Hah! So she doesn't read my blog.
Not that I think she should. Of all the many things about which I have strong opinions, whether care providers should google their patients is not one of them. They can have that discussion among themselves.
Trust My Psychiatrist?
Then last September David Mintz wrote about Psychodynamic Psychopharmacology. Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment.
One particular paragraph brought my therapist's question and my tucked away post back to mind:
The Prescriber and the Placebo Effect
An analysis of the data from a large, NIMH-funded, multicenter, placebo-controlled trial of the treatment of depression found a provocative treater x medication effect. While the most effective prescribers who provided active drug (antidepressant) had the best results, it was also true that the most effective one-third of prescribers had better outcomes with placebos than the least effective one-third of prescribers had with active drug. This suggests that how the doctor prescribes is actually more important than what the doctor prescribes!
Turned to the patient's perspective, if your meds don't work, maybe you don't need different meds. Maybe you need a different doctor.
That is not where David Mintz, MD went with this finding. He cites research indicating that a strong therapeutic alliance is one of the most potent ingredients of treatment. Well, an alliance has two partners. But his article focused on just one side of the alliance, on patients, how our personal psychodynamics might interfere with treatment, (with a passing reference to countertransference in relation to overprescribing). He pretty much ignored, as in, totally ignored the nature of the alliance.
Today I ask the question the way the patient would ask the question:
What helps me trust my doctor?
I didn't trust my first two psychiatrists. I had very specific reasons. When I told one of them that a particular behavior on her part had decreased my trust in her and damaged our relationship, she said, I don't do relationships. I use pharmacology to treat psychological disease.
Well, I knew where I stood.
But I do trust my current psychiatrist.
I walked into her office predisposed not to trust. Yes, I did. I had so little expectation of being heard that I had laryngitis, literally. Some of that distrust came from my own long-term issues, the psychodynamics of a trauma history. I will own that.
OMGThat'sWhatTheySaid feature, disrespectful language, and reading case after case after case of unethical sales practices in the pharmaceutical industry, resulting in lawsuits and fines (not to mention neglectful prescribing practices and consequent harm to patients).
Part of it came from my experiences with those other two psychiatrists.
I can identify specific behaviors on the part of my current psychiatrist that helped me overcome this distrust.
The very first thing -- she apologized. It was an institutional screw-up, not hers, that had me sitting in the waiting room for thirty minutes before our first appointment, not filling out paper work, not answering questions, just sitting, no explanation, silence. But on behalf of the institution, she apologized.
Ellen Frank wrote in Treating Bipolar Disorder, ...perhaps because many patients with bipolar disorder have had the great personal or familial success that often accompanies the energy and enthusiasms of bipolar disorder, a subset of patients with bipolar I disorder present with an entitled stance that is rarely seen in other outpatient populations [such as self-effacing unipolar] ... your IPSRT patients will sometimes expect that... you are never late for an appointment, that you never change or cancel... sometimes there is nothing that can be done other than to apologize for this "affront."
That "affront," in quotes, confused me. The notion that expectations about being on time come from a sense of entitlement confused me. Oops -- that the doctor would be on time. Me, when I am late or I cancel, I apologize, because I respect the doctor. My new psychiatrist canceled once, is late occasionally. Each time she apologizes. I don't think she thinks I have a sense of entitlement. I think she respects me.
Maybe Frank ought rather to be concerned about her self-effacing unipolar patients. Maybe part of their depression is the habit of internalizing the disrespect of authority figures.
Respect As The Ground For A Therapeutic Relationship
Last October, John McManamy published a Mental Health Patients' Bill of Rights. They included:
- The Right to a psychiatrist who listens
- The Right to a psychiatrist who values us as human beings
- The Right to a psychiatrist who values our uniqueness as human beings
- The Right to a psychiatrist who is committed to getting us well, not just stable.
I think "The Right to a psychiatrist who respects us" is the overarching category. John's list includes actions and attitudes that proceed from respect.
If my doctor respects me, I can expect certain things to follow. I can expect that the doctor has my interests at heart when handing me a prescription. I can expect that the doctor will listen to, care about and remember my concerns, my values, my life outside the office, and the effect of treatment on that life. I can expect that the doctor pays attention to the results of a particular treatment on me, specifically me.
These issues are important, because the treatments are powerful. Whether or not they help, they sure can harm. If my doctor respects me, I can believe that she will pay attention to the harm.
Then I can feel safe(r). Then we can have a therapeutic alliance.
Next week -- more specific behaviors that demonstrate respect and build a therapeutic alliance.
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