Sunday, November 24, 2013

The "Magic" of the Doctor-Patient Relationship

There is no doubt that in psychotherapy, some of what heals is the relationship the patient has with the therapist.  Medicines can be helpful, even when they are prescribed by a doctor with no personality, but no one enjoys going to see a doctor "just to get a prescription."  In therapy, it's hard, if not impossible, to heal if the patient does not see the therapist as being reasonably kind, empathic, and mutually valued, at least some of the time.   Aside from any medications, aside from the exact use of the words chosen, and aside from what tribe of psychotherapy the therapist aligns with, part of what heals is the relationship itself.  This we know.

But kindness, empathy, and interest are helpful in all doctor-patient relationships.
Psycritic has a charming post up called The Wizard: Psychopharmacology Magic.  Psycritic writes:

What most amazed me about The Wizard was his Zen-like serenity. Regardless of how much noise the patient was making or how many toys went flying around the room, he would be like the calm eye of the storm, holding still while everything else moved around him. His gaze was remarkable, intense yet warm and soft, like a bright candle. He would focus intently on whoever he was talking to, making that person feel important and special. His voice was smooth and soothing, almost soporific; perfect for those in emotional distress.
He took no notes during the appointments. His dictated progress notes were usually just a couple of paragraphs long, without pesky details like what medications the patient was taking and what medication changes were made during the visit. However, he did not have to remember those things. During the visit, he would shine his bright gaze upon the parents and say, "So tell me, what did we decide to do with the medications last time?" And the parents always provided the details. Maybe they knew that they would be quizzed this way, so they prepared so as to not be embarrassed. More likely, I think the parents were pleased that this eminent psychiatrist trusted them enough to empower them in this way.

Psycritic ends the discussion with: "However, I firmly believe that just being in his presence was one of the major therapeutic interventions that he provided for his patients and their parents."

It's not quite so lyrical, but over on KevinMD, Dr. Brian J. Secemsky, an internal medicine resident wise beyond his training,  also gives pointers on how to make your patients happy. He tells us:
1. Know your patients' names and interests and bring them up often.
2. Allow your patients to know something about you.
3. Communicate promptly, even if you have no answer.

Do those things, and in any field of medicine in our checklist era,  a doctor is  likely to be quite successful.

Let me add a few more pointers for good measure.   You can apply them to psychiatry/psychotherapy if you'd like, but they'll do for any field.

~Know the names of your patients' spouse, children, and pets, and ask about them.
~At the end of an initial evaluation, ask the patient how the appointment went for him/her.
~At the end of an initial psychiatric evaluation, or any medical appointment no matter how brief, leave a few moments to ask "What would you like to ask me?" (It's fine to admit you don't know the answer to a question).   
~Don't tell patients their problems are all in their heads.
~Don't tell patients in distress how others are worse off.  Patients already feel guilty for complaining or being unhappy.
~If a patient does not wish to follow your recommended course of treatment, explore the reasons why, respect them even if you don't agree, explain why you think it's important, and if the patient still does not consent, offer alternative forms of treatment. If there are none available, let the patient know that.
And finally:

What would you add to the list?


jesse said...

I wouldn't necessarily add anything to the list, but what you are talking about is right on. Whether we call it part of positive transference or not, it is a part of satisfaction and getting good results in any endeavor. No one likes to be treated badly and all of us respond well if we see that the other person cares.

One worry I have is in regard the new system of note taking that is becoming prevalent. I can see psychiatric residents looking into their laptops as they talk to patients. It is so true that we often hear the most important things when the patient knows he is being heard, that we care, and that he has the time to venture into areas that he might think are irrelevant.

I voiced my concerns to a younger colleague who assured me my fears have already come true...

dish said...

jesse's comment reminded me of a post from the david allen family dysfunction blog a long time ago. There was a recording of a pdoc, dunno if it was video or voice, who was preparing to take his boards and had three senior pdocs watch him evaluate a patient. On the recording, you can hear the patient tell the pdoc that she had been sexually molested as a child, can't remember by whom, and had to testify in court about it. She didn't just quickly mention under her breath, "I was molested as a kid."

