Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Sunday, May 31, 2009
Hold on Tight!
A lot of psychiatrists I know always have "full" practices and they don't take new patients. I kind of wonder what this means. For those who do psychotherapy (like me), does it mean that every slot is filled with a patient who comes at the same time every week, or even more often? Or some come every other week but those patients patients sync up perfectly?
I never feel totally and completely 'full' for very long: My patients disappear (oh, they reappear too, quite often). Well, they don't disappear, but they announce that they are better and either don't want to come any more or they want to come less often. While most people start therapy in a state of distress and come every week, many people I see start to feel burdened by the inconvenience and expense of weekly appointments, so after some period of time, they start cutting back to every other week or every month, and some come less often then that, maybe only a couple of times a year if all is well and they need medications renewed. And my patients who have standing times-- sometimes they are students and their class schedules change every few months, sometimes they change jobs and can't get that same time off, sometimes there is a meeting at work or a child's school event to attend. Maybe we skip a session, but often we reschedule, something I couldn't do if everyone were rigidily assigned to a spot. Sometimes patients move to other cities. People get sick and go on vacation. Or my schedule is full and a former patient calls saying they need help again--I never turn away former patients, I just don't-- I usually feel flattered when that they feel comfortable returning to me.
A friend tells me that some psychiatrists are better than others at holding on to their patients. This must be true, and I'm not very good at holding on. When people want to leave treatment or decrease the frequency of visits, if I don't think it's a good idea, I tell them why. I list the reasons like bullet points. They've heard. If they choose to leave/decrease the frequency of their sessions anyway, I usually just accept this and say "fine." If, a few weeks down the road, they aren't doing as well with less frequent visits, I say "Maybe we should go back to meeting more often?" Do patients who've left treatment return? All the time, sometimes after years. And since I've been at it for a while, I have patients I've been seeing for a long time, some for over a decade. It doesn't seem reasonable to say they must come for regular therapy sessions or see someone else-- they know me, and generally I let them come and go as they want, the least often rate may be my comfort level with writing a prescription. In theory, I'd have no trouble saying to a patient, "Look, you've just had a huge issue (hospitalization, suicide attempt), and if you won't come in as often as I'd like, I'm not comfortable treating you." But so far I haven't given many ultimatums. Usually I just present it as the patient needs to come more often until things are better and they just do it.
I talked about this in the post on the final In Treatment session...the TV therapists tries much harder than I do to hold on tight. He's successful with some patients, though he lost a bunch in both five-week seasons. Psychotherapy is process over time, but sometimes people feel very much helped by only a few sessions -- and many sessions in the journey along the way can be total duds.
Sometimes I wonder if it would be better to hold on tighter? Might I be able to do more for my patients? Might I make more money? Might I live a somewhat more predictable life? The predictable life thing doesn't suit me so well--- I like having flexibility...some shrinks have 4-12 week long waits for appointments, and I can't imagine having a patient call with a problem and saying I can't see them within days. I also can't predict my own personal life more than a few weeks in advance and I generally don't even give out appointments more than 6 weeks in advance (You want to come back in 3 months? Call me closer to the time.) It seems like if I mapped my schedule out that far down the line, either patients would be calling all the time with "I have a conflict" or I'd be calling them because... a meeting was scheduled, an event's happening at my kids' school, and over time, I've moved pretty far away from a 9-5 work day mentality. I figure it suits me, but I don't hold people quite so tight as maybe our TV therapist would. Then again, he has time to care for abandoned turtles and to just leave to take a patient to chemotherapy.
What do you think: What holds patients tight? And does that result in better psychotherapy results?
Posted by Dinah on Sunday, May 31, 2009
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I agree with you that being about to see a patient in a pinch is a good idea. My shrink can easily be booked a month in advance, which means that I book precautionary appointments just in case I need to see someone.
Your practice sounds like it's run by a human being with a full life and as a client, I would apprepriate being treated by you. Flexibility is key on both sides. I see a therapist with a standing appointment but we are both flexible and if life interrupts the regular time slot (on both sides of the couch) it's usually not a problem to find an alternative time.
I hear too about therapists with long wait lists. As a client, when I finally decided to seek professional help, it was nice to know I wouldn't have to wait more than a day or two to be initially seen.
