The Relationship Is Everything
**warning, this article mentions suicide**
When psychiatry adopted a medical illness model, it became standard practice for shorter episodes of care. In the consultation-only model, it is not uncommon for a psychiatrist to meet a patient once, elicit a checklist of symptoms to meet diagnostic criteria, and hand off a list of medication recommendations to the family physician, then closing the case.
This model prioritizes having more people seen and medicated. I would like to think that this model has improved the mental health and prognosis of patients but the truth is, this conclusion is not so clear-cut. We are in the midst of a mental health crisis, particularly amongst our youth. Rates of addiction and severity of addiction are on the rise. News stories of crimes being committed in the throes of mental illness are increasing in visibility. All of which highlight the limitations of the current model of care. Medications can be effective, but non-adherence remains a massive barrier. Furthermore, short-term assessments mean patients bouncing between multiple clinicians leading to conflicting opinions. This exposes the reliability issues inherent in modern psychiatric diagnoses, especially as patient presentations become increasingly complex.
I initially had set up my clinical practice as consultation-only. It was what I saw my peers and mentors do and when done efficiently, could be more lucrative.
However, very early on, I saw how this was not going to be possible, not if I wanted to provide good mental health care and be consistent with the hippocratic oath “to do no harm”.
Adrian was referred to me with a history of a severe eating disorder and anxiety. She was presenting to her family physician with low mood and suicidality. When I saw her for the first time, she was pleasant enough, but her answers were short and curt and I could tell we were not really connecting. She said she had no clear plans to end her life, but admitted that she was ambivalent and thinking about re-engaging with her restrictive eating behaviors. If this meant she might die, so be it. She was seeing a nutritionist and had completed an inpatient eating disorders program. She was a stable weight, which doctors saw as a success, but Adrian was still deeply unhappy about her body. She was already on medication for sleep and anxiety that were partially helpful.
Under the single-consultation model, I would have recommended an increase in her antidepressant, specialized therapy, and sent her back to her family physician. It probably would not have bothered me that I found her somewhat unreliable and detached in the assessment. I could easily justify how this was her problem and not mine.
But I will find out that I am not that kind of psychiatrist. Over the next 5-10 years of my practice an internal conflict raged within me between the psychiatrist I wanted to be and the one I was trained to be. I am not the kind of psychiatrist a health care system obsessed with numbers as a measure of success would want to hire. I am a psychiatrist who sits ill-at-ease when a patient is not honest with me. I actually do not care about the objective truth as much as why the patient does not trust me in the first place. Seeing Adrian and trying to help her taught me about a common sense truth that the medical system has ignored and actively discouraged: the relationship is everything.
With Adrian, I knew one session would not cut it. I therefore offered 6-8 sessions and thought myself very generous. We would optimize her medications but also spend time talking about her ambivalence in her recovery and with being alive. I wish I could say things got better from there, but they did not. In fact, they got worse. In the following 3 appointments, she continued to be quiet, answering most questions with “I don’t know” and resisted questions that required self-reflection. I thought we were getting somewhere, but this was wishful thinking. I was trying so hard to like her and warm myself to her that I tricked myself into believing it was reciprocal. Reality came crashing in the third appointment, when she told me her suicidal thinking had in fact increased in the time we started seeing each other and she had cut out one of her snacks as well.
I was speechless and panicked. I asked her if she felt our sessions were helpful, and she said she did not. This caught me off guard and felt like a slap in the face. I was also aware that because eating disorders is not my area of specialty I felt out of my depth in how to handle the situation. I will also admit, I was angry. I felt she was taking me for granted, wanting to get a reaction out of me and sabotaging therapy.
“Therapy does not work with a nutrition-deprived brain”, I said, trying to reason with her.
“I know,” she responded.
“What would you like our work to accomplish?” I asked.
“I don’t know,” she says.
Because she had relapsed in her eating disorder and our therapeutic alliance was clearly absent, I discussed with her whether or not we were a good fit and that perhaps we should stop therapy if it was destabilizing for her. What strikes me now, is how ending therapy with her was the wrong thing to do, but clinically, it was completely justified.
