A Patient Letter

[thoffen]

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I rarely get correspondence from patients, and I do mostly inpatient work. Don't know how regular it is, but I do want to share what was in my mailbox this morning.

Hello Dr. Thoffen,

I wanted to tell you how much I appreciate (that word is not enough to cover it) your kind attention and concern for my well being. you and your colleagues at [psychiatric hospital] are exceptional.

My gratitude is more than I can express. Words just won't cover it.
​

I want to share this letter not because it makes me look good. Well, not just because of that, but because I didn't recognize the patient name and went to my notes to see who it was that was thanking me. Here's a snippet from the d/c summary:

We clearly recommended to patient that [s/he] not return to [bad environment], however [s/he] did not elect an alternate disposition. We also offered and recommended residential substance abuse treatment which [s/he] refused. By [his/her] evidence and collateral from [important person from bad environment], there has not been abuse in that [bad environment] for several years. Although not an optimal environment, I have no evidence to suggest it places [him/her] in danger, and do agree that [s/he] should not be living alone with access to alcohol and drugs.
​

This feedback came from a patient who stayed only a short while and left refusing our treatment recommendations. That is what I find important. I don't know if this patient got out of their bad environment and got sober, but I think respecting their autonomy and humanity was the only intervention I truly provided.

 

[NickNaylor]

Reminds me of a story Yalom talked about in one of his books when both he and a patient wrote down their thoughts about each individual session and then, at the end of the patient’s treatment, they exchanged their notes. For a session that Yalom described as a “turning point,” he thought the session was positive because he had made a great interpretation that the patient seemed to respond to. The patient similarly thought the session went well but wrote something along the lines of “Dr. Yalom seemed softer today.”

I’m becoming more aware of just how much therapeutic power there is, for some people, in just listening to their story and trying to be helpful - even if they rebuff your attempts to do so. Doesn’t work for everyone, but for some folks really listening without judgment (or at least not expressing what judgment you might have) seems to be the most effective intervention you can offer.

 

[singasongofjoy]

​

This feedback came from a patient who stayed only a short while and left refusing our treatment recommendations. That is what I find important. I don't know if this patient got out of their bad environment and got sober, but I think respecting their autonomy and humanity was the only intervention I truly provided.

Thank you for sharing this!

 

[smalltownpsych]

I rarely get correspondence from patients, and I do mostly inpatient work. Don't know how regular it is, but I do want to share what was in my mailbox this morning.

Hello Dr. Thoffen,

I wanted to tell you how much I appreciate (that word is not enough to cover it) your kind attention and concern for my well being. you and your colleagues at [psychiatric hospital] are exceptional.

My gratitude is more than I can express. Words just won't cover it.
​

I want to share this letter not because it makes me look good. Well, not just because of that, but because I didn't recognize the patient name and went to my notes to see who it was that was thanking me. Here's a snippet from the d/c summary:

We clearly recommended to patient that [s/he] not return to [bad environment], however [s/he] did not elect an alternate disposition. We also offered and recommended residential substance abuse treatment which [s/he] refused. By [his/her] evidence and collateral from [important person from bad environment], there has not been abuse in that [bad environment] for several years. Although not an optimal environment, I have no evidence to suggest it places [him/her] in danger, and do agree that [s/he] should not be living alone with access to alcohol and drugs.
​

This feedback came from a patient who stayed only a short while and left refusing our treatment recommendations. That is what I find important. I don't know if this patient got out of their bad environment and got sober, but I think respecting their autonomy and humanity was the only intervention I truly provided.

Respecting their autonomy while still being honest about your feedback. Excellent. Places responsibility for their life where it belongs and avoids the control/resistance dynamic.

 

[thoffen]

Respecting their autonomy while still being honest about your feedback. Excellent. Places responsibility for their life where it belongs and avoids the control/resistance dynamic.

If we can't contain our own aggression toward a patient's self-destructive decisions enough to provide honest and compassionate care, how can we possibly expect the patient to do the same in their own lives?

 

[Fan_of_Meehl]

Respecting their autonomy while still being honest about your feedback. Excellent. Places responsibility for their life where it belongs and avoids the control/resistance dynamic.

The VA bureaucratic 'Powers-That-Be' could learn a thing or two from this right about now. If they keep up their pushing, they may not have any therapists left on the front lines in a year or two.

 

[Liquid8]

This feedback came from a patient who stayed only a short while and left refusing our treatment recommendations. That is what I find important. I don't know if this patient got out of their bad environment and got sober, but I think respecting their autonomy and humanity was the only intervention I truly provided.

Thanks for sharing this.

Sometimes respecting one’s autonomy is all that is required. In a typical doctor/patient relationship, we prescribe a treatment and patients go off and do it. Some doctors will experience an injury to their pride or ego if their treatment recommendations aren’t agreed to, and relinquishing any control in the treatment setting can be very difficult to do. I thought it was interesting that you didn’t remember who the patient was initially which suggests the above isn’t a problem for you.

With psychiatry I think we are more used to dealing with more resistant patients compared to other specialties and are more likely to adopt a default position where there’s no benefit from pushing or forcing a patient to do something that they don’t want to. I did wonder if this patient had never experienced a prior interaction where there treatment decision was respected, or they were expecting to be threatened with involuntary treatment etc.

Have you contacted them since? Unless they were particularly difficult during the admission, if this were one of my patients I'd think about calling them to confirm you received their letter and would be curious to know how they have been travelling since discharge.

 

[thoffen]

Thanks for sharing this.

Sometimes respecting one’s autonomy is all that is required. In a typical doctor/patient relationship, we prescribe a treatment and patients go off and do it. Some doctors will experience an injury to their pride or ego if their treatment recommendations aren’t agreed to, and relinquishing any control in the treatment setting can be very difficult to do. I thought it was interesting that you didn’t remember who the patient was initially which suggests the above isn’t a problem for you.

With psychiatry I think we are more used to dealing with more resistant patients compared to other specialties and are more likely to adopt a default position where there’s no benefit from pushing or forcing a patient to do something that they don’t want to. I did wonder if this patient had never experienced a prior interaction where there treatment decision was respected, or they were expecting to be threatened with involuntary treatment etc.

Have you contacted them since? Unless they were particularly difficult during the admission, if this were one of my patients I'd think about calling them to confirm you received their letter and would be curious to know how they have been travelling since discharge.

Thanks! I am by no means immune to those dynamics, and there are situations where respecting someone's autonomy is far more risky. It is, however, something I actively pay attention to and consider through an empathic stance.

For this patient, the letter was misdelivered, so it was a few months after d/c that I received it. I think I will write a letter in reply, at least thanking them for the correspondence. I have been paying more attention to the idea of transitional objects in relation to inpatient work lately. I really like when I can find things that are not intrusive but retain some connection to anything that was valuable about their stay. I'll do things like point out explicitly the the unit numbers are on DC paperwork and ask people to follow up if something doesn't work out. I figure if I do something in the patient's interest clearly outside of my job requirements but clearly inside my job description, I have reinforced any help I may have otherwise provided.