When patients are invested in a diagnosis

[psychma]

How do you break it to them that they just don’t have it? I run a clinic that evaluates for autism. People have 30-50 page google documents that they have put together that they have categorized by traits to prove their case. They engage in reciprocal conversation, have little difficulty with social communication and understanding social cues, have a better social life than me, only temporarily don’t look at me when they talk, can’t think of a single thing they’re interested in and know a lot about, but “relate” to content on TIK TOK and YouTube. They cry an entire hour when you tell them they don’t meet the criteria or get angry and hostile. It really is challenging for me. How do you do it? And yes, I’m qualified and licensed to do what I do.

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[Fan_of_Meehl]

V911 - Other Specified Diagnosis-Deficit Disorder

 

[wolfvgang22]

How do you break it to them that they just don’t have it? I run a clinic that evaluates for autism. People have 30-50 page google documents that they have put together that they have categorized by traits to prove their case. They engage in reciprocal conversation, have little difficulty with social communication and understanding social cues, have a better social life than me, only temporarily don’t look at me when they talk, can’t think of a single thing they’re interested in and know a lot about, but “relate” to content on TIK TOK and YouTube. They cry an entire hour when you tell them they don’t meet the criteria or get angry and hostile. It really is challenging for me. How do you do it? And yes, I’m qualified and licensed to do what I do.

Well, first, you have to acknowledge you aren't going to please everyone no matter how nice you are, but it is still worth being empathetic. Keep in mind these types of folks are usually at the beginning of their mental health journey, and the most therapeutic thing may be for them to hear from 3 or 4 professionals that they don't have ASD, but that there are still real issues to work on.

I spend time providing active listening and empathize with their problems and validate their feelings. I then tell them I have listened carefully and have spent years working with patients with similar problems. I ask them if they are willing to be open minded and spend the necessary time getting to the bottom of their problems as a necessary condition of treatment.

I advise them as gently as I can in a clear, concise manner if they do not meet DSM-V criteria for ASD, but say we will stay open minded, since I just met them. I tell them what I think their diagnosis, if any, most closely matches their symptoms (such as Social Anxiety Disorder, which is common in these patients.) I advise them that the symptoms they do have is a serious matter. I advise in detail the diagnosis, course, and prognosis. I tell them I primarily do medication management as leader of a team in my clinic. I say we can speak about medications for their symptoms if they would like (if appropriate.) I advise that once in a long while I am wrong, and we can keep an open mind about diagnoses. I tell them I have a trusted therapist on my team that I have a lot of confidence in that I communicate with daily, who has had success with helping people with similar problems and can spend the large amount of time they will need to discuss their problems as a good place to start. If the patient disagrees with this, or is skeptical, I advise them that they are certainly welcome to seek another professional opinion and we will be available should they decide to later commit to further evaluation and treatment. If they start crying or yelling or bargaining or demanding and all that, I stay calm and empathetic. I suggest perhaps we should meet again later when emotions aren't so high. I am quick and firm in telling them I will not tolerate verbal abuse.

For me, even with a calm, empathetic approach, 7 out of 10 of patients like this will get angry and storm out. Out of those, half eventually come back to see me after seeing 2 or 3 other mental health professionals. And that's ok.

 

[randomdoc1]

I ask them, at the end of the day, what are they trying to get out of this? What are their goals? What are they hoping a diagnosis will bring to them. Many have their minds already made up anyways. And then I ask them, well...how's that workin' for 'em? Are they living the life they want or still not satisfied. And if the latter, ok, well let's focus on that because that seems to be the more pressing issue.

This reminds me so much of the adult ADHD mess out there. After being on 70mg Vyvanse with 30mg Adderall....did they finally meet their goals? Nope, and now they have a stimulant dependence. Congratulations.

 

[annoyedpsychiatrist]

How do you break it to them that they just don’t have it? I run a clinic that evaluates for autism. People have 30-50 page google documents that they have put together that they have categorized by traits to prove their case. They engage in reciprocal conversation, have little difficulty with social communication and understanding social cues, have a better social life than me, only temporarily don’t look at me when they talk, can’t think of a single thing they’re interested in and know a lot about, but “relate” to content on TIK TOK and YouTube. They cry an entire hour when you tell them they don’t meet the criteria or get angry and hostile. It really is challenging for me. How do you do it? And yes, I’m qualified and licensed to do what I do.

Very interesting post because this has happened to me 3 times in the past few months. Im just at a regular private practice. Tik tok has caused substantial negative impact to mental health treatment...

