I have spent the last two days mulling over an interaction with a patient and with his therapist.
The patient is a brilliant, young man who has somehow entered into a conflictual relationship with me.
The nature of that relationship was encapsulated for me in a comment by his therapist. She called to let me know that he was escalating into mania. When I suggested that I call him to see how I could help, she said that he didn’t want to talk to me about how best to treat this change in mood. He felt I might become “punitive” and suggest that he needed to see me sooner than his next scheduled appointment in a month. And she wondered, would I really do that.
Of course, my immediate reaction was to want to reassure the therapist that I would never punish someone for calling about a change in mood. But then I started to think about the implications of the whole conversation.
The notion that encouraging someone to come in and see their doctor when they were doing poorly was “punishment” was a hard one to incorporate into my world, a world where I try very hard to not “stigmatize” those with mental disorders. In other words to treat people with those conditions similarly to the way that a person with any other chronic condition (hypertension, heart disease, diabetes) would be treated.
Is it possible that someone with diabetes calling their doctor because their blood sugar was out of control would feel that the doctor was “punishing” them by suggesting an office visit? Probably. But would the doctor go along with that view and back away from the recommendation?
I am sensitive to the fact that coming in to see me costs money. But my experience is that offering not to charge for extra visits almost never solves the problem.
That offer is seen as a “manipulation” or coercion to get the person to come in.
The basic issue seems to be that needing to see a psychiatrist is stigmatizing to the person, and the suggestion to come in early is seen as further stigmatization.
But, just backing away and saying come in and see me when you want to can sometimes lead to catastrophe.
So, what to do?
I am not sure what the right answer is, but I think that ultimately I have to refuse to accept the view that treatment is punishment.