At the end of the interview, you can hear the pdoc talking to the other three pdocs who were watching him interview. The pdoc said he suspected that their might have been some sexual molestation in her past. The other three agreed with him...

All four of them totally missed what she said about having been sexually molested. The interviewer was so focused on his own performance, and the pdocs watching him were also 100 percent occupied with his performance, that they forgot to focus on the patient.

I don't know if there was a laptop involved, but I could imagine a lot of things could distract a pdoc.

Unknown said...

I think the list pretty much covers it. One thing I will say is that my psychiatrist often asks me what I think about what we should do to address any issues I'm having before making suggestions. If I'm not sure, or he has other suggestions to add, he will list them and then ask my opinion.

The only other thing that comes to mind is a willingness to look beyond traditional treatment. Supplements, exercise, etc. can often be helpful. When I brought up using L-theanine to help with my anxiety, my pdoc told me he didn't care if I found relief at his office or whole foods; he just wanted me to feel better. I definitely appreciated his willingness to keep an open mind in regards to treatment.

Dinah said...

Cassara: everyone feels better at Whole Foods. They have a new cookie bar that has strong anti-depressant properties, but sadly, I think they may be associated with weight gain (especially in this psychiatrist).

Jesse & Dish -- I think the risk of the new frontier of computer screens and accreditation-dictated questions that must be asked, and CPT-categories for reimbursement is that the patient may get left out of the process. Are you asking if my spouse abuses me because you care or because it's a requirement. Do you care that I'm in pain or do I just need to check the right smiley box and sign the sheet?

Somehow psychiatry has become very susceptible to check lists about mental status, symptoms, side effects, and we forget that people are human within the context of their lives.

Jesse, I'm sorry if I wasn't empathic to your latest interest yesterday. Is there anything more you wanted to discuss with me?

jesse said...

The "watching-the-screen-history-taking" has already happened. You can't really show interest in an interview if you are actually more interested in the bullet points and billing codes than you are in the patient. I think these new methods are going to seriously hurt psychiatry. The residents will learn the new methods and before long the computers will be wearing the white coats...

L said...

don't patronize. no matter how many depressed patients you've seen, you don't know my story.

don't run to the second to the point where you cut me or yourself off in order to end at 2:45 and 3 seconds.

don't bring your next patient in at 2:45 and 10 seconds, at least not every time.

have respect for me as a person, not just a psychiatric disorder.

Believe me when I bring you side effects of the med you really really want me on.

if I don't want to talk about something, that's my right. You don't own my brain or heart. You are not entitled to my thoughts or feelings. You may earn them.

Steven Reidbord MD said...

At the end of many first-visits, before I discuss my impressions or recommendations, I ask: "Is there anything else I should know about you that I haven't asked yet?" About half the time I hear something unexpected and useful. I believe collaboration is most of the magic of the doctor-patient relationship.

Anonymous said...

At my first appointment, my psychiatrist said to me that he knew I had suffered for a long time, and he was going to help me feel better. He was the first psychiatrist who ever conveyed to me that I could actually get better, and not surprisingly he helped me do just that.

Another thing he did, is that he could tell during the first few appointments that I didn't want him looking at me so he averted his eyes. I found that very respectful that he would notice this and care about my discomfort. No one else had ever did that.

Compassion, respect, and good medical care sums up his practice.

My psychiatrist provides medication only, but he kind of sneaks in some therapy, too. He's great.


Anonymous said...

I meant, No one else had ever "done" that.


jesse said...

On further thought: P-K and others here have put their fingers on an all-important quality, one which I have found if lacking can doom otherwise excellent by-the-book treatment.

This is Empathy.

Decades ago this point was reiterated to me by Dan Winstead, my old army buddy who went on to become chairman of psychiatry at Tulane. I did not understand it then but realized later he was completely right (although he never took credit, but rather gave it to Kohut and Ornstein).

So thank you, Dan, and Happy Thanksgiving to all Shrink Rappers!

Dinah said...

Jesse-- so is empathy something you can learn? It brings back the question of whether good therapists are born or made.