People dont usually take it well no matter how you break it to them. It borders a delusional disorder of which tik tok reinforces this false sense of self. You become the enemy for challenging their false reality. One of the most popular psychiatrists on tik tok is a "hollistic" psychiatrist who often posts crap like you can cure bipolar with supplements. This is what were up against. She charges $500 cash for initial evals, and these snake oil salesmen are raking in the money because of this health movement rooted in avoidance and delusion.

 

[Fan_of_Meehl]

Very interesting post because this has happened to me 3 times in the past few months. Im just at a regular private practice. Tik tok has caused substantial negative impact to mental health treatment...

People dont usually take it well no matter how you break it to them. It borders a delusional disorder of which tik tok reinforces this false sense of self. You become the enemy for challenging their false reality. One of the most popular psychiatrists on tik tok is a "hollistic" psychiatrist who often posts crap like you can cure bipolar with supplements. This is what were up against. She charges $500 cash for initial evals, and these snake oil salesmen are raking in the money because of this health movement rooted in avoidance and delusion.

New for the DSM-6...

Social Media Induced Psychiaform Disorder, TikTok Subtype, With Poor Insight

 

[annoyedpsychiatrist]

New for the DSM-6...

Social Media Induced Psychiaform Disorder, TikTok Subtype, With Poor Insight

with associated poor prognosis

 

[docksan]

with associated poor prognosis

requiring substantial reassurance

 

[Stagg737]

I also utilize an approach similar to RandomDoc's and just ask them why they are so invested in the diagnosis. I find the patients who really glob onto a diagnosis tend to have fairly significant personality traits with identity disturbance. I saw a similar phenomenon in residency working with "non-binary" teens on our adolescent unit. Many of them weren't non-binary at all, but found a community that was accepting of the identity they were trying to meld with that month. Same thing with older patients wanting an ADHD diagnosis, though there is often more secondary gain/wanting the magic pill with that group as well.

Don't be afraid to ask them why they think they have that diagnosis as well as why they want that diagnosis if they're fighting so hard for you to call them that. We ask about a lot more personal and invasive subjects than why someone thinks they have a diagnosis all the time. Figuring that out can help immensely with both how you should address the situation moving forward as well as their actual diagnosis.

 

[Candidate2017]

You could gently break the news that they've been living decades with undiagnosed intellectual disability, which often masquerades as autism. Let them know there are many others with the same condition, and they have, and can still lead, a full and rewarding life in the face of this devastating diagnosis. A full day battery of psychological tests will be required to confirm the correct modifier of mild or moderate; $2k cash pay, of course. Followed by weekly supportive therapy.

BTW, being licensed and qualified to do something are two very distinct concepts. And then there is the matter of whether one ought to. But I don't think someone with a master's is qualified to run an autism clinic.

This reminds me so much of the adult ADHD mess out there. After being on 70mg Vyvanse with 30mg Adderall....did they finally meet their goals?

There's still room to go higher with Adderall. So, they still have a little further to go before reaching goals.

 

[psychma]

You could gently break the news that they've been living decades with undiagnosed intellectual disability, which often masquerades as autism. Let them know there are many others with the same condition, and they have, and can still lead, a full and rewarding life in the face of this devastating diagnosis. A full day battery of psychological tests will be required to confirm the correct modifier of mild or moderate; $2k cash pay, of course. Followed by weekly supportive therapy.

BTW, being licensed and qualified to do something are two very distinct concepts. And then there is the matter of whether one ought to. But I don't think someone with a master's is qualified to run an autism clinic.



There's still room to go higher with Adderall. So, they still have a little further to go before reaching goals.

I am my own clinic. I have years of specialized supervised training under a PhD neuropsychologist.

 

[comp1]

I'm guessing the OP is not a prescriber, so I'll stay away from how you manage that dynamic. My general philosophy is that patients have symptoms; doctors have diagnoses. Patients usually know their own symptoms best; doctors usually know diagnoses best. There are exceptions, most of psychosis for example. That said, I very rarely see successful talk therapy that focuses on diagnoses at all. It should focus on symptoms. I think where the OP is running into trouble is that they only treat autism in particular AND they appear to be viewing autism as a binary when it's really the most spectrumy of illnesses. So if the patient falls on the wrong (or right?) side of their autism line, the patient only gets rejection. Since the OP only manages what appears to be severely disabling autism, I would recommend they pretty much stop telling patients they don't have autism all together. Instead, tell the person that they have significant symptoms, but that they can't be well managed at this particular clinic. Then they need to have a very deep referral list available.

 

[sloh]

You could gently break the news that they've been living decades with undiagnosed intellectual disability, which often masquerades as autism. Let them know there are many others with the same condition, and they have, and can still lead, a full and rewarding life in the face of this devastating diagnosis. A full day battery of psychological tests will be required to confirm the correct modifier of mild or moderate; $2k cash pay, of course. Followed by weekly supportive therapy.

