Before a patient walks into your office, you’re just a random mental health clinician the patient got an appointment with. That patient could have just as easily gone to see a psychiatrist down the hall from you, or across the street, or across town. At that point, we’re all interchangeable. What leads a patient to see you as opposed some other provider often has nothing to do with who you are but with your office location or the patient’s health insurance plan or some other such factor.
But once the patient’s eyes meet yours, everything starts to change, sometimes slowly and sometimes quickly. You are no longer just another random clinician. You are becoming that person’s trusted advisor, and that person will start to imbue you with all types of significance. You are now unique and better than the mental health provider down the hall or the one across town. You are better because you now belong to that patient.
When I was a second-year resident, I first became aware of this process of an unfolding relationship between myself and my patients. I started to realize how patients started to incorporate me into their inner lives. If a person said, “During the week I was thinking about what you said last time we met” you’d think I’d be pleased with the impact I was having. I am now, but at that earlier stage of my career, I was mildly freaked out. I felt like the patient somehow captured part of my soul, and the rest of me squirmed.
Was my emotional response rational? Of course not. But my inchoate discomfort was indicative of something important going on. And that something is the nature of the relationship that develops between a psychiatrist, therapist, or other mental health clinician and their patient. I now realize the power of this relationship and am able to harness it (often? Sometimes?) for the patient’s benefit. Back then, I was beginning to see the power of the relationship but was daunted by it because I didn’t know how to harness it and where it might lead.
What happens when a patient starts to form a relationship with you? They start to become attached, and you become their attachment figure. Remind yourself that patients are people often struggling, in pain, with fear, and usually without adequate supports. You have the chance to become their advocate, their guide, and perhaps their surrogate parent. You are a powerful person or, rather, you are a person in a powerful position: you have the knowledge and the status to help them. You can deploy your resources on their behalf.
But with such interpersonal power comes responsibility. I like to say that to truly own your power as a clinician and do so without ambivalence, you have to be clear of mind and pure of heart. We should periodically remind ourselves that we must always act in the patient’s best interests. That’s what a fiduciary relationship requires ethically and legally. Sometimes this requires saying “no” to a patient’s requests. Sometimes it means disagreeing. Sometimes it means recommending seeing another clinician for a second opinion.
But with this interpersonal power also comes great potential benefit. Consider how much time and effort most of us expend trying to decide which psychotropic to prescribe. We should do so, of course, but consider that in meta-analyses, all newer antidepressants have more or less equal efficacy.
Now consider how little time and effort we expend on using the relationship to the patient’s benefit. As an example, I truly believe that over the years, some of my patients who might have died by suicide did not do so because they did not want to hurt me or disappoint me. They were staying alive to not hurt me! Isn’t that amazing? And powerful? Hey, if that’s what it takes to live, I’ll take it!
Or how many times did I tell a patient to do something that would benefit them – as a form of behavioral activation – and they didn’t do it. I would then say, “Please do it for me then.” And some would because at that point in their despair, avoiding disappointing me was more motivating than avoiding disappointing themselves.
Now, of course, some patients who come to see us don’t care that much about us, and their relationship with us is purely transactional: they come in to get a prescription and then leave as soon as they can. They’re not looking for a guide, an advocate, or a parent. This is OK and expected. Different patients have different needs, and I’m willing to meet them where they’re at – as long as I don’t think what I’m doing is detrimental to them.
But for many patients, their relationships with me or you are very important – perhaps the most important- relationship they have and that relationship can be an instrument of healing.
As an experiment this week, try saying one of the following to select patients and see what kind of response you receive:
- “You know I was thinking about you this week and … <share a thought or recommendation here>.”
- “I wanted to get your advice on something regarding your treatment.”
- “I’m glad to see you today. I was a little worried about you when you missed your last appointment.”
Thanks much and write me with the results of your small experiments. And, if you feel hesitant to try, then please do it for me. It would mean a lot. 😉
Until next time,
“Love all, trust a few, do wrong to none.” ― William Shakespeare
“Our bodies have five senses: touch, smell, taste, sight, hearing. But not to be overlooked are the senses of our souls: intuition, peace, foresight, trust, empathy. The differences between people lie in their use of these senses.” ― C. JoyBell C.
“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.” ― Marie Curie Sklodowska
“The best way to find out if you can trust somebody is to trust them.” ― Ernest Hemingway