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Challenges in outpatient psychiatry

The patient who shuns our recommendations can be very frustrating to treat


Editor’s Note: This is the first in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

“I don’t understand why it’s so hard for me to get up and get started in the mornings,” my patient said. She was on the verge of losing her job for repeatedly being late to work.

“I really believe you’d have an easier time if you didn’t drink every night then start your mornings with that wake-up shot of gin,” I replied.

“Here we go again,” she said, exasperated with me.

It was a conversation that has been going on for years (literally) and with which we have both been quite frustrated. My patient wants to get better, she asks for my help, and then she refuses any solutions I might suggest.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

Dr. Dinah Miller

Patients with addictions have their own challenges; this patient does not want to stop drinking and all my efforts to suggest that alcohol is part of the problem simply don’t matter. When it became clear that it was not simply a matter of her willingness to believe that alcohol was a problem, I made stronger suggestions. She should try a 12-step program, and when that recommendation was scorned, I insisted she go to an outpatient intensive program and pressed the name and phone number into her palm. There have been prescriptions for oral naltrexone, which initially was helpful until the patient stopped taking it, and an offer for a topiramate trial. At the suggestion of a colleague, I even offered to go with her to an intake for substance use treatment. None of my efforts, however, change the fact that this patient does not want these interventions, and our treatment plans don’t seem to converge.

Patients with addictions are often complex, and the forces in play are more than simply the agreement that a problem exists and a desire to stop. Patients who want – yet don’t want – help come in many varieties. We’ve all sat with patients who refuse to take the medications we prescribe or who come back appointment after appointment still never having turned on the lightbox we convinced them to purchase. There are patients who are miserably troubled by being overweight but are not open to changing their diet, exercising, joining a weight-loss group, taking medications, or having bariatric surgery. There are patients who insist they can’t stop smoking but won’t give any of the available treatments a try. There are those we badger to get the lab work that make it safe for them to continue on the medications we prescribe. There are moments when we may wonder what more we have to offer patients who either can’t or won’t follow our suggestions, what may have once been considered “doctor’s orders.”

These are the patients we’ve referred to as “noncompliant.” It’s a term that recently has been questioned, and one that implies a willful refusal to abide by a physician’s decision. Often, it’s worth exploring what holds them back from following our directions. The term noncompliance implies that the person is a bad patient and it does not leave room for the idea that the patient may not agree with the diagnosis or treatment plan or is unwilling to accept the cost or risk of the prescribed solution. Sometimes, understanding what leads a patient to resist can be helpful; unwarranted fears can be addressed and logistical barriers may be overcome.

In some cases, these patient encounters may leave us feeling helpless and worried. In the worst of these cases, where a patient’s refusal to follow through with treatment suggestions may leave them vulnerable to very bad outcomes, I personally have had times when I’ve felt like I’m standing by helplessly watching as a Mack truck speeds into a brick wall.

“In my experience noncompliance is almost always a sign of deeper resistance or ambivalence that needs to be explored,” notes Neha Jain, MD, a geriatric psychiatrist at the University of Connecticut, Farmington.

Dr. Jain communicated with me about patients who don’t want to take the medications she recommends. “A typical scenario is when a patient comes to see me, but says that either they don’t believe in medications or are extraordinarily sensitive to them. I almost always offer medication as a choice and am quick to offer not taking medication as an option for those who are safe. If they refuse, I’ll review their goals and talk about why they came to see me, a primarily prescribing psychiatrist. This often leads to a deeper discussion of why they are resistant to meds, ranging from the stigma of ‘taking a crazy pill’ to what taking a medication means for their ego. For these patients I might offer a few ‘consulting’ sessions, which are really therapy sessions. Often they either become receptive to taking medicines, or they may continue with therapy alone, either with me or with someone else.”

Peter D. Kramer, MD, a psychiatrist in Providence, R.I., and author of “Ordinarily Well: The Case for Antidepressants,” says that the issues are even more complex when patients hide that they have not complied with the psychiatrist’s recommendations. “It seems to me that noncompliance that remains secret, not discussed with the therapist and then discovered incidentally or belatedly, presents an occasion to consider the success of the therapeutic alliance – in older terms, to think more about the transference.”

Dr. Kramer notes that, as our approach to psychotherapy has changed, the psychiatrist’s response to such behavior has also changed. “The prevailing focus on cognitive therapies assumes that when patients realize that a belief or behavior is illogical, they will correct it. When psychotherapy was more analytic, it focused on the reasons patients engaged in irrational and self-destructive acts repeatedly – and patients’ failure to self-correct didn’t frustrate the therapist so much. Instead you thought, ‘If education worked, I’d be out of a job.’ We deal with failures to trust. We deal with what philosophers call weakness of will. While I can’t say that I am never frustrated or surprised, I do see working with these problems as the reason I am there.”

Sometimes we learn that the patient who dismisses our suggestions has already tried the remedies we are suggesting and is just as frustrated as we are. We may be left with the unfortunate situation that nothing we do seems to foster meaningful change for the patient. In these instances it may be helpful to clarify the goals of treatment and inquire whether he feels he is making progress. We may consider trying other forms of treatment, consultation with another clinician, or more intensive therapy if the patient will agree. Other times, we may be left to rethink our treatment, consider the ways in which the patient does find the treatment helpful, and empathize with our patient’s distress while continuing to gently suggest that there might be options available whenever they feel ready.

So my patient did lose her job. She found another position with more flexible hours and, despite her heavy drinking, her life has gone mostly well. She comes to see me only rarely because the medication I prescribe helps stabilize her mood, but she stopped scheduling her regular psychotherapy sessions. Still, while she manages her life around her drinking, I worry about the toll it is taking, as there has been ample evidence that her body cannot sustain this for much longer. From what I can tell, the fact that I remain available is helpful to both the patient and her family but yes, it’s a little like standing by helplessly and watching a Mack truck race toward a brick wall.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

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