BTW, being licensed and qualified to do something are two very distinct concepts. And then there is the matter of whether one ought to. But I don't think someone with a master's is qualified to run an autism clinic.



There's still room to go higher with Adderall. So, they still have a little further to go before reaching goals.

Your posts are the best haha

 

[Fan_of_Meehl]

You could gently break the news that they've been living decades with undiagnosed intellectual disability, which often masquerades as autism. Let them know there are many others with the same condition, and they have, and can still lead, a full and rewarding life in the face of this devastating diagnosis. A full day battery of psychological tests will be required to confirm the correct modifier of mild or moderate; $2k cash pay, of course. Followed by weekly supportive therapy.

BTW, being licensed and qualified to do something are two very distinct concepts. And then there is the matter of whether one ought to. But I don't think someone with a master's is qualified to run an autism clinic.



There's still room to go higher with Adderall. So, they still have a little further to go before reaching goals.

I think the DSM-6 will need an extra section under each disorder commenting on--what would we call it--the relative social desirability of the diagnosis. There are some disorders that people will get offended, on average, if you give them (and they generally do not want to receive) such as substance use disorders or intellectual disability while there are others such as PTSD, ADHD or autism that people will tend to get offended at you if you don't give (or retain) the diagnosis. To believe that these patient wishes (and tendencies to throw a fit or file a complaint) don't in any meaningful way affect the frequencies with which these conditions are diagnosed would be naive in the extreme. I think the majority of the PTSD literature is hopelessly corrupted by the implicit consequences inherent to 'giving' or 'withholding' the diagnosis of PTSD in certain (cough...VA...cough) settings. There are times I want to go into the consultation room wearing a paper Burger King hat and a 'Have it Your Way' t-shirt and just diagnose patients based on their order that they place with me like they're going through the local burger joint drive-thru. Half-kidding. I swear this was rarely an issue when I began training 30 years ago and has become progressively more of an issue over my career up to the current ridiculous state of affairs.

 

[Ceke2002]

I think the DSM-6 will need an extra section under each disorder commenting on--what would we call it--the relative social desirability of the diagnosis.

It's interesting that even among folks with actual genuine diagnoses of mental health issues, there is also a 'desirability hierarchy' that sometimes develops. In my experience it mostly seemed to be centred around perceived deservedness and gains in terms of care and attention - eg: an emaciated anorexic was perceived to be somehow more deserving of receiving a perceived amount of extra care and attention from health care professionals compared to someone with bulimia; someone with bipolar mania was perceived to be somehow more deserving of extra care and attention than someone who was emotionally disregulated due to BPD (nobody wanted that diagnosis); someone suffering from psychosis was like peak jealousy, because oh wow, now they really deserve and presumably get all the care and attention. It was a rather bizarre form of playing oppression olympics, albeit in a sad, desperate and needy kind of way.

 

[alina_s]

I think I just got fired by a teenager I’ve worked with for years over her belief in autism. Mom came to the visit and surprised me with some questions about the last psychological eval, which she didn’t agree with either. The teen has said that the diagnosis has made it so that her parents can understand that some things are hard for her, but I don’t think we need a lifelong diagnosis for that, and her social and communication skills are too high. Can we get a new V code for “adolescence is hard”?

 

[mistafab]

I think I just got fired by a teenager I’ve worked with for years over her belief in autism. Mom came to the visit and surprised me with some questions about the last psychological eval, which she didn’t agree with either. The teen has said that the diagnosis has made it so that her parents can understand that some things are hard for her, but I don’t think we need a lifelong diagnosis for that, and her social and communication skills are too high. Can we get a new V code for “adolescence is hard”?

Z60.0 (V62.89) phase of life problem

 

[FlowRate]

I think I just got fired by a teenager I’ve worked with for years over her belief in autism. Mom came to the visit and surprised me with some questions about the last psychological eval, which she didn’t agree with either. The teen has said that the diagnosis has made it so that her parents can understand that some things are hard for her, but I don’t think we need a lifelong diagnosis for that, and her social and communication skills are too high. Can we get a new V code for “adolescence is hard”?

Learning to fit in and get along involves trial and error and, for some, a lot more failure and discomfort than for others.

Like with "ADHD," we're in a phase where being below the mean/median in a given trait must be "pathological."

The message I think a lot of us are trying to give to patients is that it's entirely possible to work on relative deficits and, despite putting in effort, one may still end up not being as good at something as they'd like. Sometimes the appropriate response is to come to terms with having weaknesses rather than to try and excuse or medicate them.

