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.
Thursday, September 03, 2009
I Don't Have That!
I'm enjoying asking hypothetical questions these days!
Okay, here's a scenario, tell me what you think the shrink should do.
A patient comes for an evaluation. He's seen a psychiatrist before, but he stopped going because the psychiatrist diagnosed him wrong. Total idiot, that doc. It's clear this diagnosis is meaningful to the patient, and the meaning is very negative. The patient isn't in a place to hear that this is the problem (fill in the diagnostic blank however you'd like). The new shrink does a careful evaluation. He listens to the symptoms, he listens to the course of illness, he gets info from any outside sources the patient wants him to consult. He doesn't call the last shrink because the patient doesn't want him to: the patient doesn't want his diagnostic thoughts colored by information from that idiot, and the new shrink is okay with this. However, the new psychiatrist, with the data he has, has come to a diagnosis: the patient has what the idiot doc said he has. If he tells the patient this, the patient will be gone (yet another idiot shrink)-- the psychiatrist may be "right" but what good is that if he can't help someone who won't come for treatment? So what should the new psychiatrist tell the patient about his diagnosis?
Posted by Dinah on Thursday, September 03, 2009
Labels: #30+comments, diagnosis
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i want a cat.
not an uncommon scenario. i often handle this by overting from the beginning of the assessment how i too might disappoint the patient with a diagnosis he dosent agree with, and how would WE handle that if that happens. plus exploring the meaning of the diagnosis previously provided
You have to be honest with your assessment of the patient - they will interpret hedging as lying when the truth of what you think comes out. Bottom line - you have to be true to your own assessment.
I would start by asking the patient if it was more important to have a diagnosis, or treatment? If he came for treatment I would treat him (for the diagnosis). I would use the most general diagnosis code for billing purposes. I would explain the patient that his symptoms would best be treated with this drug...
so if a patient was really upset with the label of "bipolar," I would use some other mood disordered diagnosises (depression, anxiety) in the beginning.
I would probably explore the stigma of mental illness and labels with the patient.
I would then review each symptom and observation with the patient and discuss. This would be over time, slowly.
I think the stigma of mental illness plays a huge roll in this, consciously or not.
I think I'd be very clear in how I reached my diagnosis. Which symptoms fit into which parts of the DSM etc...
If you believe something is true, then have the guts to stand behind what you write in the patient's medical record. It's really easy to write stuff in people's records that you think they'll never see. That's what my former psychiatrist did. Patients have a right to know what's going on with their treatment. My former shrink could write a whole lot of crap, but he didn't have the guts to address any of it. My diagnosis of him is: Coward. A complete waste of my time and money.
Finally, finding out his truth was a good thing for me. It made me realize why I got worse under his care. After I read the records he attempted to keep me from obtaining, I severed the relationship with him and ended up with a therapist who was both respectful and honest. I improved under her care. If you're treating adults then treat them like adults.
You would have a hard time arguing the patient gave informed consent if you deliberately keep him in the dark about info you know will affect his decision to continue treatment with you.
I really think these situations have more to do with what's most comfortable for the shrink than what's best for the patient. I always hear this is a disease just like diabetes. Can you imagine an endocrinologist asking if they should tell the patient they have diabetes because the patient might not come back?
Establish a relationship with the patient.
I've seen this on a support board I frequent. (DBSA. I recommend it if the patient in question has depression or bipolar.) Some people are very resistant to a diagnosis, and they seem to bounce around through a couple of psychiatrists, though by about #3 the pattern does emerge. But I think the relationship matters too. One thing I hear is "how could he know that in one visit/10 minutes" and that sort of thing.
Psychoeducation is helpful for patients who need to see themselves in a diagnosis first. I recommend the site psycheducation.org for those confronting a bipolar II diagnosis.
