My Practice Emphasizes Discharge as an Important Goal

My practice model prioritizes discharge. That means that my goal is to get patients to a point where they do not need to see a psychiatrist anymore with as few (if any) medications as possible. My hope is that patients can finish our work together feeling resilient and strong enough to handle life's challenges. Unlike many other mental health doctors, I do not plan on keeping patients perpetually, but rather wish to help patients finish their work feeling "cured".

Q: How will having discharge as a goal help my patient?

A: Engaging with psychiatric care takes time, energy, and money. These three valuable resources are better spent in pursuit of a meaningful life, not perpetually seeing a psychiatrist. It can at times feel daunting for patients to commit to seeing and paying a new doctor while already having so many other appointments already. Patients will feel more comfortable knowing they are seeing a professional who will be temporary and is always working on minimizing their need to continue engaging with them. They will finish our work feeling like you can be your own therapist and no longer needing to depend on a professional to manage your mental health.

Q: How does having discharge as a goal help the community?

A: One of the benefits of proactive discharge is that I have a constantly rotating panel of patients. This means sooner openings for new or established patients as well as a greater exposure to psychopathology that keeps me experienced and builds my skills.

Q: Does having discharge as a goal mean patients have limited sessions with you?

A: The decision for length of treatment is collaborative and depends on the individual patient's needs. My plan is not to pursue discharge unless the patient feels confident in their treatment plan. This also does not mean they cannot see me again in the future; when we reach a natural stopping point for our appointments, I will tell patients to come back if they begin feeling stuck in their psychotherapy progress or if they experience a new surge in symptoms. Since my model proactively discharges patients, I would readily have spots available in a reasonable time frame. 

Q: Are there some patients that would still need to see you perpetually?

A: There are some patients with severe mental illness that may still require perpetual appointments with psychiatry (e.g. schizophrenia, bipolar disorder), but even then my goal would be to minimize your necessary appointments as much as possible. I think it is a big difference for a patient to feel good enough to only see a psychiatrist every three or six months for a quick check-in instead of weekly or biweekly for thirty minute or hour long appointments.

My goal for treatment is improving overall wellbeing

My goal for treatment is improving overall wellness and functioning, not mere reduction of symptoms. I hope to help patients create a balanced life that feels worth living. I do this by focusing on not just the biological processes, but also their psychological and social functioning. 

Q: What do you mean by balanced life?

A: A balanced life is a flexible, value driven life where you are consistently growing and moving in the directions your values take you through concrete goals you can commit to completing. It also means a life where we accept ourselves the way we are, since we, while always trying our best, will always be imperfect. 

Q: What do you mean by flexible?

A: By flexible, I refer to the idea of psychological flexibility, which is when we are open to life's experiences and feel confident in our ability to improvise and adapt to whatever life throws at us.

Q: How is emphasizing overall wellbeing helpful in medication management?

A: All medications have benefits, risks, and side-effects. By returning to the patient's "life worth living", I am able to center medication prescribing to their goals. When they choose medication, they feel like they are making a balanced decision that appreciates the benefits while accepting the way it may negatively impact their body. By centering the discussion on their life goals, it also makes it easier for them to identify the moments where the balance turns to "getting off medication", to help minimize unnecessary medication interventions.

I see a variety of patients of all types and offer multiple different types of treatments

One element of my training at University of Washington that I really appreciated is how they made me able to effectively treat any patient in whatever circumstance. The Pacific Northwest is a sparsely populated area of the world, and the University of Washington trains their psychiatrists to be the only psychiatrist in town, capable of seeing both mild, moderate, and severe cases regardless of age, background, or specific psychopathology. 

What this means to you as a patient is that I am confident in understanding and managing the vast majority of psychopathology effectively by myself. I am a competent diagnostician who will be able to give patients a clear formulation and explicit recommendations not just for medication, but also for psychotherapeutic approach and behavioral/lifestyle change. The vast majority of the treatments I will recommend I would be able to provide myself, but also feel comfortable collaborating with other psychotherapists the patient may be working with.

Q: Would it be better to see someone who specializes only in my patient's specific population?

A: I caution people to not confuse specialization with mere competence within a narrow portion of a field that one is overall incompetent in. The harsh reality is that there are many mental health professionals who purport a narrow scope of work not because they are very competent specialists, but because they only feel comfortable with a single intervention. In other words, their only tool is a hammer, which means every problem you present to them would be seen as a nail. Having someone whose expertise arises not from a limiting of their scope, but arising naturally from their work with the whole population is the true "specialist" you wish to send patients to. By allowing myself to work with patients with all kinds of backgrounds and all kinds of psychopathology, I keep my diagnostic and clinical skills sharp and effective to give patients the best possible care.

Q: Is there any patient population that you would prefer not to work with?

A: I am always happy to be available to provide guidance to anyone who needs help, regardless of their psychopathology. Even if I am unable to provide to you the specific treatment modality I think would be effective, I would still be able to provide them with a recommendation of how to find that treatment and what an effective next step would be. I am also always happy to remain available for appointments to help patients navigate our complex medical system until they reach the point you feel you have found what you need. 

Q: Do you do second opinions?

A: One of the benefits of my unique skillset is that I am able to provide you with an effective second opinion and collaborate with you to help improve their care. Unlike many other psychiatrists, I am confident in providing both medication and psychotherapeutic recommendations. Because my practice model is highly collaborative, I create a comfortable environment for all involved and do not make others feel like I am trying to usurp their treatment approach. I am a particularly good resource to have for patients with whom you feel are stuck in your mental health treatment. I am more than happy to be available for discussion prior to consultation so I can provide the best possible recommendation.