As a patient, I know what I do not like and what I do like in a therapist and I know what "holds" me with my psychotherapist-psychiatrist. What I do NOT like. These are all based on 3 real-life therapists:
1. I do NOT like a therapist who listens to my situation, knows what he/she thinks is best for me then starts actively pushing to have me make a huge life change because he/she knows what's best for me. I can know my feelings but not be ready to act.
2. I do NOT like a therapist who does not make eye contact with me and does not look at my face.
3. I do NOT like a therapist who says "You said...." and then states something that is totally wrong and when I disagree, the therapist argues.
4. I do NOT like a therapist who refuses to talk about my "issues" and problems and will only discuss my diagnosis (from another doctor) and how to deal with that diagnosis. That therapist's sole aim was getting me to accept my diagnosis and learn to live with the side effects of medication and learning to accept and live with an incapacity to feel(caused by medications) and inability to live life the way I had been living (due to medications). She refused to discuss ANY of my personal problems.
5. I do not like a therapist without empathy.
6. I do not like a therapist who makes overt and veiled insults to the patient and who ridicules the patient.
7. To summarize the above I dislike a lack of empathy, a lack of understanding me, a lack of concern, and a dismissal of the client's opinion.
Next post is what I DO like.
What KEEPS me in psychotherapy with the same psychiatrist for a long time:
1. He is totally nonjudgmental about things I have done in my life that I personally do not feel proud of and of things that society as a whole might judge negatively. Nothing is taboo with my psychiatrist.
2. He is totally engaged and empathetic. He feels pain along with me as I feel pain and joy when I feel joy. He's right there with me emotionally every step of the way. When I have no feelings at all about some situations, I can see on his face what sort of feeling I ought to perhaps have been feeling (but have suppressed).
3. I like that he makes me feel good about myself. I am not quite sure how he does this. In some situations where I am facing obstacles, I start feeling that the roadblock is somehow my FAULT. He's able to help me see that it is not my fault. Removing self-blame for a situation can move me from depressed to light-hearted in a single session.
4. He helps me to see my strengths and reminds me of my strengths and capabilities when I feel hopeless and incapable.
5. He accommodates me in "emergencies". He has had a few (paid) normal-length sessions with me on the telephone between appointments. Sometimes those have been some of the best appointments because they have come at times when my feelings are very accessible. Sometimes I just can't reach my feelings (because I am in my "brain", not my "in" my feelings).
6. Related to the last but not the same, he will talk to regular clients between appointments (10 minutes before the hour until the hour mark) and at home. These are very short calls...just 2, 3, 4 minutes but he is so very good at getting right to the heart of what is troubling me, then can say just the right thing in a few sentences that he can usually take me from the edge of an abyss to back on track very quickly.
7. He remembers accurately and correctly everything I tell him and he never writes things down. He knows my life story and my emotional life totally and completely, better than anyone in the whole world.
8. He REALLY UNDERSTANDS me. He totally completely understands. he understands me better than I understand myself.
Continued in the next post....
9. He's patient. He gives me time...weeks, months...to get my story out piece by piece. He gives me time to change. He patiently lets me analyze and discuss the same issue over and over in different ways...the same thing, again and again.
10. We laugh together. We both make jokes and see the funny side of things. He doesn't think therapy has to be serious.
11. He is on my side. He's my advocate, my best friend, my biggest supporter, my best cheerleader. He's my rock when everything is crumbling. He's totally "there" for me and believes in me.
12. I care about him too. I like him. He's kind and loving and a good person. I am "there" for him too. When life was at its grimmest I would not hurt myself because I knew it would hurt him if I did and I could not do that to him.
13. He gives power to the patient and (almost) never says that he knows what is best for the client. The patient decides what is best for the patient.
14. He has helped me get in touch with my feelings more than anyone else ever has.
15. He cares. He's concerned.
16. He shares his personal experience as it relates to my situation and does not try to be a blank canvas.
17. He's "right" about things and insightful.
18. I never have a "dud" session. I always feel uplifted. I always feel understood and supported. I always gain insight. On my side, I take the content of the last session and I mull it over, and rework it in my mind. I digest it, roll it around, think about it. When I come back I have something to say about the last session and how it affected my life in the last week. On his side, he always dives into what I say with questions. If I don't "know" the answer he will return to it over and over in future sessions until I finally figure it out. I always feel as though I could talk to him for hours and hours. I always leave wanting more.
full practice means they have a source of referrals and fill empty slots that way,they don't just take anyone who calls. so sometimes full is a way to keep the gate closed when there actually are spaces. some docs as they get older, wind down gradually so full to them is maybe 3/4 day to someone else. full means that when there are no shows or drop outs they have more time for paperwork or themselves and they can choose if and when to pick up someone new. full is like the bag of chips with 6 inches of air at the top.
