The first psychiatric visit

When I see patients sitting in my waiting room for the first time, they often look embarrassed and ashamed. Most are anxious. I thought that if I demystify the first psychiatric visit,  it could help with these awkward feelings.

As a psychiatrist, I am just a medical doctor who specialised in illnesses of the brain. A visit to a psychiatrist is very similar to visiting any other specialist. I will never ask you to lie on the couch. (A psychoanalyst might. Psychoanalysis is a specific form of therapy, usually only offered to people who are in a therapeutic process.) I cannot read minds. You are unlikely to freak me out, I have probably heard worse.

The first session is an hour long, with half-hour follow-ups. I  like to have a working diagnosis and a treatment plan by the end of the first session. A working diagnosis is not cast in stone. It evolves and might change completely as more information becomes available. Unfortunately, for medical aid purposes, I might have to give you a diagnosis that does not capture the whole picture. Patients might then feel that they have been “labelled”. I will always tell you what my reasoning is and try to check if you agree with it. A diagnosis is a construct, the beginning of a plan. It is not the end of the story.

Some of my patients come in saying “I just want a pill to make me feel better”. Others say “I don’t believe in psychiatric medication”.  Whatever you have coming in is fine. It’s a collaborative process whereby I make my best assessments and recommendations, and then discuss options based on your preferences. A psychiatrist can only “force” treatment if a patient is a clear and present danger to themselves and others. And even then we have to go through the process of certifying the patient. The Constitution defends your right to refuse treatment; the days of straitjackets are long gone.

Confidentiality is a given. You can talk as much as you want about your session, I never may. Sometimes I might discuss chatting with a third party with you. I might ask: “can I talk to your psychologist?” or, “what can I put on your sick certificate?”  If there is an especially delicate situation, for example, that your ex may not even know that you are seeing me – tell me, and I will be extra careful.

In the first session, we cover a lot of ground. We discuss symptoms, your medical history, your life history. Many patients freeze when they come in or have so much to say that they might forget something important. I am quite good at teasing out the issue, but if you want to make the most out of the session, it’s often helpful to jot down a few notes in preparation. It will help order your thoughts should you feel overwhelmed.

The kind of thing which would be useful to note:

• • What are your symptoms? What makes them better/ worse? What have you done thus far to address them?

• • What are your goals for treatment?

• • What medications have you been on in the past? It is essential information. We can waste weeks trying things which have failed in the past.

Sometimes we discuss several treatment options. Feel free to jot things down. If you are uncertain about something I said when you reflect later,  I invite you to call/ email me to clarify.

People lie for many reasons. They might be embarrassed or ashamed. They might try to exaggerate or diminish some things. Psychiatry is interesting because the correct diagnosis depends on what the patient tells us. For most of our illnesses, there are no objective measures like blood tests or x-rays. I may or may not know if you are lying to me, I may or may not call you on it. But what lying definitely will do is slow down our progress and your recovery. Don’t tell me what you think I want to hear, nor try to “direct” the diagnosis. Just answer as accurately as you can.

Psychiatrists often work with other professionals to help get you better. I might send you to a psychologist for therapy, or a pathologist for blood tests. You are unique and need an individualised plan.

Well done for taking the first step of getting help. Unfortunately, the first session is unlikely to resolve everything at once. It’s a process; be patient. Finding a psychiatrist who listens to you and whom you can relate to is essential to your recovery.