L: I agree with all you said except for understanding why it's a problem for a therapist to start and stop on time. I realize there can be extremes here, but isn't that generally a good thing? It shows respect for someone else's schedule that they aren't left waiting, and makes the statement that the patient's time is to be valued as is the doctor's.

Thank you, Jesse. Wishing everyone a wonderful holiday.

dish said...

@Dinah: I actually agreed with L. I think that rushing in a patient ten seconds after the last one (2:45 and 10 seconds ) or running up to the last minute so the patient gets cut off every time could be annoying. Gotta plan the session a little better. Especially if it's only med management. Instead of 15 minutes for everyone, that might be a sign that some sessions should go for longer. I really think that makes for a more distracted doctor to fit everyone into neat little time slots. And it's very annoying for me to walk into a pdoc's office, state my symptoms, get prescribed a med, and then the pdoc will not discuss the med with me ("google it)" because he is too busy trying to stay on schedule and wants to be done in ten minutes. However, if the doc is also doing psychotherapy...well...I can tell you right now, the most distracted psychotherapists I have ever met were the ones who were churning patients in and out within ten seconds of each other.

I was turned off when my last pdoc visit ended abruptly, despite my having questions about the drug he prescribed. He told me to look it up on the internet, and if I want something else then I should come back later and ask for another drug. More and more I am seeing the tendency to quickly prescribe, tell me (the patient) nothing about the drug, and instruct me to just do my own research because of time constraints.

jesse said...

Empathy - I doubt it can be taught, as a subject in school, but it can possibly be developed over time. One can learn to value the empathy one has, as opposed to being taught otherwise.

I understand what is being said about stopping on time, but in traditional psychotherapy the therapist/analyst does keep on time. The patient learns that it is the time that has run out, as opposed to all of the other factors that might go into the patient feeling he has not been interesting enough, or that the therapist just wants to hear more, etc. These fantasies then become part of the therapy. If the therapist is sometimes on time, sometimes runs over, and sometimes stops early (!) then the patient may feel criticized, or think he has not been interesting enough, or perhaps what he has been talking about is too interesting to the doctor (you can easily imagine what kind of subjects might provide these thoughts).

All of that said, I frequently run over, but never stop early.

Anonymous said...

I met a woman once that set my mind in motion, "what is this woman on about? she's cute and all, but ain't nothing worse than a pretty hippy."

Then you showed me something no other counselor had, or could have, and my mind was blown. You set in motion a series of changes that have made me a better man, inside, outside, among others, or when I'm alone

At the time, my mind was free to contemplate liaisons, but that would breach the rules, you are a provider, I am a patient. So I tried to keep it to myself, unsuccessfully at times. I leaked innuendo and couldn't help but admire your fashion sense. I hung on every word, and you were so sweet and patient to listen to me ramble on and listen to the sounds of my tortured voice. But alas, patient doctor separation rules... Sacrosanct

The first bomb was strong, but not insignificant... you were married. It was actually a relief. Meant I could put all that tension behind me. We could get back to some healthy help.

To be Continued...

Anonymous said...

Continued 1

That went well until your friend came, and started stabbing at buttons I didn't like being stabbed at. Time was short, so I carelessly "opened a can" and just let fly whatever first came to mind. Actually, you were the first thing to come to mind. We have had many laughs about this since, but that was stressful and explosive and grossly uncomfortable. The flowers weren't meant to act as a peace offering, they were an apology and a promise that I would try never to try to hurt your feelings again.

It also reopened my desire, your husband be damned. I was going to indirectly pursue you until I got a solid yes or no. Yoga pants and rooms to ourselves didn't help, but you managed it very well. No lunches off campus, no beers after work. Talk time was during business hours and limited to schedule (though never to time). I understood my place, and I had been put in it and that was all well and good. It was reason enough to keep my mouth shut.

Then came the second bomb, my wife, who had been so open to my liaisons before, confessed that the arrangement was tearing us apart (all news to me), effectively ending my sex life in its tracks. You see, she has a condition that makes that aspect of her and I's relationship off limits, and she outright refuses alternative methods. This was Devastation, that meant breaking ties with women I LOVED just because my first wife couldn't stand it. She can't have sex, so no one gets to have it. But I love her most, and she earned my vows. She raises my daughter, for that I am grateful. I had a hard time during those first few weeks, slipped up a few times. I hope they all understand now... I'm afraid to stay in touch.