I think the commenters thus far have nailed this - a good psychiatrist holds on to patients...
Accessibility though, has become increasingly important to me though - in the case of my own psychiatrist, I've asked him to leave me on his cancellation list, meaning that in times of crisis, etc, I can get an appointment very quickly (this only works for me because my own work schedule allows for this flexibility).
I've been on the edge of leaving my longtime therapist (strong psychoanalytic orientation) for months now. I feel he's driving me to it, so maybe my comment will be interesting to you. What is definitely not "holding" is to let me talk about a major problem I'm having with his behavior toward me (unresponsiveness), but not responding to it, instead treating it like nothing but an interesting phenomenon that is useful for me to go through, repetition compulsion. I feel I'm actually being damaged because Mr. Analyst doesn't believe in displaying support. (The Anonymous commenter above says "He is totally engaged and empathetic. He feels pain along with me as I feel pain and joy when I feel joy. He's right there with me emotionally every step of the way." This is utterly alien to my experience.) Rather than being committed to helping me get better, I feel he is committed to a one-size-fits-all psychoanalytic method. Let the process do its work, in other words, and the more the patient is in distress, the more it's a sign that things are working. To the man who has only a hammer, the whole world looks like a nail, and he just keeps hammering away at me. I've said it's too much for me, but really, the only choice he leaves me is "stay and take more of the same," or "go."
I have previously reached the conclusion that the best thing for me was to leave him, and he disagreed. I allowed as how he might be right, and so we continued. This issue keeps coming up again and again, which makes him think we're on the track of something important. No doubt he's right, but that's not the whole story. Sometimes patients need evidence that the therapist cares, and is taking care of them, even if that means putting aside strict analytic neutrality.
In conclusion, he is like you--he's not going to try too hard to keep me in therapy if I say I need to go, regardless of whether that's best for me. But I can't fathom what it would be like to actually believe that my therapist was on my side. Knowing that if I leave, it won't be good for me but I feel I have no choice and no one is going to stop me--that's a terrible feeling. I would advise any therapist who wants to know how to treat a patient who makes noises about leaving before you think they're ready: Listen to them and find out where the pain that's making them say that is coming from. Treat the pain, even if it might mean acting like a real person who cares about them. Don't just let them go, sink or swim. Because some of us are gonna sink, and yes, you will be partly responsible.
Anon who likes their psychiatrist: I hope my peeps think such nice things about me.
So holding tight is a Good thing?
With the last commenter, well, maybe this is a complicated thing, but generally I think of holding tight as being somewhat disrespectful--- a patient says they're better, or they've gotten out of treatment what their is to be gotten. If they want to leave and they aren't doing anything scary, isn't it it the decision of the patient? I leave people with, "call me if you want to come in." They are welcome to call and say they want to come in just once or to call and say they want to resume regular treatment. I'm not terribly intimidating, 'ex' patients call regularly.
If someone is in pain over the issue and feeling tormented, they need to let this be known...I'm a psychiatrist, not a mind reader.
And really, other then saying to someone who is still having significant problems, "You've made progress but there are still things to work on-- you've gotten much better on medication and I think you're making a terrible mistake by stopping therapy and medications now," there's not much more I can do. Maybe someone else has better words? If they insist they want to do this anyway, I feel I'm left to respect this, and I make it known that they are welcome to change their mind and come back.
Anon with the Analyst...ewwww, he sounds like a "Svengauli" (sp?)...i could n e v e r go to a therapist like him...i absolutely need feedback and support.
i go to a Psychiatrist/therapist every other week-i would go every week, however, he does not accept insurance (like many psychiatrists who do therapy, i think) and i can only afford the EOW. He is fairly young and just opened his own practice, but so far, so good. My three best, have been him (#3), a Psychiatric Resident i got to see for only 10 months, who seemed to have a natural "gift" for therapy as well as diagnosis (#1) and (#2) a Psychiatrist who had been in practice for about 20 years whom i still miss despererately, he was very personable, willing to share of himself, but had very strict rules..ie, no etoh, etc. The only reason i left the first two was because of a move and the Resident went on to do a Fellowship...sniff.
