Posted by: thealienist | July 11, 2011

What to Expect From a First Visit

Many of my patients are nervous when they come for their first visit to my clinic.  Many have fantasies about what will happen or concerns about things they will be asked to talk about.  They may worry about what I will think about their problems or if I will coerce them into some situation they fear.  I am writing this post for my patients and for others who might have concerns about what psychiatrists do.  This post addresses only my practice.  Other psychiatrists may do things very differently.

My first visit with a patient is usually scheduled for one hour.  During this time, I have many things I would like to accomplish:

1.  Familiarize my patient with key characteristics of the psychiatric interview,

2.  Get an overall understanding of my patient’s complaint,

3. Get a broad (if superficial) understanding of my patient’s physical and mental development,

4.  Get an overview of my patient’s past experience with mental health providers,

5.  Review my patient’s medical history, and

6.  Review my patient’s social history.

Each one of these goals actually encompasses numerous smaller objectives.  This makes the first visit a very busy session.  If possible, I would also like to establish a diagnosis (if one is applicable), discuss this diagnosis with my patient, and outline the available treatment options.  I find that I can usually accomplish this during the first hour, but sometimes achieving these goals will take longer.

CONFIDENTIALITY

I address the first goal by explaining to my patient that the information I receive from him is confidential within certain limits.  I tell him that while thoughts of harm to himself or others may occur during evaluation and treatment, these are confidential except in cases in which I have cause to believe that an imminent threat to himself or others exists and no other option can be found to address this threat.  In that case, I will be forced to hospitalize, inform the police, or inform Child Protective Services.  These, I tell him, are the options of last resort and should be avoidable under most circumstances.  I also inform him that his records may be released if compelled by a court order.  Finally, I tell him that if I get any information about him from any source other than him, I will tell him what information I received and who I received it from.  This part of the session is usually ended by asking the patient if he has any questions or concerns.

THE CLINICAL INTERVIEW

Goals 2 – 6 are achieved with a clinical interview.  During the early part of the clinical interview, I try to have my patients tell their stories in their own words.  I may occasionally ask questions to make sure I am understanding the story correctly, but mostly, the patients are free to tell it as they like.  Depending on the complexity of the story and the ability of my patients to tell it without excessive digression, this part of the interview may take between 15 and 30 minutes.  Most of the remainder of the session usually consists of questions aimed at eliciting the required information that was not provided in the patient’s story.  If there are important facts that my patient is not comfortable talking about, I will explain to them the need for this information and their right not to discuss it if that is their wish.  Often, they can convey at least a general impression of the needed information.  This additional questioning usually takes between 15 and 20 minutes.

FEEDBACK/DIALOGUE

If time is available, I will give my patients immediate feedback.  I will inform them of the diagnoses I am considering (if any), how I would determine which diagnosis is most appropriate, and what this distinction means in terms of treatment.  I will ask for feedback on the information I have given and ask if they have any thoughts on how they would like to be treated.  Any remaining time is spend considering treatment options, needs for referral, frequency of sessions, and/or medication informed consent.

Throughout the session, I make sure that my patient understands that he is responsible for change and that I am ready to help him to the best of my ability.  He gets to decide what changes are to be attempted in his life, and he gets to decide what measures are used to attempt these changes.  Most of my patients think that this is a satisfactory arrangement.

If all of this seems to be too much to achieve in one hour, it often is.  I must admit that one of my relative weaknesses is adhering to strict time limits for sessions.

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