I myself was in that diagnosis-resistant category. Six years ago there was less awareness of bipolar II (especially in the popular literature) and when my then new psychiatrist brought it up in the first visit (having seen previous records), I flatly refused to consider the possibility. (No hypomania as far as I knew.) It took eight months of his continuing to treat my recurrent depression, pointing out features that would be consistent with bipolar, pointing out how my treatment wasn't quite working, and experimenting with new meds (for depression) before I finally did some research of my own and was willing to acknowledge that I could see why he might think that.
One upside of the long time to diagnosis is that I have never been tempted to go off my mood stabilizer. I understand quite well what it controls.
I had a friend who was quite delusional. He thought his neighbours were in league with the police, bugging his house and spying on him. He was convinced that they had planted a bug in his mobile phone and remained so even after it was taken apart by another friend and 'cleared'. The delusions were getting to the point where he was about to rip out the walls of his house to find the bugs, and had purchased a 'stud finder' to find the metal listening devices in the walls.
He was also (not coincidentally) having trouble sleeping.
I got him to see the psychiatrist (I was a psychologist working in the community team at the time) and once he had medication that helped him 'sleep better' he wasn't so worried about the neighbours anymore.
So, while he would have proabably fit the diagnosis of delusional disorder/psychotic disorder etc the focus of his treatment was the sleep rather than the label.
So how about not messing about trying to label him, but working with what he can and does want to do? Clearly he is willing to accept your help or he wouldn't be there.
So instead of looking at him and saying,
"that dude's got XYZ, so now I shall tell him that and further distress him while making an attempt to treat him as I treat everyone else with xyz [which will probably fail as he won't believe me but that's OK because then I can say he's delusional too]",
how about looking at him and saying,
"that dude has this symptom on a daily basis so I'll try to help him live with that; also he feels ABC and struggles to cope with JKL so I will help him deal with those things too".
It's really not that difficult, you just have to dare yourself to work without the tickboxes...
So the issues and the answers aren't so clear.
--Honesty is good, and I agree that if someone is directly saying "What do you think my diagnosis is?" an honest response is required.
--What if the patient isn't asking the diagnosis? Do you shove it in their face (I'll vote with 'Build a Relationship' first)
--Okay, the big problem: the statement for insurance reimbursement: vagueness works with some disorders, not others...in the treat 'em for insomnia instead of delusions theory...you can't put insomnia on the form...it's also a number code, but do you stick delusional disorder and not say anything
--Or do you just lie on the insurance form (I'm not proposing this...just throwing it out there)
--And is there some rush? What about waiting a few sessions until there's some trust.
This is all difficult if the patient is very manic or very psychotic (drilling holes in the wall and unwilling to look at the option that someone isn't really there)
Okay, just to stir the conversation a little more.
Group Therapy with others who share the same diagnosis!
Maybe not all the group, but many. The best way for a person to believe a diagnosis may be to see others with similar cluster of symptoms diagnosed with what they deny they have. Sometimes we need to discover for ourselves what inds of behaviours we are displaying. Seeing is believing.
The other way might be to discuss ""why" the diagnosis is so upsetting/disconcerting, or why they do not believe they have it, what maes up different diagnosis (in easily understood terms), and how other diagnosises are decided against)
My psychiatrist with over 40 years experience does not tell patients a diagnosis. He treats symptomatically. He believes in continuums and that all people with an illness are not alike. If psychiatrists did not try so hard to come up with a diagnosis in 10 minutes, the patients would be better served. Most listening and less labeling would help a lot of practitioners in my opinion.
If indeed a doctor has done a careful assessment of a patient as described above, and there is an extremely high probability the patient has the disorder that he/she rejected the first time, I think it is your responsibility to tell the patient. The key would be in how this is delivered. If the patient is seeing a psychiatrist, that already means he/she is not necessarily completely adverse to the idea that they may have mental illness. To normal people seeing a psychiatrist is a huge deal, something you just never ever do. Regular people with a strong stigma against MI would go to their GPs first I would think.
So that the patient is even in a psychiatrists office means he or she is potentially open minded to the possibility they are "CrAzY".
Possibly, the patient in this case is rejecting the label of the first doctor because of trust issues. The patient does not trust the previous doctors assessment, knowledge, skills, senses that the care is poor or whatever.
