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Relationships Matter. Consistency Matters. How Change is Implemented Matters

new-mexico-signI’m a doctor–I specialize in psychiatry. My patients are mostly kids and teenagers, generally 5 years old and above. While the families and caretakers of these kids are not my patients, they nonetheless almost always play an irreplaceable role in my patients’ care. I rely on the information that I get from the adults in the room–I could rarely do my job without it.

When I see a child for the first time, and I ask them something like “What’s your understanding of why you’re here today?”, they more often than not have no idea. Often, the child is somewhat apprehensive, is unsure of what to say–I’m a stranger to them, and I’m also new to the adult(s) who are with the child. Basically, we’re all just starting to get to know each other in the context of the mental health provider/patient relationship. The children wonder, what’s this doctor like? Is he nice? Can I play with the toys in here? The caretakers are wondering about pretty much the same things–what’s this doctor like? Can I trust him? Do I like him? Do I think he knows what he’s doing? Does he care? Is my child going to be comfortable around him?

The answers to these questions matter, and like most relationships, building them takes time. I will often tell the families I work with that it takes about 10-12 visits to get the information required to know the child really well, to know much of the relevant circumstances of their past and present really well. If I see them once a month, for 20-40 minutes at a time, almost a year has passed.

Part of the reason it takes so long is because, for most children and adults, it takes time to get to know someone new, to trust them, to feel comfortable around them. Just because I’m a doctor, just because it’s my job to try and help people, that doesn’t mean that they open up right away. Especially when it comes to their kid’s health. Even more especially when it comes to their kid’s mental health, their kid’s behavior, or the family’s situation. A lot of things that a doctor might need to know about you or your kid is incredibly private–these are things most people don’t talk about, certainly not publicly, and certainly not with a stranger or with just anyone. These things require TRUST.

And as a human being just like everyone else, I understand that. I feel the same way. So though it’s part of my job as a doctor and psychiatrist to try and build trust and comfort as efficiently as possible, it’s also my job to realize that rushing that process can be counterproductive, or even detrimental. Make a bad impression the first few times you work with a teenager, and good luck getting them to change their mind about you. It’s not impossible, but it’s often not that easy either. Bore or scare or worry a child, and what do they often do? They shut down, they ignore you, they try to tell you what they think you want to hear, or they simply make things up. These reactions are often natural, to be expected–or for lack of a better word, they’re “normal”.
So when a patient, a child or a teenager, and the adult(s) that take care of them, trust their doctor, are comfortable with their psychiatrist, or therapist, or case manager, or social worker, that’s a special relationship. It isn’t to be taken lightly–it’s often not easily replaceable. It’s sturdy and fragile at the same time, like most other meaningful relationships.

Lives can depend on it.

Doctors rely on information to help their patients. Mental health providers rely especially on information that comes from talking and interacting with their patients. If you treat kids, you receive information from talking and interacting with their caretakers as well. A good and established provider-patient relationship increases the chances that what you, the provider, see and hear will be helpful–it increases the chances that your patients, who feel secure in their trust in you, who feel cared for by you, will give you accurate information, will tell you what you need to know when you ask, and sometimes even when you don’t. This is not a trivial matter. It can literally mean the difference between life and death.

When I say “a good and established provider-patient relationship,” I don’t mean just between me and my patient. As a doctor, I can’t do my job alone–most of us can’t. The work demands a team effort. So ideally, the patient is comfortable enough with the whole team–from the person that greets them and helps them when they come in and check in, to the person that gets their blood pressure and heart rate and asks them how they’re doing, to the person that answers their phone calls, to the person that assists them with messy insurance issues, or financial challenges, or transportation problems, and so on. And I don’t even mean just the team either–I mean with the place, too. The waiting room. The doc’s office. The bathrooms. The parking lot. When all these aspects are in sync with the patient’s needs, the greater the chances of success. The greater the chances of achieving whatever the goal at the time may be: feeling better. Healing. Staying well.

So, when I hear that as many as 30,000 New Mexicans who are receiving some form of mental health services are suddenly forced to contend with significant changes in those services, I become concerned. Regardless of whether those changes are appropriate, or deserved, or have merit. That’s a separate issue from the immediate, and often continuous, needs of people whose daily well-being is heavily dependent on those services. On the reliability and accessibility of those services. Anyone who’s worked on any kind of project of some significant size and scope, anyone who has that kind of experience, will tell you that it’s just about practically impossible to suddenly, virtually overnight, change services–any kind of services, mental health or otherwise–to 30,000 people without causing serious disruption to some of them. Maybe to many of them.

Maybe another “audit” is in order: how many patients missed appointments? How many went without medications for a few days or more? How many had their symptoms worsen? How many missed school days or work days because of it? How many have given up on getting help because the provider they built a therapeutic relationship with is no longer available? How many have relapsed? How many have ended up in the emergency room? In the hospital? Or worse?

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