But now I am here, and the opportunities are ripe. I receive a kind glance every day, and more overt attempts weekly plus. I'm not that great looking a guy, but I look young, and square my shoulders. I guess it works.for these British girls.

While my pining has not dimmed even an illum for you, there has been a new light brought into the castle. The sweet London lawyer who wants to be a philosopher has made her intentions known. Takes the train up north for school, and then back to London the next day. She is older, mature, well-off, and very flirty. The tension is really high and I am actually scared of what might happen if we actually found a dark corner. She's married too, but she talks about him like he's a garden gnome or something... insignificant.

So here I now stand, my entire life in front of me. My 7-yo daughter's future in the balance, My home life in the balance. I want 3 women. 1. my dearest inertial wife, through no fault of her own unable to share intimate contact. 2. My sweet and cheerful little introvert, married with children, but who has given me so much of herself while I burden her to rebuild "me". 3. the cougar mistress who I know nothing about and could be psychotic, but is imminently available and willing at the drop of a hat, and who treats me like I am an intellectual demigod (she is a skillful flatterer, and I have a stroke-able ego).

I have carefully nursed my interest in you, and you give me plenty of fuel to work with, calling often and allowing my email antics to go on for days. I hope our conversations aren't therapy. I hope you love hearing from me and that is the reason you let me call.

I think I know how the story might end, but in fact, I long for the simple times of before...

This confession is true and without malice. I simply know no other way to present it without it becoming known to others.

Anonymous said...

As a patient, I think the thing with running on time or close to it, is also respecting the complex nature of discussions that are occurring. Assuming the fairly standard 45-50 minute appointment starting on the hour, one does have a certain flexibility to adjust to what is being said at the moment. Sometimes you'll be in the middle of something important at 2:45 and it might make sense to go until 2:55 today. If you've reached a natural end point of a topic at 2:40, alert the patient to the small amount of time left, and discuss something minor - maybe review goals or ask a simple question about the patients upcoming week as it relates to whatever your working on. If you're running late, apologize - I'll understand because you took those extra 5 minutes last month when I was really struggling with something - but do acknowledge that you did keep me waiting today.

dish said...

Wow. Did somebody write Dinah a love letter? I kinda didn't follow it but whoa. That was a really descriptive anon comment.

ClinkShrink said...

Nope. Dinah doesn't wear yoga pants.

dish said...

Oh okay. I see now. Joel finally revealed his true feelings for Clink.

ClinkShrink said...

LOL Clink definitely doesn't wear yoga pants. That leaves Roy.

dish said...

Jesse is in love with Roy?

Dinah said...

So is the issue one of saying it's harmful to the doctor/patient relationship for the doctor to start/stop the sessions on time? Or is it one of saying that it's a problem if the doctor is dismissive of the patient's concerns,or does not allow enough time in the appointments to adequately address concerns? Maybe ask for longer sessions or for 2 "med check" spots?
I think the issue of "Listen" includes "be tactful."

I admit, if a patient starts to bring up a very difficult topic at the very end of the session, I interrupt and ask them to save it for the next time, rather than risk having to cut off someone at a very sensitive time. And people often will ask if there is time for them to bring up a new topic, but is only the therapist's responsibility for controlling the flow of the session? People bring things up at the end for a reason.

jesse said...

Completely agree with what Dinah just said. In psychotherapy the patient understands how the therapist conducts the session. there is no "right" way but each variant has its own advantages and disadvantages. In insight oriented therapy anything that happens can provide an opportunity to learn.

If a patient brings an important issue up right at the end of a session when the patient knows that time is up shortly, is there a reason for this?

A doctor can go over the time allotted for his own reasons, not just for the patient's good.

dish said...

I think the patient should only have responsibility for flow if there is a clock near the patient. Some therapists, for whatever reason, don't have a clock within the patient's line of sight. In that case, the therapist should say if they are halfway done or ten minutes to finished.

jesse said...