If a patient rejects a diagnosis, it doesn't always mean he or she is in denial. It could mean he or she is intelligent enough not to trust someone just because they claim to be an authority... when there were red flags NOT to trust.
If you have done a careful clinical assessment, interviewing personal contacts and such, it is your responsibility to tell the patient what you think. If the patient is in denial, nothing you say is going to change that, odds are they wouldn't want treatment anyway because medications suck and no one wants to take them. If the issue is trust, careful practice should prevent such problems. If a doctor is cautious, conservative and through, isn't pushing meds for vague reasons trust won't be an issue.
I don't have a psychiatric diagnosis- that I am aware of- but I had a doctor once who gave me a diagnosis I didn't agree with. My anger in that case came down to personality. The doctor adopted an attitude of "I am the doctor and you will do what I tell you to do." It put me in full belligerance mode. In fact, I thought he was an idiot.
All doctors I have subsequently developed a raport with, have been doctors willing to listen to me, answer questions, explain, and discuss. They treat me like I am intelligent- not a lower life form.
I would suggest that the idiot doctor in your case analysis may not have bothered to explain why he thought the way he did. He may not have adopted a team approach. If the new doctor communicates honestly in a give and take manner, the patient may not react as badly as the doctor is afraid he might.
At the end of the day though, does it matter what "label" you give the patient? It seems to me that if a patient has come to see a doctor, there is something that needs working through, or fixing or whatever other metaphor you care to employ. Shouldn't the ultimate goal be to help the patient find strategies to overcome their difficulties? (is there such an insurance billing code?)
Having been in just such a situation, on a number of occasions over the years, it's my opinion that, as part of the assessment, it's crucial to go into as much detail as possible with the patient regarding the patient's objections about the prior diagnosis. I also feel adamant that lying is never an acceptable strategy, especially since so much of psychotherapy is based on the patient's ability and/or willingness to trust the therapist, and to believe that the therapist has the patient's best interest as a priority. Lying never adds to these essentials.
Louis Heit MFT, LCSW
Well, if someone is psychotic or manic or you otherwise can't hold off on treatment, I would guess you treat it, you call it what it is to insurance, and you discuss the diagnosis with the patient after the treatment has had some effect, if they are resistant to hearing it right away. I'm thinking you can't really have a reasonable conversation with someone in the middle of mania or psychosis anyway.
Otherwise, what about Mood Disorder NOS or something catchall like that? I've also seen BP NOS used to finesse (in the short term) the issue of how much bipolar there is.
My anecdote of course was addressing the doc/patient aspect. Being an Australian I don't feel at all qualified to comment on the dx coding for reimbursement aspect. Our system doesn't require such detailed information - eg I see patients under our medicare system. There is a code that classifies the service (ie office/out of office, length, group vs individual) but has nothing to do with diagnosis.
When I speak with potential patients by phone before we schedule a first visit I ask if they have ever seen a psychiatrist before and / or I ask who prescribed their psychiatry medications in the past. If they had seen a psychiatrist I ask why they are not calling that doctor. I find people are fairly straight-forward and tell me it was not a good fit or the office did not run well or whatever.
In person at an intake, I would ask someone who had had a past psychiatrist what we can do as a team to make this relationship work better for the patient and encourage the patient to let me know if there are signs that our working relationship might be going south so that we can address the problems. I find that decreases patients' anxiety enormously.
And when I finish my intake, I leave 15-20 minutes to wrap things up and I "sum up" my thoughts about what is going on and some of my thoughts about plans to help. I always ask patients to correct me if I missed the boat.
I don't think telling a patient your opinion (which they are paying you to do) is "shoving it in their face" unless you do it in an ugly, hateful way. I think that's extreme. I do think deliberately hiding information from the patient that you know is important to that patient is unethical. The patient in the scenario was pretty clear that they didn't agree with the assessment of the previous psychiatrist, and it might have been the reason he sought a second opinion. Withholding this information from him is a lie by omission. Will it be better when he trusts you and finds out from his insurance company? Is this really a good way to model trust?
