The customer is not always right

I often remind psychiatry residents that while a patient’s treatment preference is important, it does not take the place of their own evaluation.  It is a bittersweet irony that many of us are mistaken about, or repelled by, what would most help us.

Some patients, with depression for example, only consider medications, and have tried many to no avail.  Even after a dozen adequate but unsuccessful medication trials by past psychiatrists, some call me in desperation to ask whether the 13th, usually with the newest heavily promoted product, could be the miracle they seek.  I generally tell them — right on the phone — that it is unlikely.  I also assure them that if they come in for an evaluation anyway, I will respect both their preference and past experience.  What I don’t tell them:  People who avoid psychotherapy because they fear having to face uncomfortable memories or feelings often end up getting the most benefit out of it.  By the end of our first in-person meeting, I hope to engage such a patient’s curiosity about his or her emotional life as more than simply a collection of symptoms.

Conversely, some patients pursue psychotherapy for years, and would never dream of taking psychiatric medication (“mind-altering chemicals”).  This makes excellent sense when the problem is based on personality factors and relationship issues.  But sometimes it’s not.  Even the best psychotherapy won’t quell the hallucinated voices of schizophrenia, nor the behavioral excesses of mania.  Some patients are too depressed or anxious to use psychotherapy.  (And sometimes the problem is medical, not psychiatric at all.)  At these times it becomes my duty to advise medication, to explain why I do, and to explore with the patient their concerns and hesitation.

Some research says the best treatment for depression is a combination of medication and psychotherapy.  This often seems to be the case for problems other than depression, too.  As a psychiatrist I can provide one or the other or both.  And on rare occasions, neither:  A few patients have come to me who do not have a treatable problem at all.

The challenge for psychiatrists and other mental health professionals is that patients choose their own providers; they select us knowing their own preferences, and ours.  Persons who seek medication and not psychotherapy will likely see a psychopharmacologist who will share their viewpoint and only discuss medication.  Even more often, persons who seek psychotherapy and not medications (or a medical perspective) will see therapists who are not physicians.  Despite the advantages — there are many more non-psychiatrists to choose from, and the fees are usually lower — patient self-selection carries the risk of confirming their own prejudices.  It may sound harsh, but the “customer” is not always right.  It is incumbent upon us professionals to look past patient preference to what is most apt to be helpful — even if we do not provide it ourselves.

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