Thursday, March 21, 2013

The Basic Treatment Plan



There's a lot of discussion going on in the comment section of the post where I asked people to take a survey on mandatory reporting of dangerousness.  Our favorite commenter, Anonymous, mentioned a therapist who refused to treat him/her unless s/he got rid of her gun.  Then Jesse and Clink got into it over whether it's reasonable to ask patients, on the first appointment, to get rid of their guns.  Clink said, "Jesse, the problem with the approach that you're suggesting is that the therapist has then taken on the responsibility of caring for a patient who has announced at the outset that they will not follow the most obvious treatment recommendation."  Clink later noted that a therapist would not likely take on a patient who announced at the outset that he'd be late to every session and pay the bill late.  This all made me think.

So enough with guns, I want to discuss treatment plans.  Clink would be appalled: some of my patients are late to every session, and some take their time with paying the bill.  I don't really press people on the payment issue, I just like to be paid eventually.  I'd say it's because I don't have a dollar-to-dollar cash flow need, but when I was younger and my lifestyle was limited by cash flow, I didn't hassle people about paying in a timely fashion either, so I think it's me and my distaste for discussing money issues, not my generous spirit.  

It occurred to me that I frequently take on patients who 'announce' at the outset that they will not follow the most obvious treatment recommendations.  They don't want to take the medications I suggest.  I can live with that, so long as they aren't demanding I prescribe medications I feel are  not indicated for their condition, or that will do them more harm than good.  Then I say no, and yes, I do screen patients quickly before I see them, so that if their only reason for seeking care is to come in briefly every three months to get a specific controlled substance (for example, Adderall or Xanax), then I can say that I'm not the doctor for them.  Not because I won't prescribe those medicines, but because I don't like to see someone who is looking for a very specific service that I don't feel comfortable providing.  

I often suggest that people work on putting more structure into their lives, exercise, eat healthy foods, experiment with different diets to see if that has an impact on their psychological state, drink a little coffee, don't drink a lot of coffee, and don't drink alcohol if that seems to be adding to their problems.  If they taking sleeping pills at night and sedatives during the day, I suggest this might be a reason why they feel tired all the time, and perhaps they should come off.  I always recommend that people stop smoking.  I often recommend a frequency for therapy visits at a rate that is more often than some patients want.

So what's my success rate with getting people to follow my most obvious treatment recommendations?  Honestly, it isn't so good.  Most people take the medications I recommend and nearly everyone pays their bills, eventually.  The people who like exercise anyway will exercise.  It's not unusual for people to call me in a crisis, in which case I usually see them within a day or two.  During those periods of distress, we will formulate an immediate treatment plan.  During those episodes, people generally follow my recommendations for about two days.  Every now and then, someone is so resistant to following any recommendation at all despite continued difficulties, or they change the dose of their medicines so often without consulting with me, that I wonder if they are really patients, because the state of patient-hood does require at least the willingness to collaborate and consider treatment recommendations.

Is it me?  My impression from how people react, is that I'm not particularly intimidating.  No one seems to shy away from telling me they never filled the prescription I gave them or they aren't going to stop drinking.   I sort of figured it was the nature of the work, and that part of the job entails treating people as they come, and respecting the fact that not everyone is willing or able to do what I might think is best, and most people get better anyway.

But I don't need to ask people to give up their guns to know that I'm fine to work with people who won't follow the most obvious of treatment recommendations.  What about you?