 

[alina_s]

Learning to fit in and get along involves trial and error and, for some, a lot more failure and discomfort than for others.

Like with "ADHD," we're in a phase where being below the mean/median in a given trait must be "pathological."

The message I think a lot of us are trying to give to patients is that it's entirely possible to work on relative deficits and, despite putting in effort, one may still end up not being as good at something as they'd like. Sometimes the appropriate response is to come to terms with having weaknesses rather than to try and excuse or medicate them.

Tell all the truth, but tell it slant.

I’d slanted it in earlier conversations with the teen, but not enough when mom asked me directly in front of the teen. A relative challenge doesn't have to be labeled with a lifelong diagnosis.

 

[MedMan80]

Had a teen pull out a book, "my little book of autism" and start telling me about it and why they feel they're on the spectrum. Referred to ASD clinic, who stated, "why can't psych MD diagnose ASD?" - well, there was a reason I referred them to you!

Basically I ended up getting fired, which was fine by me!

 

[mistafab]

Had a teen pull out a book, "my little book of autism" and start telling me about it and why they feel they're on the spectrum. Referred to ASD clinic, who stated, "why can't psych MD diagnose ASD?" - well, there was a reason I referred them to you!

Basically I ended up getting fired, which was fine by me!

The whole point these folks miss is they ARE on the spectrum. We ALL are lol. There is just a cutoff we decided meant the autistic traits warranted early diagnosis and treatment.

When I approach folks this way they seem to take it better when I say they have traits but don’t meet the cutoffs.

Little do they know they just lost the chess match against me. They feel validated but I also tore apart their false beliefs and built therapeutic alliance. Haha, chumps. They’ll get better even if they don’t want to.

 

[randomdoc1]

The whole point these folks miss is they ARE on the spectrum. We ALL are lol. There is just a cutoff we decided meant the autistic traits warranted early diagnosis and treatment.

When I approach folks this way they seem to take it better when I say they have traits but don’t meet the cutoffs.

Little do they know they just lost the chess match against me. They feel validated but I also tore apart their false beliefs and built therapeutic alliance. Haha, chumps. They’ll get better even if they don’t want to.

I do the same thing too!! lol. CHUMPS.
Especially with the ongoing bipolar talk. I'm like well...everything is on a spectrum. Take diabetes and insulin resistance. There's prediabetes, DMII, DMII that develops to being insulin dependent. Even PCOS is a manifestation of insulin resistance. But they don't all get a blanket treatment. They don't all automatically go on an insulin pump, imagine the great harm if we did that. Buddy, we need to find the treatment customized to YOU. Tends to work really well.

I also found other hacks, billing and collections is a big one. Angry patient calls about their copay with all sorts of nonsense excuses trying to get out of payment and I'm like "you know what, I don't want to make this more trouble than it is worth." And basically tell them FINE, don't pay then and let's call it at that. Then they be like -- what u insinuating? That I can't? I'm like -- bruh, you the one throwing a hissy fit about it. Then they're like -- FINE, I WILL pay it. Take my money, take the damn money! I'll show you. The dialogue is much more professional sounding than that. But it's basically what happens on the phone. It's hilarious and reminds me of those cartoon skits where Bugs Bunny switches his argument and Elmer Fudd keeps on arguing against him just to keep arguing.

For young adults I also like to mail bills to their parents when they start getting delinquent. It's on their family if they violated a law and opened their mail. Daddies especially like to pay the bills of their daughters. But their parents get their kids' EOBs from insurance anyways so....

 

[MedMan80]

The whole point these folks miss is they ARE on the spectrum. We ALL are lol. There is just a cutoff we decided meant the autistic traits warranted early diagnosis and treatment.

When I approach folks this way they seem to take it better when I say they have traits but don’t meet the cutoffs.

Little do they know they just lost the chess match against me. They feel validated but I also tore apart their false beliefs and built therapeutic alliance. Haha, chumps. They’ll get better even if they don’t want to.

see this is the approach I would take in a private practice clinic, wanting to retain this simple patient. BUT, i am in a medicaid "see everyone and everything" clinic and so, no such loss at all!

 

[PikminOC]

requiring substantial reassurance

And no insight

 

[Liquid8]

I ask them, at the end of the day, what are they trying to get out of this? What are their goals? What are they hoping a diagnosis will bring to them.