I can say from previous experience that finding out the psychiatrist wrote negative things in my medical record AFTER forming a therapeutic alliance with me was even more destructive and painful. I also think it says a whole lot about his lack of character.
It's interesting to me that most people who are commenting on this post are thinking that the diagnosis that is negatively viewed by the client is an Axis I condition....like bipolar disorder, or some kind of psychotic disorder.
But when I read Dinah's post I immediately thought that the diagnosis in this example was an Axis II diagnosis...specifically, something like BPD. I don't think that it is wrong to say that this disorder is very stigmatized within the psychiatric community. I also don't think that it's wrong to say that this diagnosis is sometimes overused, or used in a pejorative or maybe non-specific way...so a patient who is wary of this diagnosis, or who feels strongly that this diagnosis does not really "fit", or who in any case does not feel that this diagnosis would be helpful for any number of reasons does not seem like a difficult patient to me. This seems reasonable.
I guess it does seem to me to be a bit unsettling to have someone make this kind of diagnosis within 1 or 2 sessions. I find it very hard to believe that this diagnosis can be made with any kind of confidence within the first few sessions...especially if the patient is having difficulty explaining symptoms, or explaining the history. If the patient is so resistant to a particular diagnosis why not 1) find out why, and respect that the patient may have very valid reasons for resisting this diagnosis, 2) if the concern is needing a diagnosis for insurance purposes, isn't it possible in the interim to name comorbid conditions that might not be the primary cause of distress..etc..but that are maybe less stigmatized (e.g., even if the psychiatrist thinks that the primary diagnosis is BPD, if there is also a comorbid mood disorder or anxiety disorder, then listing this instead for insurance purposes, even if this might not be the main problem? Maybe that only works for some diagnoses, such as Axis II diagnoses...I don't know.
Yeah, what Ladyk73 says. And what the anonymous who writes about honesty says.
I have recently been through the same shit - almost exactly what was written by that anonymous. The worst part was the lack of honesty. (I'd like to know how he/she finally got the records, because my last shrink also refused to release them.)
And what everyone who mentioned treating symptoms and a clinical picture, not a "diagnosis" which is hardly validated.
I'm glad this post came up, at least. Everyone commented much more eloquently than I did, and I"m glad to see I'm not the only one having gone through this. Being treated like you are x, y, or z often causes the very behavior.
Myalterego, my previous pdoc behind the "it's not best for me" bs when it came to releasing my records. Because I guess I was the child and he was the adult. The truth is it wasn't best for him. He was a coward in every sense of the word. I have a friend who is a therapist (not my own therapist by the way). I had the records sent to her. If I had not known a therapist or a physician, I would have turned one of my friends into one so I could get my records. While pdocs and therapists can refuse to send the records to you, they cannot refuse to send them to another practioner. (He did attempt to ignore those requests also, so I looked up the time period in my state that they have to send records, I think it was 14 days and I put that in my 3rd request and sent the last records request by certified letter). It's a shame it had to get so ugly. Lo and behold the records showed up, then. I think it's your right to have access to information that's about you, and while it can be very hurtful especially if the person didn't have the guts to address any of their thoughts (the kind of paternalism that makes me nauseated), it was instrumental in helping me realize why things were so out-of-kilter under his care.
There are practioners out there who believe in being open about everything with you and because they're open have no problem with you having access to your records. I did end up finding one who practices that way and we worked together for 3 years. We spent a whole lot of time trying to deal with the previous pdoc's deceit as well as the crappy messages he wrote but didn't say. I'm really grateful to her for showing me what the standard of care should look like. We didn't always agree, but that's life and that's the way a relationship is. I do miss her. When I think of her, the word integrity comes to mind.
Anonymous - wish you had some contact information.
The one I'm in this mess with offered to send "a treatment summary" - which would be obviously sanitized. I'm sure that's what he'd send to another practitioner too. Anyway, the law here says that medical records in their entirety essentially belong to the patient. But no one ever requests them. While the law is very progressive, unfortunately the medical culture is still rather paternalistic.