P-K left a post that got eaten by Blogger, but it went out over email. So here is that post:

My psychiatrist is generally on time, but sometimes late. I assume if he's late, that he was helping a patient in crisis. It doesn't bother me. Sometimes my appointment goes over 15 minutes, sometimes less. But, it always seems to work. If I'm doing well, and I've been on a particular medication for a while, then I don't need (or want) the full 15 minutes. When I was not doing well; paranoid and agitated, my thoughts all over the place, he also kept it really short. There have also been times when it's gone over 15 minutes because there were things that needed to be addressed.

I don't ever feel slighted if the appointment is less than 15 minutes, though, because he has gone over the 15 minutes other times. He is also available by phone and has made it clear that I should call him if needed. He doesn't charge for the time spent on the phone calls, so patients are definitely not being slighted. I think I've only ever contacted him twice outside of an appointment - once for insomnia, and once because another doctor wanted my psychiatrist's opinion about starting me on a particular medication. He didn't charge me for those phone calls, so really it all works out.

It would bother me if he always ended the appointment at exactly the 15 minute mark, because I would feel he was spending the 15 minutes counting down the seconds until the appointment was over. That would be irritating.


jesse said...

Going right with the clock fits well if one has an analytic/psychodynamic psychotherapy practice, otherwise it can be very disconcerting as people have noted. P-K, it is good to hear of your experience with your doctor. Intelligence, ability, and flexibility are all good traits!

But, dish, if you are seeing a doctor who goes precisely by the clock can you not wear a watch? In my own office I have two clocks set up so that both I and the patient know the time. It is useful to know the time, as both the doctor and patient have good reasons to know how much of it is available.

dish said...

Do people still wear watches? I just look at my cell phone, but I think that might look weird in a therapist's office. I guess I could buy a watch specifically for those occasions so I can discretely look down and notice the time.

It probably also depends on insurance and the nature of the practice you are going to. I get what Dinah is saying about just scheduling two appointments, one after the other, if you think it's gonna take longer. But, and I have no clue if this is insurance related, most pdocs I have seen are VERY rigid about their schedules. No one gets in to see them for more often than they dictate. They won't allow that kind of appointment scheduling. I have been in to see a med management pdocs a couple of times where it was requested that I come back in a week or two because they couldn't decide what to do (these were new guys). But, regardless of what is wrong, they typically demand that you only come in when it's time for a refill. And if you have any kind of intervening problem that you think requires a doc then you should go to ER or urgent care. I'v had pdocs get pissed when I've had a problem and got in early (I gave you three months worth of pills! What are you doing back here in 2 months?).

Though, ocassionally, I do find a gem who will fit me in earlier if there if a problem. But I think the most annoying thing is when I show up to a rigid pdoc's overflowing waiting room, he is an hour behind, and I hear a patient ask the receptionist, "Why did you guys rush me in? All I needed was a refill. You could have just refilled and fit me in later when there was less people."Refills are immediate problems requiring rush appointments for these docs? The logic escapes me.

dish said...

And rigid pdocs always, without fail, doublebook. That way they see about six patients or more an hour and if someone doesn't show they still get a good income. Ugh. So annoying. And yet they always think their time is so important.

HIGurl said...

I think that there's a baseline to what makes therapy successful -- and it involves being attentive to the patients' needs. Each person is different and knowing what is important to that specific client is key.

For example, let's say that you have a client who is very impatient and needy, who also has an attachment issue. You wouldn't want to run late, so maybe you'd want to (1) consider scheduling med-checks for the prior appointment or (2) make sure you have a larger break after the appointment just-in-case of overage. Maybe you have a client with a control issue. Pre-scheduling appointments or not asking what he/she wants to discuss may want to be avoided.

I feel it's paying attention (listening) that is an important element in successful therapy. However, I also feel it's a two-way street. Therapy as a patient involves work. You need to be able to take note and identify the issues/problems. So if you're the type of person who can't say no to people (but are frustrated because damned-if-you-do, damned-if-you-don't), you need notice it and learn to speak up.

