The first psychiatric visit

When I see patients sitting in my waiting room for the first time, they often look embarrassed and ashamed. Most are anxious. I thought that if I demystify the first psychiatric visit,  it will help with these awkward feelings.

A psychiatrist is just a medical doctor who specialised in illnesses of the brain. A visit to a psychiatrist is very similar to visiting any other specialist. I will never ask you to lie on the couch. (A psychoanalyst might. Psychoanalysis is a specific form of therapy, usually only offered to people who are in a therapeutic process.) I cannot read minds. You are unlikely to freak me out, I have probably heard worse.

The first session is an hour long, with half-hour follow-ups. I  like to have a working diagnosis and a treatment plan by the end of the first session. A working diagnosis is not cast in stone. It evolves and might change completely, as more information becomes available. Unfortunately, for medical aid purposes, I might have to give you a diagnosis that does not capture the whole picture. Patients might then feel that they have been “labelled”. I always tell my patients what my reasoning is and try to check if they agree with it.

Some of my patients come in saying “I just want a pill to make me feel better”. Others say “I don’t believe in psychiatric medication”.  Whatever you have coming in is fine. It’s a collaborative process, whereby I make my best assessments and recommendations, and then we discuss options based on your preferences. A psychiatrist can only “force” treatment if a patient is a clear and present danger to themselves and others And even then we have to go through the process of certifying the patient. The constitution defends your right to refuse treatment; the days of straitjackets are long gone.

Confidentiality is a given. You can talk as much as you want about your session, I never may. Sometimes I might discuss chatting with a third party with you. I might ask: “can I talk to your psychologist?” or, “what can I put on your sick certificate?”  If there is a situation which is especially delicate, for example, that your ex may not even know that you are seeing me – tell me, and I will be extra careful.

In the first session, we cover a lot of ground. We discuss symptoms, your medical history, your life history. Many patients freeze when they come in, or have so much to say that they might forget something important. I am quite good at teasing out the issue, but if you want to make the most out of the session, it’s often useful to jot down a few notes in preparation. It will help order your thoughts should you feel overwhelmed.

The kind of thing which would be useful to note:

  • What are your symptoms? What makes them better/ worse? What have you done thus far to address them?
  • What are your goals for treatment?
  • What medications have you been on in the past? It is essential information. We can waste weeks trying things which have failed in the past.

Sometimes we discuss several treatment options. Feel free to jot things down. If you are uncertain about something I said when you reflect later,  I invite you to call/ email me to clarify.

People lie for many reasons. They might be embarrassed or ashamed. They might try to exaggerate or diminish some things. Psychiatry is interesting because coming to the correct diagnosis depends on what the patient tells us. For most of our illnesses, there are no objective measures like blood tests or x-rays. I may or may not know if you are lying to me, I may or may not call you on it. But what lying definitely will do is slow down our progress and your recovery. Don’t tell me what you think I want to hear, nor try to “direct” the diagnosis. Just answer as accurately as you can.

Psychiatrists often work with other professionals to help get you better. I might send you to a psychologist for therapy, or a pathologist for blood tests. You are unique and need an individualised plan.

Well done for taking the first step of getting help. Unfortunately, the first session is unlikely to sort everything out at once. It’s a process, be patient. Finding a psychiatrist who hears you and whom you can relate to is essential to your recovery.

 

 

8 Comments

  1. I still remember how anxious I was at my first psychiatric visit. The stigma around mental health is still very real, but there comes a point where you really have to weigh up your own health and sanity against what people think. Thank you for demystifying the process of treatment. And you’re right, finding a doctor who hears your heart and understands your fears is so crucial to the treatment process. I enjoy your weekly posts and find them insightful, thank you very much!

  2. I was wondering why most people are so apprehensive to make that first appointment and why, when they turn up, so many feel sheepish and embarrassed during their first session. I think most of it is down to popular misconceptions about what psychiatrists do behind closed doors. As you mentioned psychiatrists are not mind readers so they can only work with what their patients tell them, although sometimes a patient’s body language may speak volumes. Patients are not mind readers either so if your psychiatrist in not forthcoming about what he or she is thinking about or possibly planning as a treatment, you need to ask them. Obviously you and your psychiatrist will never be of the same mind about everything but you should be of the same resolve about addressing you problem.

    What makes psychiatry almost unique, with one exception, is that your recovery is largely in your own hands. Yes there are drugs and tests and maybe scans involved but how you take them is up to you. I believe the analogy between physiotherapy and psychiatry helps to demystify the latter. Physiotherapy treats physical ailments of the body’s muscles, joints, tendons and ligaments with the use of physical therapies like weights, hot or cold compresses, joint manipulation, massage, lasers, electrolysis and surgical support devices. Psychiatry on the other hand treats mental ailments arising from dysfunction or dysregulation of parts or circuits within the brain using chemical therapies such as pills, capsules and injectables. However the brain, just like the rest of the body is a physical (biological) thing, so that there are certain physical or chemical indicators that we can monitor. Finally physiotherapy and psychiatry only work with the full participation of the patient in his or her own recovery – halfhearted efforts don’t count.

  3. In my haste to reply I forgot to mention the primary reason why I thought of that analogy: Neither physiotherapists nor psychiatrists can experience or see the pain they are treating. They have to rely on verbal reports, analogies, metaphors etc. At least at the physio you can point to the general area of the problem and say, “There! It feels like I am being stabbed by a screwdriver”, with psychiatry you can’t point to a hurtful memory or an anxious moment, however you might say, “since she is gone, I feel like all the colour has been drained from my life” and so be understood.

  4. I have a question. Why is it that more women seek treatment compared to men?

  5. I can answer that one if I may. It is not that women suffer more from psychiatric disorders than men, although they are over represented in some disorders like anorexia and under represented in others like psychopathy or conduct disorder. I think the tendency has much more to do with our macho culture in South Africa. Men don’t ask for directions or help with a DIY project, especially not from a woman. It falsely believed that it is a sign of honour for a man to “tough it out” whether through sickness or grief. Also men not showing or suppressing emotion is an anlage from another time.

    For these reasons I think that men are largely intimidated or embarrassed to ask for psychiatric or psychological help until matters come to a head or are out of their control or until they to hit rock bottom. Of course I am generalising but it would be interesting to compare South African men’s attitude to asking for psychiatric or psychological help with those of Icelandic men. Iceland has the most egalitarian society in terms of gender and they display some interesting trends, such as girls being consistently better than boys at maths from grade 1 to PhD level.

    So the short answer to you question: It is a product of our culture.

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