My Practice Emphasizes Discharge as an Important Goal

My practice model prioritizes discharge. That means that my goal is to get the patient to the point where they do not need to see a psychiatrist anymore with as few medications as possible. My hope is that patients are able to feel like they achieved their goals in seeing a psychiatrist. Unlike many other psychiatrists, I do not plan on keeping patients perpetually, but rather wish to help patients feel equipped they have what they need to succeed in therapy.

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 mental health professional 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.

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 your psychological and social functioning. 

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.

Q: What psychotherapeutic style do you use for this?

A: I primarily use acceptance based psychotherapeutic approaches like DBT and ACT. I find the concepts of dialectics help ambivalence around medication by acknowledging both the ways the medication helps as well as how it hurts. The concept of making "value driven decisions" can help patients overcome apprehension around medication they truly think will help them. I work to instill psychological flexibility to help avoid all-or-nothing thinking and instead see medications as flawed and temporary tools that they can use for as long as it is helpful for them.

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 patients is that I am confident in diagnosis and managing the vast majority of psychopathology effectively. 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. 

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

A: I caution referrals to psychiatrists who portray themselves as specialized in an overly narrow scope of work. A psychiatrist who does not experience the vast variety of psychopathology can often limit their range of diagnoses to only the ones they see themselves as an expert in, rather than maintaining a flexible approach to formulation and treatment. In other words, their only tool is a hammer, which means every problem presented to them will 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 refer 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 you 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 I think would be effective, I would still be able to provide 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 they feel they 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 stuck in your psychotherapeutic progress. 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 you are experiencing and how you feel about it and express myself genuinely to you. I base my approach on Carl Rodgers’ Person Centered Therapy approach and its three main values: unconditional positive regard, radical genuineness, and empathic understanding.

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: It is normal to be anxious when making decisions about your health. I would hope that my approach would give you enough information and understanding of your circumstances to feel confident and informed about the decision you are making.

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.

I minimize medication as much as possible.

I always work to make sure patients are on the least amount of medication possible with the lowest possible dosages. I am a good resource for patients who are worried about having a doctor who "throws pills at every problem" or who is worried about being on medication that will hurt them more than it helps. I also work well with patients who would like to reduce the medications they are taking or want to get off of medication safely.

I can reinforce your psychotherapeutic goals.

Since I am trained in many different types of psychotherapies, I am able to more effectively understand your psychotherapeutic approach and goals with the patient. I am able to ensure my prescribing does not accidentally go against your psychotherapeutic work (for example, avoiding anxiolytics in patients who are doing exposure therapy). I am also able to give patients an "outsider's perspective" on their psychotherapy to help improve their buy-in to treatment. I am also happy to provide focused time-limited psychotherapy that you may not feel comfortable offering, such as CBT for insomnia, acceptance and commitment therapy (ACT) exposure and response prevention (ERP), and exposure for panic disorder.

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, both you and their medical doctors, 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 a psychotherapist after the initial appointment. In some cases, I may discuss your case with you ahead of time. After this initial communication, I communicate with you as often as is indicated in their case.

My model translates well with individuals with complex medical & psychiatric needs.

One patient population I often work with is medically complex individuals with psychiatric needs. I am able to bring their experience with their medical issues and integrate them into their psychological state. I am also able to collaborate effectively with their medical doctors, helping them understand how to best interact with the patient in question.