Monday, January 14, 2008

Fill In The Blanks

This is kind of a How-To post, if that's okay. It's about "How To" start off a therapeutic relationship in such a way that the patient's ability to feel hopeful is optimized, and the patient feels confident about the Shrink's skills. We've talked about people getting to Shrink Rap when they Google "how to manipulate your psychiatrist." This post is going to have a tinge of "how to manipulate your patient." Sort of, not really. This technique works well for psychiatric evaluations and the beginning of psychotherapeutic relationships, but it works just fine for other medical specialties, and probably in any field where a client comes to a professional seeking help solving a problem. There's no science here, just my own observations of patients, and my own feelings when I've seen a doc.

I'll call the technique Fill in the Blanks, but I'm not sure that's quite right. It could also be You're the Type of Person Who....

Quite simply, people feel a degree of confidence in a doctor who understands them, who helps them rephrase their feelings with new words that resonate, who knows things about them before being told. If the doctor can predict the future, well that's helpful, too.

So I'm struggling a little to really explain this and I don't have a great example. Often it boils down to saying to people, "You're the type of person who...." Here's an easy one that I often resort to: I can usually get a quick handle on whether someone is an introvert or an extrovert, and from there it's easy to make some quick assumptions about them. To an extrovert: You live in the moment, you sometimes forget that things will get better soon. To an introvert: Sunday nights are hard for you, you tend to get anxious about the upcoming week.

There are some basic Fill-in-the-Blank rules:

  • In the course of telling a stranger about themselves, it's important to eat your words quickly if the patient tells you it's not true. If the patient says "actually I'm not that kind of person at all," the doc should ask, "What kind of person are you?" No one wants the blanks filled in wrong (even if the doc is right!), it leaves the patient feeling unheard, misunderstood, and rapport and confidence are killed. If someone is a touchy type of person who is easily offended, they may read too much into such statements and Fill-in-the-Blanks is risky.

  • It's good to Fill in the Blanks with positive things about people. "You're the type of person who would sell your children as sex slaves to get your next drug fix" doesn't work. "You're the type of person who does a great job taking care of other people but doesn't always take the best care of yourself" is a better risk-- it paints the patient as selfless. ClinkShrink is the type of person who is always polite to everyone. Roy is the type of person who is always up for a new challenge. Dinah is the type of person who is always happy to eat a good meal with a friend.

  • Perception is more important than fact. If the patient feels understood, it doesn't matter if the interpretation is perfect. "You have a strong moral code and sometimes this causes you to be angry at people who cheat the system." If it works for the patient, don't worry about the fact that they plagiarized a term paper or shoplifted a few times.

  • Watch their face: expression says it all. People nod and light up when they feel understood. Some people are compliant and will say "Yes, doc" to everything. If they get grit their teeth and eye the vase to throw it at you, you've got it wrong. If you're fumbling, just say so. "I have the sense I've got you pegged wrong. Can you help me here?"

  • It's okay to lie a little, but not a lot. Well, not really lie, but I tend to be reassuring in a way that may be more powerful than I can know for absolute sure. From your story, you've had a few episodes of depression before and they've always resolved, this one will resolve too." People feel buoyed by hopefulness, they don't tend to come back and say "You promised I'd get better and I didn't." So far (should I even say this?) no one has demanded a refund. But don't lie a lot-- if the patient has two weeks to live, it's poor form to assure them that their terminal condition will resolve.
Coming soon: a series on benzodiazepine use.