After this session ended, within 10 minutes, I got a frantic call from her family physician.
“I just got off the phone with Adrian’s mother,” she said, trying to stay calm. “She is reporting Adrian is having intense suicidal thinking after your meeting with her. She is in acute distress, what should I do?”
When I explained my reasons for ending our therapy, the family physician was very understanding, but still wanted my guidance in what to do more immediately. We talked about assessing safety and to see if we needed to bring her to hospital, or if Adrian was amenable to being seen by her family physician the next day for a debrief.
I could not sleep that evening. Why was my gut telling me I was missing something, when my psychiatry training told me I was in the right? I admit it was a relief discharging a patient like her from my care. I no longer had to worry about her safety and dealing with all the emotions and stress that came with knowing I was not getting anywhere with her in our appointments. It felt like despite being in the same room together, we were heading in completely different directions. But I also knew that it wasn’t her eating disorder that caused her not to connect with me in the first place. I knew that she had one foot out the door from the outset, and that even after committing 6 sessions to her, she shrugged in ambivalence and did not voice any enthusiasm when I suggested the care plan.
She was never on board. Here is an attractive, intelligent, young woman from a loving family. Why is she ambivalent about living? And was I going to find out in 6 sessions where I basically interrogated her with questions, or left her in silence when she had nothing to say? What crystalized for me was realizing that even though I was asking the right questions, she did not trust me. And with no trust, both she and I would never get the answers.
What made me think I deserved her trust? Because I am a physician, a psychiatrist? Because I am a nice person? Because she is supposed to? It caused me to challenge the assumption that just because I am a mental health expert, does not mean I am a person who is emotionally safe, especially when I routinely see patients who have been deeply traumatized and betrayed in their relationships. It also made me think deeply about what trust is and how it is built. What is obvious to me now is that trust must be earned over time. What would help is making a commitment. What is vital is the communication both verbal and with action that I am with you, no matter the outcome. Trust can only be earned when I am accountable to her.
The next morning, I called Adrian. I told her I thought more about our session and believed I missed something important, and that is that she did not trust me. I had done nothing to prove to her I was trustworthy. I apologized for this and informed her that, if she was willing, I would commit to seeing her for 1 year, every 1-2 weeks where we would talk about whatever she felt was important. I threw the initial therapy plan out the window and noticed immediately that when I stopped adhering to others’ expectations of what kind of psychiatrist I should be, I could listen with my whole heart to Adrian as she told me, directly and indirectly, what kind of psychiatrist she needed me to be for her.
I ended up seeing Adrian for 3 years. In that time, I saw her complete university where she graduated top of her class and made good friends. I saw her through the start of her first serious romantic relationship and when she decided to move out on her own, become financially independent. Her suicidality had resolved completely as she learned she could survive making mistakes and realized the mastery she was capable of when faced with life’s challenges.
Adrian's case highlights a broader, challenging population: individuals with chronic, rational suicidality. This kind of suicidality is different from the suicidality seen in moments of acute stress, or the kind that is impulsive and paired with emotional dyregulation and self-harm.
Patients with chronic, rational suicidality are often highly intelligent, financially stable, and have tried numerous medications and therapies. These patients can be particularly challenging because the reasons they have for why they should end their lives are logical and can be hard to dispute. Be it a life of regret, chronic pain, or loneliness, the most universal characteristic in this population is a pervasive hopelessness and apathy that never lifts.
This kind of suicidality is the psyche asking the question, what makes my life worth living? and determining, “I have tried many things. I do not matter. My life experience reflects this truth. This will not change. There is no point.”
I hope it is intuitive that an antidepressant will not have much effect here. The only force capable of shifting this mindset is a genuine therapeutic relationship, which provides the connection, emotional safety, and validation that make a person feel they truly matter. And it is this relationship that can be life-saving.
Rather than relying on what AI or new pharmaceuticals can do, we need to refocus on the time tested, common sense human traits that gave us our survival advantage in the first place. These characteristics are innate to all of us but we have been distracted by our attention-driven, productivity-obsessed, individualistic and capitalistic culture and politics. It is as basic as spending unhurried time together, listening without an agenda, and building authentic trust over time.