I recently posted 50 pieces of advice to clinicians on how best to help their patients.1
It seems fitting here to provide an equal portion of advice intended this time for the patients the clinicians seek to help.
These 50 tips are derived from 50 years of learning from my own patients, who were always also my best teachers.
1. There are lots of different treatments—no one size fits all.
2. Many treatments have a strong base of supporting evidence, but some do not. Whenever possible, evidenced-based treatments are preferred.
3. Psychiatric treatments are about as effective (but also as ineffective. as treatments in the rest of medicine).
4. Outcomes are very variable and initially unpredictable. Most people experience at least some benefit from psychiatric treatment, some people have full recovery, a minority have no response, and a few are harmed.
5. The success of treatment depends on the person; the nature of the problem; the accuracy of diagnosis; the type of treatment; clinician skill and flexibility; patient effort; the strength of the therapeutic relationship; and the presence or absence of good luck.
6. The choice of optimal treatment depends on the person; the nature of the problem; its severity; patient preference; clinician training; availability; and the results of serial systematic trials to see what works best.
7. “No Treatment” may also be the treatment of choice—especially for people with normal, expectable problems of everyday living and also for those who have had no or bad responses to previous treatments.
8. For mild symptoms, watchful waiting, the healing powers of time, reduction of stress, and support from friends and family may be all that is needed.
9. In contrast, severe/persistent symptoms require immediate attention—the longer you wait, the harder they may be to treat and the slower and less complete the treatment response.
10. Good clinician/patient match is crucial to good outcome. If possible, interview several clinicians before picking the one you are most comfortable with. If choice permits, always avoid clinicians who don’t feel right for you.
11. Don’t be too ashamed to seek treatment—half the population has substantial symptoms at some point in their lives and any stigma of being in psychiatric treatment has mostly evaporated.
12. Be an informed and skeptical consumer—use the internet (though don’t believe everything on it); have probing questions prepared before visits; and expect good common sense answers. Second and third opinions also often help in good decision-making.
13. Put your heart, mind, and guts into the treatment; the more you put into it, the more you will get out of it.
14. Psychotherapy is usually the best treatment for mild to moderate problems and may also help people in managing more severe ones.
15. Psychiatric medication is essential for most severe problems; often necessary for moderate ones; and to be considered whenever symptoms persist and don’t respond to psychotherapy.
16. There are many effective specific psychotherapy techniques—cognitive; behavioral; interpersonal; psychodynamic; family systems; and group.
17. The best psychotherapists know most or all of the many techniques and apply them flexibly as needed by a particular patient at a particular moment.
18. A strong therapeutic alliance and good clinician/client personality match-up may be more important than the specific techniques used, so pick someone you like and want to work with.
19. Most psychotherapies are brief (5 to 12 sessions); goal oriented; and problem focused. Long-term treatment may be necessary for more persistent problems or more ambitious goals.
20. Most of the beneficial effect of psychotherapy comes from how well you use what happens within the sessions in your life outside the sessions. Expect homework from the therapist and figure out on your own how you can enhance your skills and stretch your boundaries based on what you are learning in therapy.
21. It is important to give psychotherapy a fair chance, but if it is not working, try something else or someone new.
22. Psychiatric medications are currently very overused—20% of the population is taking one; 12% are on antidepressants, including 25% of women over 40 and 4% of teens; 4% are taking a benzodiazepine, including 8% of the elderly (where they can cause falls, memory loss; confusion); 6% of kids are on stimulants. Antipsychotics are very overprescribed, especially in poor kids and seniors in nursing homes (where they shorten life expectancy).
23. Approximately 80% of psychiatric medications are prescribed by primary care doctors who have very little time to get to know their patients, receive very little training in psychiatry, and are often under undue pressure from patients wanting immediate relief as the outcome of a first visit.
24. It is easy to begin a psychiatric medication, but often hard to stop one. The decision whether to start should require careful thought and often an extended period of watchful waiting or psychotherapy before prescribing.
25. The placebo response rate combines the effects of time; expectation; and the fact that most symptoms are a response to a specific stress and remit spontaneously. Placebo response is very high (50% or more) for milder problems; very low (less than 10% for severe ones).
1. Frances A. Advice to Young Psychiatrists From a Very Old One. Psychiatric Times. October 4, 2019.