Here the vast majority of requests for an Autism diagnosis are about trying to get onto the National Disability Insurance Scheme (NDIS), because Autism is thought to be a path to automatic entry and the rivers of gold this can potentially lead to. Some are genuinely curious, and while many of my patients would have traits and be considered high functioning through evidence of their communication skills, work, relationship history etc, they can be convinced not to bother after a brief discussion. Sometimes I reference patients of mine with severe schizophrenia or bipolar who have been declined and that's generally enough.

For the more persistent, fortunately I have a few other outs. Way back when I had a patient denied access because some faceless bureaucrat decided that as the diagnosis didn't come from a psychologists it wasn't valid. So if patients are really serious about this, I advise that they will probably need to pony up $2-3k or a full neuropsychological assessment with most baulking at the cost. .

The second out is that the NDIS application comes with a 30+ page booklet, and while a lot of this requires medical input there is a section that the patient must complete to describe what difficulties they are having and what supports they want. Anything funded by our medicare system - i.e. psychiatric and medical services is not covered. People thinking they are just getting free cash to spend on whatever they want are suddenly disappointed that they have to actually do some work to justify it.

 

[whopper]

On average I get a patient ticked off about once a year because they're triggered by something I cannot avoid and had no way to know to avoid it. Of course someone can point the finger at me and say I messed up. No. (and yes I know there's a slippery slope with someone who narcissistically cannot see there own mistakes)

Initial interview
Me: How far did you go with education?
Patient: I dropped out of college, and by the way thanks for making me feel stupid. I want to talk to your supervisor (I was a resident at the time).
Attending: What's the problem?
Patient: This idiot doctor asked me how far I went in school. He made me feel stupid. Obviously there's no reason for him to ask my education. I want to lodge a complaint and have him removed as a practicing doctor.
Attending: Ahem, you realize he's required to ask this? Also someone's education level is important in our evaluation of the patient.

Patient was fuming mad, and walked out of the hospital very upset.

The attending told me what I'm going to tell you. We're going to unintentionally trigger people no matter what we do. Obviously this particular patient must've gone though something we don't know that led to this situation where she's triggered by dropping out of college, but we're only human.

In situations like this aside that I try not to lose my own temper, and try to be aware of my own ego defense mechanisms, you can try to reasonably explain why you asked the question or to the original question the diagnosis. I tell patients a diagnosis is mostly so people are talking the same language and getting people up to speed instead of spending hours on the patient's situation. Of course a patient shouldn't be defined by a diagnosis.

You will have some success, you will have some failures no matter how well you try.

I will throw a little trick that I've notices shuts up most people and puts them in the palm of my hand. Seriously. THIS IS THE MOST EFFECTIVE TOOL I'VE FOUND THAT MAKES PATIENTS SAY "YES SIR MAY I HAVE ANOTHER."

Initial Interview:
Me: What brings you in to see me today?
Patient: You won't be able to do anything until you hear my entire life story. It was a balmy day in the most beautiful city where I was born. You see my father was a man of letters. My mother was something of a spirited person although some would disagree. If you can accept then maybe you can be my doctor. Oh what a funny word that is doctor. Have you ever thought about it? I have...
Me: Ahem, I don't know where you're going with this. I treat people. What's the issue with what you need help?
Patient: As I told you, you're going to have to hear my entire life story. Let me begin again. It was a balmy day in that most beautiful city....

ME: WE ONLY HAVE AN HOUR. YOUR INSURANCE IS PAYING FOR MOST OF THIS MEETING. IF I DON'T GET A MINIMUM STANDARD OF QUESTIONS ANSWERED YOUR INSURANCE WILL NOT PAY FOR YOUR BILL. LET ME GET THOSE QUESTIONS OUT OF THE WAY. OTHERWISE YOU'RE PAYING FOR THIS ENTIRELY OUT OF YOUR OWN POCKET. I DON'T MAKE UP THESE RULES. YOUR INSURANCE DOES. IF YOU DON'T' LIKE THAT THEN PAY FOR THE BILL YOURSELF, BUT AT THE RATE WE'RE GOING THEY'RE NOT GOING TO PAY.

Let's restart,

What is the problem that brings you in today? Preferably in one sentence.
-----------
Most of the time they get the message and drop the bull$hit "man of letters" or "she was spirited or maybe she wasn't" crap. I don't feel bad about it. Cause seriously if they got what they thought they wanted at the end of the hour we would've been nowhere other than me figuring out this person likes to hear themself talk. If that's what they really want fine, but their insurance isn't going to pay for that crap and while I in general don't like the insurance companies I completely agree on them not paying a doctor who's simply going to let a patient indulge in enjoying hearing themselves talk. Also despite my slight sarcasm I actually had a patient talk like this a few weeks ago. "It was a most balmy day." I still remember it like it was happening a moment ago.