Each therapist has his or her own way of conducting therapy. Some are more empathetic than others. Some are way more empathetic than they need to be. And some, well, have no empathy at all. There are reasons why and it's dependent upon the therapist and the patient. One thing for sure though, "Listen, Listen, and Listen!"

Dinah said...

dish, no need to worry in this case-- with a doctor who double books appointments, chastises patients who come in before they need a refill, and tells people with emergencies to go to the ER, we have already ruled out any issue of "magic" or healing as a result of the doctor-patient relationships.

Docs deserve to make a living, and if the doc is taking insurance because they are either socially conscious, or because they can't get enough referrals without doing so, and if they double book because they have a high no-show rate, and if they run their practice very efficiently because there is a shortage of docs in their area and they are trying to fill a need, then more power to them. The truth is that the doc who doesn't take insurance and charges much more than the high volume, in&out, go-to-the-er or google-it doc, will be seen as the kinder, gentler doc who takes the time to listen and care and form a healing relationship. But in-and-out doc may still be providing treatment to many more patients who have no where else to turn.

And as I've always contended, a doc who doesn't like doing therapy shouldn't do it, no one ends up happy.

So pros and cons of both styles. Some of it is in personality and delivery, so you will find high volume docs who are just more low-key and empathic who are well liked, but in meds only treatment, it's not usually the relationship that heals.

dish said...

Not trying to compare med management with psychotherapy/med management combined. They are very different.

Though I do think that there can be some very real magic in the doc/patient relationship in med management. Even more so than in psychotherapy. I have had zero chemistry with some psychotherapists, but had loads of it with a med management doc. I think the high distractibility and overbooking in some high volume practices is very detrimental to this. I think it is easier to be open with a pdoc you click with in med management.

And I'm not talking Medicaid practices, which I have heard do have a high no show rate. I have seen plenty that accept Medicare (same kinda problem maybe?). Some of those high volume practices never felt rushed, they weren't more than a half hour behind, and the doc was very attentive. And they would spend around 20 minutes with me sometimes. I can't explain why some high volume practices that take undesirable insurance seem warm, attentive, and there is great chemistry and others feel rushed, harried, and cold.

Anonymous said...

The description is so distant from my own experience that it almost makes me want to cry. I had to deal with a psychiatrist who took one look at me and thereafter treated me only with distaste. She would not shake my hand, would not address me by name, and would not make eye contact. She was openly scornful and derisive. She may have been acting out some race and gender issues, but that does not make her behavior any less painful and destructive. I lasted three appointments and to this day regret that my depression kept me from bringing ethics complaints against her. It is years later and I still feel almost as if I had been molested. I still shiver at the thought of it.

Steven Reidbord MD said...

For dynamic psychotherapy I try quite hard to start and stop on time, and as a result I almost always do. ("Almost" because I'm human.) The clock is visible to both of us. This way, if someone raises a critical issue at the last minute I have grounds to wonder why they do this when they know as well as I do that the time is about up. There are a number of possibilities, and on occasion I'll go over a few minutes exploring it. The point is not to adhere blindly to a rule, nor to pack patients in back-to-back — I leave 10 minutes between patients, which I do NOT consider optional expansion space for the prior patient's session. The treatment frame creates a safe, predictable, even monotonous environment to highlight the personality features of the patient.

For medication-only visits there is less need to adhere to such a frame, although courtesy and collaboration are still crucial. I see a few meds-only patients for between 15 and 30 minutes. I don't usually link the frequency of visits to the timing of refills, since these are usually not logically related.

Anonymous said...

I have brought up issues at the end of therapy sessions because I knew I didn't have the courage to talk about it right then, but also knew it was important to get it out there so I wouldn't be able to continue to avoid it next session. I would imagine that's not all that uncommon?


Steven Reidbord MD said...

@P-K: Not uncommon at all in my experience. But what makes psychotherapy fascinating are the myriad other possibilities. Some patients threaten suicide at the last minute to assure they'll be on my mind all week. Some try to prolong the hour out of dependency or desperation, others out of hostility or sadism. Some half-wish I'll raise the topic when we next meet — and simultaneously half-wish I'll forget or brush off their comment as unimportant. And so on.

Anonymous said...

