Pearls: Six Core Conundrums
Some of the most frequent and most difficult issues faced by psychiatrists can have relatively straightforward options that can insure more accurate evaluation and treatment planning.
How to:
1. ...be more certain that a patient is not suicidal or homicidal.
2. ...respond to a patient’s insistence that his paranoid delusions are real.
3. ...manage an obnoxious patient who demands a specific medication.
4. ...manage an intimidating patient who demands a controlled substance.
5. ...deal with information from collateral sources, and.
6. ...evaluate information about collateral sources.
Responses:
1. Asking what is stopping a patient with suicidal thoughts from acting on those thoughts may be more indicative of the actual suicide risk than any plan or intent he expresses.
a. Having “no plan” can change precipitously under the pressure of unremitting depression.
b. If the patient has not attempted suicide due to a strong commitment to family or religious proscriptions, that is a significant mitigation of suicidal risk.
c. If the patient has not attempted suicide due to a concern about failing in the attempt – or is unable to come up with a reason at all – that suggests a stronger suicidal risk.
2. If a frankly delusional patient complains that all his previous providers thought he was “lying or crazy,” and asks if you believe his delusional statements,
a. Affirm that you feel he sincerely believes that what he is saying is true.
b. Affirm that you believe that he is accurately and truthfully reporting what he feels.
3. A patient who demands a certain medication may be making a good choice.
a. Do not be put off by obnoxious, demanding patients who make disparaging remarks about providers who will not give them what they need.
b. Evaluate the patient’s request within the framework of his symptoms and history.
c. Barring any clear-cut contraindications, respect a competent patient’s desire to take an older medication that he prefers.
d. Patients who are not competent, or even psychotic, can retain a recollection of what may have worked best for them in the past. Judge it on its own merits.
4. Be calm, patient, and firm with a patient who is demanding a controlled substance in an intimidating manner.
a. If he stands up and leans toward you, or exhibits other intimidating posture, calmly ask him to “please sit down.”
b. Refuse his request for the controlled substance by gently informing him:
1) That substance is not medically indicated for him;
2) It could be detrimental to his health;
3) Prescribing that medication would not be providing good medical care, and he is entitled to good medical care.
c. Finally, tell him that you are prescribing a safer substitute, give him a return
appointment and tell him you expect to see him back then.
5. Information from a collateral source is “free” – it is not subject to confidentiality constraints.
c. You are breaking no confidentiality by listening to someone who offers unsolicited information about your patient.
d. You may listen to someone who calls about a patient without admitting that you know him or that you are treating him, nor that you can answer them.
e. The information you receive from a collateral source may be invaluable in treating your patient. Don’t lose the opportunity.
6. Information that a patient reports about a collateral source – whether family, significant other, or former therapist –should always be taken with a grain of salt.
a. Patients, no matter how competent or sincere, filter their experiences through their own belief systems – delusional or not.
b. Be cautious about documenting a patient’s report of abusive treatment as factual.
c. Documentation of derogatory or accusatory statements should be prefaced by comments such as, “The patient claims…” or “The patient feels…”
Experience itself will, as usual, provide the best lessons in how to deal with situations that can lead to a damaging of the therapeutic alliance, or unnecessary consternation for the therapist. Hopefully, the above responses can be helpful.