Posted by: thealienist | July 13, 2011

Follow-up Visits

The length of my follow-up visits varies from 15 to 30 minutes depending on the complexity of the problem and the stability of the patient.  In general, I prefer the longer time, but some of my patients feel that they can get everything they need in the shorter period.

When I have follow-up visits with my patients, I prefer them to come to the session with an agenda.  Of course, this does not have to be written out, but I think it is important for the patient to be the driving force behind the work done in the session.  Agenda items might consist of (but are not limited to) the following:

1.  Ongoing or new symptoms,

2.  Ongoing or new stressors,

3.  Medication side effects,

4.  Efforts to engage in normal activities of daily living (accompanied by a report of relative successes or difficulties),

5.  New medical problems and treatments, and

6.  Current goals.

Much of the early part of the session is usually spent talking about the above topics, how to understand them and integrate them into the patient’s life, and how they affect the treatment plan negotiated between myself and the patient.  By the end of this part of the session, my patient and I should have a reasonable agreement concerning what issues need to be addressed and a mutually acceptable way of addressing them.  If not, then a brief period of targeted Motivational Interviewing (too long to describe in this post) is used to try to improve mutual understanding, clarification of the patient’s goals, and identification of obstacles to progress (from the patient’s point of view).

Later in the session, we will take time to discuss the types of new treatments or alterations of ongoing treatments that are available to address the patient’s goals.  We will discuss the likely outcomes and side effects of each of the available choices and how to monitor progress (or lack thereof).  No decision needs to be made during the session if the patient is not ready to choose a treatment.  The patient may ask questions or may simply take additional time to consider how he wants to proceed.  Once the treatment decision is made, or we agree to delay the decision to let the patient make a decision later, the session is usually over.  A return appointment (if necessary) is scheduled by the office staff.

Importantly, if suicidal or homicidal thoughts are reported during the session, these will be addressed.  Every effort will be made to protect the safety of the patient or the object of the homicidal thoughts using the least restrictive means available.  Most such thoughts will not be found to indicate imminent harm to anyone, so no immediate action is necessary.  Some thoughts may indicate some danger, though the patient and I will be able to devise a plan that adequately minimizes the danger.  If so, then outpatient treatment may proceed as planned.  Very rarely, however, the thoughts and behaviors observed will raise the possibility of hospitalization, which will be sought voluntarily unless the patient simply cannot cooperate with this procedure.


  1. “…unless the patient simply cannot cooperate with this procedure”

    I think you mean “WILL NOT cooperate with this procedure”


    • Rob,

      No. I meant “cannot.” This is a key distinction with regard to this issue. I wish I knew a way that we could come to a mutual agreement about it.

      In every evaluation I have made for involuntary hospitalization, there has been a way out. If the patient did not want to be hospitalized, they could avoid it by cooperating in finding an alternative solution. When someone tells me that they do not want to be hospitalized and that they would do anything to avoid it but then turn around and insist that they will still kill themselves, or their children, or their spouse, I have to come to some understanding of what is going on. I could choose to see them as willful and wanting to put both of us into a situation where they cannot get what they want, or I can see them as unable to do the things needed to get what they want. Both of these are possible, and sometimes both may be present to different degrees. When people behave in a way that guarantees that they cannot get what they say they most want, I tend to assume that they are unable to behave otherwise.


      • And if someone says they don’t want to be hospitalized and they walk out of your office, what do you do? Do you call the police?


      • Good question, Rob.

        I have not had to face that situation before. I have had to call the police to my office once, but the patient was still in the office and was not leaving. According to the law where I practice, if I had a suicidal or homicidal patient who I believed was an imminent danger to himself or others, I would have to call the police. Mercifully, I generally have enough rapport with my patients to avoid this situation. (Knocks wood)


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