My style emphasizes empathic understanding and genuineness

My general approach is one where I truly seek to understand what the patient is experiencing and express myself genuinely to them. I base my approach on Carl Rodgers’ Person Centered Therapy approach, which has three main values: unconditional positive regard, radical genuineness, and empathic understanding.

Q: What is unconditional positive regard?

A: As a psychiatrist, I seek to accept patients unconditionally, without judgement. This will help patients feel safe throughout our appointments.

Q: What does radical genuineness mean?

A: It means I am my authentic self as much as I can during my work with patients. I treat patients like an equal who is worthy of respect and not being “talked down” to or treated as fragile. It also means I will be honest with patients even about subjects that may be hard to talk about.

Q: What does empathic understanding mean?

A: I seek to understand from the patient's perspective. It means I will often check in to make sure I am truly understanding what they are trying to communicate.

Q: How does radical genuineness help with our collaboration?

A: One aspect with me that may be different from other psychiatrists, is that I tend to be quite direct and honest with what I think is going on with the patient and what I think will help them. I am a helpful resource for those moments where you really need someone to be truthful to you about a specific patient case or when you feel you need someone who is able to effectively tell patients "what they need to hear but don't want to hear". 

My practice emphasizes autonomy

I consider it important for patients to feel in charge of their care. My goal is to provide the best possible recommendation for the patient's unique circumstance while providing them the freedom to guide their own care.

Q: Does this mean you will give the patient whatever medication they ask for, even if it is bad for them?

A: Rest assured, I will never provide a patient with a treatment that I think is overall harmful or not indicated. They will always be informed of any treatment that carries a higher risk than what is usually prescribed.

Q: What if we disagree on the treatment I think will help a patient?

A: One thing I will always promise you is that my recommendations are what I genuinely think is the best path for the patient. That does not mean I am always right about it being the best treatment. I work with always integrating the path the patient would like to choose for themselves. I do think it is very important to serve as a consistent "voice of reason" that is always advocating for the patient's wellbeing, so there may be rare moments where we are unable to come to an agreement of what is the best path forward; in this scenario, I am always happy to continue working with them through a different path or to help them transition care to a psychiatrist they feel would be a better fit for their treatment goals.

The Concierge Model means more communication for everyone

Different from most other psychiatrists, I provide faster response times (generally within 24 or 48 hours), greater phone availability, more consistent appointments, and longer appointments (usually an hour). This means patients will no longer have to wait a week or more to hear back about prescription issues, have to wait months for an appointment, or end up feeling rushed with a fifteen minute medication management visit. Since I charge hourly and not through insurance, I am paid the same amount regardless of how many patients I see, so I am not incentivized to increase appointment efficiency at their expense. This also means I provide you the treatment I think is most effective, regardless of the time investment, and not the treatment that will reduce my appointment time the most.

The concierge model also means that I will be proactively collaborating with other members of their care team, including medical doctors like you, and will be readily available to discuss their care with you as needed.

Q: How often would you collaborate with me?

A: I generally reach out to physicians as requested by a patient or proactively in places where I think it is important for their care. I am always happy to be available for discussion at any moment that you feel it is needed.

My model translates well with individuals with both complex medical needs.

One patient population I often work with is medically complex individuals with psychiatric needs. One of the benefits of seeing a psychiatrist instead of a clinical psychologist for psychotherapy is that, as a medical doctor, I am able to fully understand their medical situation and provide therapy that incorporates that understanding effectively. Unlike a clinical psychologist, I am also able to effectively engage and collaborate with other medical doctors. This would mean I would be able to help patients navigate your medical issues effectively and help improve their ability to engage with you and other physicians.

I generally offer both medication management and psychotherapy together.

I consider it best practice to receive your medication management and psychotherapy together.

Q: How is having a psychiatrist do my psychotherapy helpful?

A: Our bodies are the primary way we experience our life. Since a psychiatrist is a physician, they understand the human body in a way that no other mental health professional can. In therapy with people without medical degrees, the physical body is an abstract concept rather than a tangible reality, which can lead to a psychotherapy that feels disconnected with the physical experience of our emotions. It is also helpful to have medication be in line with the psychotherapeutic work, so we are not inadvertently going in two different directions with these two treatment modalities.

Q: Don't psychologists get better training to do psychotherapy?

A: This is a common misconception. Psychiatrists actually have the longest training of all mental health professionals. As you are aware, we complete four years of medical school and four years of residency, during which we generally obtain significant psychotherapy training. It is also a requirement for training that all psychiatrists know how to do at least three types of psychotherapeutic modalities (supportive psychotherapy, psychodynamic psychotherapy, and cognitive behavioral therapy, although many psychiatrists train in much more). In contrast, doctoral level psychologists generally complete four years of school (two of classwork or research, followed by two years of patient facing clinical training) and one year of internship (one year of patient facing clinical training). Doctoral psychologists are often trained in at least one form of psychotherapy (either psychodynamic psychotherapy or cognitive behavioral therapy). Master’s level therapists (including LMFT, MSW, LCSW, LPCC) generally complete two year programs, which includes one year of schoolwork followed by one year of patient facing clinical work. Virtually all master’s level therapists train only in cognitive behavioral therapy.

Q: If my patient is working with a psychologist already, does this mean they need to stop seeing them to see you instead?

A: While I will always hold that doing psychotherapy with your psychiatrist is the gold standard treatment, that does not mean that a patient cannot choose to work with a psychologist as well as a psychiatrist. Sometimes, patients also have financial constraints and have to pursue the treatment that makes the most sense for them. Psychotherapy can be deeply personal, and patients may often find they have a very good personality fit with a specific therapist that would be important to keep. Some patients may be in search of a very specific psychotherapeutic modality that not many mental health professionals offer. There are many very talented psychologists who offer high quality care who I am happy to support by providing medication management that is always in line with their psychotherapeutic work.