That same patient? The problem was she couldn't sleep after a med was changed. Seriously that was the only problem. Was on Olanzapine, it was stopped, she couldnt' sleep. I told her Olanzapine causes heavy sedation and she should be weaned off of it, treat an underlying sleep problem if there is one or try something else to help her sleep if she wants to stay off of it. That was it. All of that "it was a balmy day' bull$hit. Would've taken 12 hours to figure it out if we went her way.

This trick really only works well in private practice or private insurance patients. Patients who don't have to pay a penny will have nothing to lose. And if the private practice patient is paying out of pocket, you can do a similar trick by telling the patient things will go way way way faster and more efficiently if you control the interview more, but if they want to hear themselves talk and are paying for it, SO BE IT AND DON'T FEEL BAD WHEN YOU GAVE THEM A WAY OUT MORE THAN ONCE.

 

[FlowRate]

On average I get a patient ticked off about once a year because they're triggered by something I cannot avoid and had no way to know to avoid it. Of course someone can point the finger at me and say I messed up. No. (and yes I know there's a slippery slope with someone who narcissistically cannot see there own mistakes)

Initial interview
Me: How far did you go with education?
Patient: I dropped out of college, and by the way thanks for making me feel stupid. I want to talk to your supervisor (I was a resident at the time).
Attending: What's the problem?
Patient: This idiot doctor asked me how far I went in school. He made me feel stupid. Obviously there's no reason for him to ask my education. I want to lodge a complaint and have him removed as a practicing doctor.
Attending: Ahem, you realize he's required to ask this? Also someone's education level is important in our evaluation of the patient.

Patient was fuming mad, and walked out of the hospital very upset.

The attending told me what I'm going to tell you. We're going to unintentionally trigger people no matter what we do. Obviously this particular patient must've gone though something we don't know that led to this situation where she's triggered by dropping out of college, but we're only human.

In situations like this aside that I try not to lose my own temper, and try to be aware of my own ego defense mechanisms, you can try to reasonably explain why you asked the question or to the original question the diagnosis. I tell patients a diagnosis is mostly so people are talking the same language and getting people up to speed instead of spending hours on the patient's situation. Of course a patient shouldn't be defined by a diagnosis.

You will have some success, you will have some failures no matter how well you try.

I will throw a little trick that I've notices shuts up most people and puts them in the palm of my hand. Seriously. THIS IS THE MOST EFFECTIVE TOOL I'VE FOUND THAT MAKES PATIENTS SAY "YES SIR MAY I HAVE ANOTHER."

Initial Interview:
Me: What brings you in to see me today?
Patient: You won't be able to do anything until you hear my entire life story. It was a balmy day in the most beautiful city where I was born. You see my father was a man of letters. My mother was something of a spirited person although some would disagree. If you can accept then maybe you can be my doctor. Oh what a funny word that is doctor. Have you ever thought about it? I have...
Me: Ahem, I don't know where you're going with this. I treat people. What's the issue with what you need help?
Patient: As I told you, you're going to have to hear my entire life story. Let me begin again. It was a balmy day in that most beautiful city....

ME: WE ONLY HAVE AN HOUR. YOUR INSURANCE IS PAYING FOR MOST OF THIS MEETING. IF I DON'T GET A MINIMUM STANDARD OF QUESTIONS ANSWERED YOUR INSURANCE WILL NOT PAY FOR YOUR BILL. LET ME GET THOSE QUESTIONS OUT OF THE WAY. OTHERWISE YOU'RE PAYING FOR THIS ENTIRELY OUT OF YOUR OWN POCKET. I DON'T MAKE UP THESE RULES. YOUR INSURANCE DOES. IF YOU DON'T' LIKE THAT THEN PAY FOR THE BILL YOURSELF, BUT AT THE RATE WE'RE GOING THEY'RE NOT GOING TO PAY.

Let's restart,

What is the problem that brings you in today? Preferably in one sentence.
-----------
Most of the time they get the message and drop the bull$hit "man of letters" or "she was spirited or maybe she wasn't" crap. I don't feel bad about it. Cause seriously if they got what they thought they wanted at the end of the hour we would've been nowhere other than me figuring out this person likes to hear themself talk. If that's what they really want fine, but their insurance isn't going to pay for that crap and while I in general don't like the insurance companies I completely agree on them not paying a doctor who's simply going to let a patient indulge in enjoying hearing themselves talk. Also despite my slight sarcasm I actually had a patient talk like this a few weeks ago. "It was a most balmy day." I still remember it like it was happening a moment ago.