So, i have been very fortunate with Psychiatrists....just wish i could have "my" Resident back again!
helly, I'm the Anonymous who's "on the edge of leaving." I find I can't quite answer your question without describing my personal case more. What I will say is that I think we are describing two different situations: a patient who feels secure enough (whether it may be a false sense of security or not) or bored enough or whatever to make the self-determination, "I think I'm done with therapy," although you as the therapist may disagree---versus one who is in a state of neediness that he/she feels the therapist is showing himself incapable of handling or unwilling to rise to. In the first situation, if you've at least done a good-enough job of "holding" the patient so far, I wouldn't think you should worry that you need to "hold on" more tightly. But I would just ask that psychotherapists and psychiatrists consider the vulnerability of patients in long-term/intensive therapy, who may be in a regression, and not make the leap that you should just say bye-bye because they're adults and are responsible for themselves. In a sense, someone who's going through that is not operating with full adult capabilities. You can't (and shouldn't try to) make a person in either situation stay, but you should at least provide a warmer invitation to do so.
With someone in the latter situation, I would try harder to give the person a reason to stay and a path out of his desire to leave. Maybe you do that already; it's just that this post touched a nerve with me. I heard a little hand-washing attitude there, so to speak, an extra fillip of convenient analytic distance (What can I do? The patient is a grownup, after all) when that is the issue that's pushing my buttons currently. I may be being unfair to any psychotherapists reading this, though. I'm aware that you're fully trained for these situations. I am not sure I should have posted to begin with, as my perspective is not the one that was asked for. (I mean that sincerely, not in a huffy way.) I'm just saying that from the patient's perspective, sometimes we want therapists to be more responsive and human than they may used to, depending on their theoretical background. See if you can meet the patient's needs just a tiny bit more (within ethical bounds, and while avoiding the Svengali type of situation).
You say, "If someone is in pain over the issue and feeling tormented, they need to let this be known...I'm a psychiatrist, not a mind reader." Well, yeah. So what if the patient has let you know this, repeatedly and clearly? What do you do then? Patients aren't mind readers, either, and sometimes we have no idea whether our trust--which may be decaying by the session--is justified or not.
Dear Anonymous who's "on the edge of leaving:
From: Anonymous who posted about why I like my psychiatrist
Anon, I don't think you are imagining the tone. When I read this:
"When people want to leave treatment or decrease the frequency of visits, if I don't think it's a good idea, I tell them why. I list the reasons like bullet points."
The "I list the reasons like bullet points" made me cringe. Literally cringe. I am absolutely positive that my psychiatrist would not handle it that way. I think that first he'd explore how I feel. If it were an issue of not getting what I need, he'd find out what I am needing and wanting and not getting. He has told me numerous times that he'd be interested in my feedback on his psycho-therapeutic technique. He opens the door to negative feedback and says he's welcome it and I believe him. If he thought a patient were at risk without psychiatric support, I am sure he's deliver that message in a very caring, concerned tone of voice. I am also sure that in that case if the patient said they were uncomfortable with his style or personality that he'd give them referrals and offer to keep them as a patient until a new appointment were made. There would be no bullet points.
"Bullet points" was a really poor choice of words because it conjures up images of guns and shooting at patients! I simply meant that if someone wants to leave treatment and I don't think they are ready, I tell them why in fairly unambiguous ways.
It's funny (ironic, not 'ha ha') but I often have the sense that Shrink Rap readers resent paternalistic approaches to patient care and get angry at psychiatrists for pushing treatments on them.
I thought the idea of respecting a patient's wish to leave (with the 'call if you need to, I'm here for you' caveat) would evoke comments and feelings, but I've been surprised by the sentiment that psychiatrists should not honor a patient's request or should debate with a patient their readiness to leave treatment or their ability to make their own treatment choices (psychotherapy being a treatment).
I don't think I foster this type of therapeutic relationship (that was kind of the point of the post!). Usually people leave saying they feel better. People don't generally leave saying they are in pain and tormented. Though if a patient were to tell me that despite my efforts to help, they continued to suffer, I would think it would be reasonable to see if someone else could help them more than I have.
Treatment is supposed to make the patient better, if it's making them worse, it's not working.
I hope that helps.