This is tricky. I've worked with clients who are in heavy denial about whatever the problem may be. But I've also worked with people who turned out to be right about their diagnosis being wrong. There was also a time when psychiatrists worked with clients without diagnosing. And the accuracy of diagnosing is constantly being challenged (i.e. the overdiagnosing of Bipolar Disorder and ADHD, the misdiagnosing of Schizophrenia and Bipolar Disorder instead of PTSD). Why not work with whatever the client believes the issue to be and see what develops over time? Be honest with the client that you can see why the other psychiatrist might have rendered the diagnosis they did, but that you are open to the client's perspective as well. Either the diagnosis will prove to be wrong or the client will begin to see a pattern of behavior over time as he or she works on it with the clinician.
I do agree that being dishonest and/or withholding information is high-handed and compromises the integrity of the therapeutic relationship.
Mysadalterego, I'm sorry you're having such trouble. I have helped several people who have run into similar situations with their psychiatrist or therapist obtain their records. I'm not an attorney, but I would be happy to share some of what worked with other people in the past. I clicked on your link, but it didn't work. You can email me at email@example.com if you want.
(I'm assuming you're in the U.S? I wouldn't know anything about other countries)
I am glad to see some of the therapists/psychiatrists weigh in here about the importance of being open and honest. I think to sit and write catty comments like my pdoc did and not share any of it, is pointless. I will say I had none of this drama with my subsequent therapist nor have I encountered this with any other health care professional I've ever worked with, thank god. He was uniquely jerkish.
My first doctor said, "we think you may be a little bit bipolar" then did not even bother with helping me address this.
When I complained to the assessment place they said, "let's change your medication, and have you talk to someone else."
I was okay about talking to someone else, but another medication change I was not okay with. I was on Paxil, and was fine. When I said I didn't want to go through a med change I was refused therapy.
I did start seeing a psychologist several years later, and when I began having phobias, and panic they had me back on an anti-depressant. I did okay on the anti-depressant. Okay but not great.
When my time ran out with this doctor, I started seeing a psychiatrist. 4 months after seeing this new doc, she labeled me bipolar. When I asked her again, how she came up with this label, she said, "a doctor said so 12 years ago." She then admitted to not seeing a single solitary sign of this disorder, in me, while in her care.
The next doctor said they did not see any signs of bipolar. He said maybe there were some disconnected signs but something that may not even warrant a label.
He then wrote a letter to my doctors stating that he felt satisfied in labeling me bipolar. He did not share this with me. His notes stated the opposite of what was discussed.
The next doctor diagnosed me bipolar II within the first 5 minutes of seeing me, when my current problem was anxiety only.
I tried to trust, but a part of me says not to.
Would the answer to this question be different in different contexts?
For instance, if a doc was just starting his/her private practice, would there be more of a focus on telling the patient what they want to hear?
Alternatively, in a salaried job, would there be less of a concern about alienating the patient by telling the "truth" about the diagnosis?
I like to think that I would practice the same in any context and that I would tell the patient the "truth." I put "truth" in quotes because diagnosis is subjective and dynamic, not objective and static.
Also, here is a potential pitfall of not telling the truth to the patient but then writing the truth in the chart. More and more patients request their records (HIPAA, as I understand it, requires that a provider must have a very good reason to deny a patient this right.)
Finally, the transaction in which we dialogue about the diagnosis (or anything) with the patient is much more growth promoting than the alternative (stifling the dialogue) even if it does get uncomfortable.
Like you would tell a patient you diagnose with leukemia that they suffer from psoriasis because leukemia has a negative meaning for them? I say refuse to treat them at all unless they authorize the other psychiatrist to provide records. How do you know why they really dumped him/her?
The moment the patient finds out you concealed the diagnosis you assigned to him, that's not only another doc who's an idiot, but a doc who's a liar and a manipulator as well. I don't care if your diagnosis is "eye-swivelling loony", you don't have a right to refuse to tell the patient the diagnosis if he asks.
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