That same patient? The problem was she couldn't sleep after a med was changed. Seriously that was the only problem. Was on Olanzapine, it was stopped, she couldnt' sleep. I told her Olanzapine causes heavy sedation and she should be weaned off of it, treat an underlying sleep problem if there is one or try something else to help her sleep if she wants to stay off of it. That was it. All of that "it was a balmy day' bull$hit. Would've taken 12 hours to figure it out if we went her way.

This trick really only works well in private practice or private insurance patients. Patients who don't have to pay a penny will have nothing to lose. And if the private practice patient is paying out of pocket, you can do a similar trick by telling the patient things will go way way way faster and more efficiently if you control the interview more, but if they want to hear themselves talk and are paying for it, SO BE IT AND DON'T FEEL BAD WHEN YOU GAVE THEM A WAY OUT MORE THAN ONCE.

I've had several patients like this in the last few years. I think the causes for the behavior span a bunch of different issues but several of them also happened to drop some sort of semi-inappropriate ask on minute 59 (usually relating to a benzo) and so I think one of many reasons for this is running the clock to force you to make more difficult decisions at the last second.

 

[whopper]

It was only one patient, but I had one back when I lived in Ohio who'd at the last minute would always present me a document to fill out that would take about 15 to fill out. I told her not to do it again because had she done it earlier we could've gotten it out of the way during the meeting instead of talk about a lot of BS.

Then she did it again, then again, then again.

In hindsight what I should've done was charge her money if she's going to present me me documents I got to fill outside of a meeting. I hate saying it but some patients will all of a sudden cooperate and be more reasonable when they realize they got to pay more money.

Also those patients that are triggered by things we can't tell? The only way around that is to not ask questions (we'll get nowhere) or go at a snail's pace. Now this is for the "all things being equal" reader. Of course there's been some narcissistic and unempathetic doctors who are a-holes.

Another trick I employ is I pretend my patient is Sasha Baron Cohen and is trying to piss me off for a video. I do everything reasonable I can without wasting time or being overly too nice to get that patient to the point while, as if I were on video, placed in a situation where I have to lay down the law, or tell it like it is I don't look bad. I've come up with a "3 chances rule." If a patient is being extremely unreasonable and I can detect it, I give them 3 chances. Then I get to business. Lay down the law. "Sir-we got 30 minutes. I want to help you, but so far I don't know where you're going with this."



I also give them an example, "there's a convenience store robbery. The thief robs the store and there's a witness. The police arrive and ask the witness to describe the thief. The witness repeatedly says there's a bad dude and you have to catch them. This won't help the police officer catch the thief. They need info like the license plate number, the height, identifying information. Bad dude doesn't help much. If you keep giving me bad dude answers to my questions I'll let you know."

 

[Ceke2002]

Here the vast majority of requests for an Autism diagnosis are about trying to get onto the National Disability Insurance Scheme (NDIS), because Autism is thought to be a path to automatic entry and the rivers of gold this can potentially lead to. Some are genuinely curious, and while many of my patients would have traits and be considered high functioning through evidence of their communication skills, work, relationship history etc, they can be convinced not to bother after a brief discussion. Sometimes I reference patients of mine with severe schizophrenia or bipolar who have been declined and that's generally enough.

For the more persistent, fortunately I have a few other outs. Way back when I had a patient denied access because some faceless bureaucrat decided that as the diagnosis didn't come from a psychologists it wasn't valid. So if patients are really serious about this, I advise that they will probably need to pony up $2-3k or a full neuropsychological assessment with most baulking at the cost. .

The second out is that the NDIS application comes with a 30+ page booklet, and while a lot of this requires medical input there is a section that the patient must complete to describe what difficulties they are having and what supports they want. Anything funded by our medicare system - i.e. psychiatric and medical services is not covered. People thinking they are just getting free cash to spend on whatever they want are suddenly disappointed that they have to actually do some work to justify it.

In my experience getting onto the NDIS is ridiculously hard, and I doubt there's any 'one true way' mental health diagnosis that would help with that. When I was in long term therapy it was suggested to me, by my treating Psychiatrist, that I should try and get NDIS access to be able to access return to work programs (in South Australia at the time there were no real decent return to work programs except through the NDIS). I wouldn't have gotten much to anything in the way of payment, because my husband was working at the time, but access to programs was definitely something I wanted.

Anyway round 1 of applying the application was rejected, because apparently my Psychiatrist had used non DSM IV terminology in some of his descriptions. Onto round 2 and the application was rejected because no enough detail on the exact nature of my diagnoses/symptoms was given. Round 3 and they lost my application all together and asked me to do the entire process again; that was the point I just gave up.

If anyone thinks getting NDIS access is just a matter of getting XYZ diagnosis, then I think they've been sorely misinformed.

