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?