure that's quite right. It could also be You're the Type of Person Who....

Quite simply, people feel a degree of confidence in a doctor who understands them, who helps them rephrase their feelings with new words that resonate, who knows things about them before being told. If the doctor can predict the future, well that's helpful, too.

So I'm struggling a little to really explain this and I don't have a great example. Often it boils down to saying to people, "You're the type of person who...." Here's an easy one that I often resort to: I can usually get a quick handle on whether someone is an introvert or an extrovert, and from there it's easy to make some quick assumptions about them. To an extrovert: You live in the moment, you sometimes forget that things will get better soon. To an introvert: Sunday nights are hard for you, you tend to get anxious about the upcoming week.

There are some basic Fill-in-the-Blank rules:

  • In the course of telling a stranger about themselves, it's important to eat your words quickly if the patient tells you it's not true. If the patient says "actually I'm not that kind of person at all," the doc should ask, "What kind of person are you?" No one wants the blanks filled in wrong (even if the doc is right!), it leaves the patient feeling unheard, misunderstood, and rapport and confidence are killed. If someone is a touchy type of person who is easily offended, they may read too much into such statements and Fill-in-the-Blanks is risky.

  • It's good to Fill in the Blanks with positive things about people. "You're the type of person who would sell your children as sex slaves to get your next drug fix" doesn't work. "You're the type of person who does a great job taking care of other people but doesn't always take the best care of yourself" is a better risk-- it paints the patient as selfless. ClinkShrink is the type of person who is always polite to everyone. Roy is the type of person who is always up for a new challenge. Dinah is the type of person who is always happy to eat a good meal with a friend.

  • Perception is more important than fact. If the patient feels understood, it doesn't matter if the interpretation is perfect. "You have a strong moral code and sometimes this causes you to be angry at people who cheat the system." If it works for the patient, don't worry about the fact that they plagiarized a term paper or shoplifted a few times.

  • Watch their face: expression says it all. People nod and light up when they feel understood. Some people are compliant and will say "Yes, doc" to everything. If they get grit their teeth and eye the vase to throw it at you, you've got it wrong. If you're fumbling, just say so. "I have the sense I've got you pegged wrong. Can you help me here?"

  • It's okay to lie a little, but not a lot. Well, not really lie, but I tend to be reassuring in a way that may be more powerful than I can know for absolute sure. From your story, you've had a few episodes of depression before and they've always resolved, this one will resolve too." People feel buoyed by hopefulness, they don't tend to come back and say "You promised I'd get better and I didn't." So far (should I even say this?) no one has demanded a refund. But don't lie a lot-- if the patient has two weeks to live, it's poor form to assure them that their terminal condition will resolve.
Coming soon: a series on benzodiazepine use.


Rach said...

Great post as usual Dinah.

If anything, I don't think this is a matter of manipulation, merely yogic ability.

Generally, if people continue coming to see a practitioner (with very few exceptions, it would seem), they are buoyed by something (even if it's just the knowledge that they are going to be listened to and the center of attention for 45 minutes).

In my own experience, it's often what the practitioner doesn't say that makes me feel confident or concerned about how the conversation/discussion is going.

NeoNurseChic said...

Just wanted to let you know that your poll led to quite a discussion with my psychiatrist today. I brought it up as a way to get into things that I find difficult to talk about. It led to a pretty good discussion, filled with a lot of anxiety from me, but also a lot of honesty and I hope a little less self-censoring than usual. Just thought I'd share. I'm at a point in my therapy where I want to push myself to discuss the things that have always been difficult for me - not every time, but sometimes - so your poll about what is the most difficult to talk about worked very well to get me into that discussion!

Thanks :)
Carrie :)

Anonymous said...

I feel like I am about 8 years old the moment I step into Shrink's office. I shrink.

I always hate him and I always love him and I never believe I will get better.

It is a very, very, very weird feeling and one I do not have with Therapist.

I am constantly angry and so I am looking for doc to be wrong, and when/if he is, I will make sure he hears about it in no uncertain terms.

I will not appreciate guessing games. You either know me (therapist) or you don't and you are in the process of getting to know me (psychiatrist). I will brook no bs.


NeoNurseChic said...

OT but are you watching American Idol tonight? It's in Philadelphia!! And just think - I coulda been there! I can't believe I backed out of the idea of going to audition.... It was just because of committee work and also because my parents thought it was a dumb idea for me to audition. *sigh* Next year maybe! :-D

Take care,
Carrie :)

Anonymous said...

Rach: Thanks!

Carrie: I didn't see American Idol and I'm glad Shrink Rap inspired you. I would have voted for you.

Anon/Lily: I think you may be the type of person who doesn't like people to tell you what type of person you are.

Anonymous said...


You are so cute I just want to hug you sometimes. You made me laugh : )


Anonymous said...

You are the kind of shrink who has a clever way with words, doesn't have a god complex, cares deeply but is enough of a pragmatist to know when not to get involved, and has repressed feelings for cats even though you are a dog person. You have never ridden a dirigible, but you don't lose sleep over it on an overwhelming majority of vernal equinoxes.

There is a decision you have been putting off, but today you'll have the opportunity to receive sound counsel from a colleague you respect. Also, avoid open flame.

Did it work?

Dinah said...

Lily, actually, I am kind of cute (right clink & roy??). oh, sometimes.

ELN--- who are you? Let's see, mostly, repressed fondness for kittens, not cats.

You're right that I've never ridden a derigible, how do I change that?

And no, I got reamed out by a colleague I respect yesterday.

I have an electric stove, few open flames in my life, this weekend may finally be cold enough for a fire.

Sarebear said...

You could call it, "You've Gotta Start Somewhere" or "Breaking the Ice" but that last one has violent connotations.

Maybe because I feel a serious break in the therapeutic relationship/rapport with my ologist. As well as all sorts of other hell breaking loose (see my comment responding to your kind query on my blog; thank you, it means alot that you'd come over there).

Carrie, I thought of you whilst watching that on TIVO last night. I hadn't watched Philly yet. Don't let your parents stop you from going after your passions, goals, and dreams. If I may, anyway. Easier said than done. I still think they exploited a few mentally disadvantaged (not sure what the "best" term is for that) individuals . . . course, so did the one's co-workers who urged him to try out.

Can someone buy me a new pair of genes, please? Mine are defective. I think I'm out of the warranty period . . . no trade-ins accepted . . . . stupid DNA.

Sorry. Didn't mean to go there, but I'm all over the place if you couldn't tell. Anyway, poking my head up out of the sand, I mean snow, to wave Hi at y'all.

And I finally downloaded and set up Juice, the opensource podcatcher, to get me my My Three Shrinks audio fix. I got all caught up 'round New Years.

And Carrie, good for you, with using that to get in to some difficult things. (insert bowing smiley here).

Anonymous said...

Aww, that's no fun. Someone who's very introverted that looks forward to seeing her coworkers, I suppose. Or would you prefer my SSN?

I can make several suggestions in regards to misappropriating a dirigible, though all involve regular contact with latex gloves and Clink in less-than-ideal circumstances.

PS: It may appear I am mistaken, but neither I nor the stars can help those who overlook opportunity.
PPS: A fire would be lovely, provided you made it through Saturday, eyebrows and arm hair intact. However, in light of your region's 50s high, cheeseheads are obligated to scoff in your general direction, at least if that were physically possible in our -25F splendor; please ask Dr. Kraft to explain masochism.