I hadn't thought of all the other possibilities. I specialize in avoidance, so I just assumed people were doing it for the same reason. The delay tactic.


dish said...

"Some patients threaten suicide at the last minute to assure they'll be on my mind all week."

@Reidbord: I am not a doc, but if I was, I would discharge that patient. Sounds like an unhealthy relationship.

And thank you for saying that about spacing the time between patients by about ten minutes. That's how I thought it was supposed to be for psychotherapy. Literally, every psychotherapist I find who is constantly rushing in the patients back to back has been soo distracted during the session.

There was one guy that I saw who was always rushed. He was late if I was the first appointment, late if I was just after his lunch break, late at all other times. He once came in late from lunch and his next psychotherapy patient went the bathroom. They missed each other. When he finally noticed her he rushed her in, and then rushed me in directly after. I had never seen him more impatient and difficult to work with.

Psychotherapists! please give yourself at least a 5 minute breather between patients. It's sucks for that patient probably as much as it sucks for you.

Steven Reidbord MD said...

@dish: "I would discharge that patient. Sounds like an unhealthy relationship."

Of course it's an unhealthy relationship. In a nutshell, that's what dynamic psychotherapy is about: making the unhealthiness of the patient's relationships conscious so it can be seen for what it is. In the case of the patient threatening (well, hinting) suicide at the end of the hour, it's only unhealthy if I don't say anything about it. But I did, and it ended up being useful therapy material. In my opinion, one needs a high threshold for discharging patients in dynamic psychotherapy. As I tell psychiatry residents: if patients all had pleasant, healthy personalities they wouldn't need to see you.

The 50-minute hour was invented by Freud himself, to leave 10 minutes between patients to collect himself, jot down notes, use the bathroom etc. While there is nothing magical about the 50 minute session length, I agree very much that being in the proper frame of mind — settled, open, not rushed, preoccupied, irritated by something unrelated, etc — is a prerequisite for doing good dynamic work, and for a good doctor-patient relationship generally.

Dinah said...

I've always been bad about stopping at 50 minutes and often run closer to 60 minutes -- it's fine by me and I don't think I get run down (I do try to schedule an hour off every 4 hours, and sometimes people run a few minutes late so I don't end up feeling exhausted and spent).

So when the new CPT rules went into effect, the choice becomes to do 37-52 minutes of therapy (~roughly a 45 minute session) or 53+ minutes(a 60 minute session) of psychotherapy, plus the time for E/M services. I decided that for most people, I code it as a 60 minute session --- my fee is the same, but the patient gets reimbursed more (or so I believe). So, would a patient rather have a 50 minute session and not see the next patient in the waiting room come in and get paid roughly $50 less per session by the insurance company, or have a 58-60 minute session, and get paid more by the insurance company, but not see the next patient enter the consulting room?

Obviously, not about 'magic' but there are some external forces that go on here that often aren't discussed with the patient. Don't tell Freud that the CPT codes won't allow for his style. Also, I think he made exceptions and was not terribly rigid about these rules.

dish said...

@ Dinah: I think it just depends on the therapist. If you can handle back-to-back psychotherapy patients without feeling overwhelmed then your doing fine and can get your patients reimbursed a little more money. I mean this more for therapists who feel rushed (and it shows in therapy) and are distracted by seeing back-to-back patients.

Steven Reidbord MD said...

@dinah: "Being bad" about stopping at 50 minutes isn't only a question of whether it runs you down or delays the next patient. In dynamic work it's also a frame issue. It invites the patient to fantasize that he or she is doing something to prolong the session (or not, on the days you don't). The importance of this will vary from patient to patient, and depending on the nature of the therapy.

The CPT issue is subtle. If it's your practice already to see patients for 55 or 60 minutes, then obviously you should use a code to reflect that. I'm less sanguine about adjusting my practice to fit the codes, a slippery slope that can lead nowhere good. I touch on some of this in my 2 latest posts, e.g.:

Freud tried all sorts of variations and exceptions. I like to imagine that most of the time he was experimenting, not merely bending to expediency or external pressures. In any case he wasn't faultless, so we can admire his groundbreaking work and continue to improve upon it.