 

[Ceke2002]

Initial Interview:
Me: What brings you in to see me today?
Patient: You won't be able to do anything until you hear my entire life story. It was a balmy day in the most beautiful city where I was born. You see my father was a man of letters. My mother was something of a spirited person although some would disagree. If you can accept then maybe you can be my doctor. Oh what a funny word that is doctor. Have you ever thought about it? I have...
Me: Ahem, I don't know where you're going with this. I treat people. What's the issue with what you need help?
Patient: As I told you, you're going to have to hear my entire life story. Let me begin again. It was a balmy day in that most beautiful city....

ME: WE ONLY HAVE AN HOUR. YOUR INSURANCE IS PAYING FOR MOST OF THIS MEETING. IF I DON'T GET A MINIMUM STANDARD OF QUESTIONS ANSWERED YOUR INSURANCE WILL NOT PAY FOR YOUR BILL. LET ME GET THOSE QUESTIONS OUT OF THE WAY. OTHERWISE YOU'RE PAYING FOR THIS ENTIRELY OUT OF YOUR OWN POCKET. I DON'T MAKE UP THESE RULES. YOUR INSURANCE DOES. IF YOU DON'T' LIKE THAT THEN PAY FOR THE BILL YOURSELF, BUT AT THE RATE WE'RE GOING THEY'RE NOT GOING TO PAY.

Let's restart,

What is the problem that brings you in today? Preferably in one sentence.
-----------

Oh dear gods I bet you'd just love me as a patient </sarcasm>

Family history of mental health issues? Sure, well I've traced my family history back to 1804, we can start there. Oh, too far? Okay.

We've got 5 minutes left in a session and you'd like to know if I need to ask or talk about anything else before we wrap up? Yes, could you explain object relations and psychodynamic therapy as it relates to the theories of Freud?

*Psychiatrist.exe has stopped working.

 

[Mad Jack]

The whole point these folks miss is they ARE on the spectrum. We ALL are lol. There is just a cutoff we decided meant the autistic traits warranted early diagnosis and treatment.

When I approach folks this way they seem to take it better when I say they have traits but don’t meet the cutoffs.

Little do they know they just lost the chess match against me. They feel validated but I also tore apart their false beliefs and built therapeutic alliance. Haha, chumps. They’ll get better even if they don’t want to.

Exactly what I do. I also go into some of the core deficits that are present in autism after having a patient describe various social situations, abstract concepts, etc. I'll discuss how they have intact abstraction, intact theory of mind, etc. This allows them to basically talk themselves out of the diagnosis as they realize it doesn't fit. If they're still unsatisfied with this, I am more than happy to provide them with various local centers that do autism testing for a second opinion. I let them know it can be a costly and lengthy process and most likely, based upon my clinical assessment, they do not have autism.

I've had quite a few insist on that second opinion. I've never been wrong.

 

[whopper]

We've got 5 minutes left in a session and you'd like to know if I need to ask or talk about anything else before we wrap up? Yes, could you explain object relations and psychodynamic therapy as it relates to the theories of Freud?

OF course there is a patient where you really do need to hear the life story. It's one of those you won't know till you get there things. But every patient I've seen almost always has the main issue. I've found that most of the patients-who are a minority, who have this underlying long term issue you're only going to find this out after you've seen the patient several times, and being efficient still gets us to that point of discovery faster.

 

[Ceke2002]

OF course there is a patient where you really do need to hear the life story. It's one of those you won't know till you get there things. But every patient I've seen almost always has the main issue. I've found that most of the patients-who are a minority, who have this underlying long term issue you're only going to find this out after you've seen the patient several times, and being efficient still gets us to that point of discovery faster.

Oh yeah, of course, I get that. Sorry I was being a tad tongue in cheek before. I would assume that there's a rather large difference between time limited (or time sensitive, eg trying to get to the main issue for insurance reasons) therapy/treatment vs the more long term (7 or so years) type therapy that I underwent (correct me if I'm wrong on that).

I do sort of know what you mean with your example. Obviously not from a physician's point of view, but just before and partly during the pandemic I was doing some voluntary work as an online peer support person, who's main job was to help people access care and provide some semblance of support whilst they were waiting for that care. In these instances I didn't need the person's entire life story, I needed a basic overview of what their issues were, whether they had any previous therapy experience, and if so what sorts of therapy they felt they responded best to/had helped in the past. Of course some folks decided to respond with an almost University level response in terms of the sheer number of words they used. It was like, okay, that's great that you feel comfortable enough with me to be so detailed, but I really didn't need a 1500 word minimum essay.