*"I've been surprised by the sentiment that psychiatrists should not honor a patient's request or should debate with a patient their readiness to leave treatment or their ability to make their own treatment choices"*
If you reread what the patients said, I think you'd find that none of the patients did say that. In fact "bullet points"/"why in fairly unambiguous ways" sounds more like a debate to me than what the patients have said. "Anon. on the edge of leaving" said she'd want her psychoanalyst to start "acting like a real person who cares". I said that I'd expect "a very caring, concerned tone".
*"I often have the sense that Shrink Rap readers resent paternalistic approaches to patient care and get angry at psychiatrists for pushing treatments on them."*
I think you are right about that. I'd guess patients that are seen face-to-face, not just Shrink Rap patient-readers would also resent a psychiatrist pushing treatments on them. I'd guess that many of the patient readers have had bad experiences with the treatment that's been pushed at us and have a reason to be sensitive on the issue. I know I have good reasons. Luckily my current psychiatrist does not push things at me, does care, and is a great doctor. If all were like him, patients would not feel the way they do.
*"I've been surprised by the sentiment that psychiatrists should not honor a patient's request or should debate with a patient their readiness to leave treatment or their ability to make their own treatment choices"*
If you reread what the patients said, I think you'd find that none of the patients did say that.
Yes, absolutely. Which makes me think that maybe it's not my imagination that therapists don't always listen attentively.
Though if a patient were to tell me that despite my efforts to help, they continued to suffer, I would think it would be reasonable to see if someone else could help them more than I have.
...why send them to someone else? Is it that hard to change what you're doing?
I am only halfway through, but I feel I'm very similar to this April girl in how I push others away.
My therapist was really surprised I showed up consistently, and I think she chalked it up to me being conscientious. It's actually because I really appreciated being taken care of to some extent.
I can't normally take the initiative to seek help, so when I was very depressed I'm sure I wouldn't have continued without some pushing.
Only problem was this therapist just wasn't for me. CBT only made sense to me on a theoretical level, but she pushed the CBT (and relaxation exercises) even when her hit and run psychodynamic comments really hit home with me, and I htought I'd made that clear to her. Plus I think it was making me worse because the navel gazing without any improvement was making me feel much worse than just having no improvement. Plus, I got kind of obsessed with sessions and I started living my life as if telling it in session, and that was the only time I'd get out during the week to begin with.
Worse, when i actually got in session, I'd blank out or be to uncomfortable to talk about any of those things. (I feel like maybe a different therapist would fix that problem, but probably not the obnoxious obsession with it.)
When we parted ways due to insurance reasons, she said I could call any time. I wasn't sure if it was sincere, especially since she later took a full time staff job at a place I wouldnt' ve able to go. Can I call her? Who knows? I'm sure as hell not going to find out, much as I'd like to. (Despite her not helping me, I used to be numb then, and Ive been doing okay recently though except for a few semi-tragedies within the space of a few months, just felt it would be nice just to talk especially since I'm not numb.)
I'd actually really appreciate if she followed up 1, 3, 6 months or a year later. Wouldn't make it seem like being able to call her is just something you say to patients. Being depressed, of course I presumed she just wanted to get rid of me. I really needed help but was too weak to ask, and too suspicious and numb to let anyone try. If a therapist had taken some of the pressure of the choice off of me, strongly advising against, telling me why, reaching out, I would have stayed. (Hey, kind of like that thing with Paul and Gina getting ready to go shopping instead of arguing...only I'm arguing because I want them to recognize and reassure me that my problems are significant enough and not too much of a burden on them that they want me there and care. It always felt like some pretty well-off white girl whining being dramatic about her horrid, horrid life.)
Right now I should probably go back in buy I can't/won't do it on my own, even knowing no one will call.
My initial reaction with this question was it depends on the person. I think some people need someone to reach out because for some reason the can't do it on their own. And others will simply leave no matter what you say. I think most will leave when they're ready regardless.
Well there are a few comments from a one-time patient FWIW.
"...why send them to someone else? is it that hard to change what you're doing?"
I hope this is a facetious comment...unsure??
If not I hope you aren't a therapist or pdoc, because yes, sometimes, it is that hard and harder, often near impossible to change.
Sometimes a new perspective, a new style of treatment, a therapist who is a better fit for the patient can make change more accesible and successful.
I think that if they come back, after any amount of time, you're doing something right. Coming back to treatment after a "break" can be difficult. Those clingy psychiatrists won't have people coming back like that. Over a decade? Obviously they remembered something good about you.
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