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Golden rules for difficult-to-treat patients

Below is a short list of golden rules for psychiatrist and therapists working with difficult-to-treat patients and clients.

1. STOP! If the treatment is not going well, stop and re-evaluate the situation instead of frantically trying harder.

2. First and foremost, re-evaluate the diagnosis or formulation. Most commonly, our understanding of the patient’s problem was off — either partially or entirely. Missed diagnosis of bipolar disorder, ADHD, sleep apnea – daily occurrences!

3. Seek a second opinion. If a patient is not clearly better within a reasonable time, it is appropriate to suggest that a second opinion be obtained. If the clinician providing the second opinion agrees with your assessment and treatment plan, then you and the patient are reassured that you are on the right track. Often, however, the other clinician comes up with some helpful suggestions.

Since assessment in mental health is very much dependent on the interview, second opinion consultations are most helpful if the other clinician actually interviews and evaluates the patient. Such consultations are much better than simply discussing the patient with the other clinician.

4. If the patient’s main treatment is biological and it has not helped so far, at least consider whether the person needs to focus on psychotherapy. And, vice versa, if psychotherapy has not helped substantially, it behooves us to at least consider adding or changing to a biological treatment. It is, unfortunately, common for practitioners of either biological or psychological treatments to persist in treating the patient with ever more aggressive versions of their treatments rather than considering changing the emphasis to the other type of treatment.

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