The Evaluation Period
A complete Psychiatric Evaluation is conducted across 2 - 4 (or more) appointments depending on the complexity of your problem(s). This Evaluation Period is used strictly to establish whether we would be a good fit to work with each other based off a discussion on the following three items:
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Practice Policies: What the provider’s limitations, rules, and expectations are.
Diagnoses: What the provider believes is the problem that is causing your issues. This is more than just assigning a DSM-V diagnosis.
Treatment plan: What the provider believes will be appropriate in resolving your problem.
Establishing a Doctor-Patient Relationship:
A “Doctor-Patient Relationship” is both an ethical and legal term.
Ethics: This relationship is confined by strict boundaries, professionalism, and expectations for what the doctor believes is beneficial and will NOT harm their patient. It also informs the basic rights that you have as a patient.
Legality: Your doctor must fully inform you of and obtain your full consent before you accept treatment services. They must also inform you of your right to privacy (HIPAA) and your right to fair payment (Good Faith Estimate). For a full list of proposed physician legal duties, refer to this link here.
The Evaluation will determine if you and I both agree to work together ethically and legally. It’s best to NOT establish a relationship if there are any reservations or disagreements.
Please refer below for a list of frequently asked questions regarding the Evaluation I conduct.
FAQ
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I evaluate for the vast majority of disorders in the DSM-V that I believe are relevant to the treatment of Depression/Anxiety. This includes (but is not limited to) Depressive, Anxious, Obsessive, Trauma-Based, Somatic, Eating, Substance, and Personality Disorders. I also evaluate Bipolar Disorders and Psychotic Disorders as those require a completely different toolset and perspective to treat.
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No, I do not. Please seek a different provider who specializes in these.
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No, I do not. Please seek out a specialist or another provider who is willing to file your disability or medical leave. I consider these items a conflict of interest particularly if you're intending to utilize them for Depression/Anxiety.
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No. I never skip evaluations. Those clients for whom I skipped the evaluation in the past ended up getting stuck or got worse. I imagine that's not what you would want for yourself.
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Yes! My philosophy and approach to treatment tends to be different from that of other providers. I heavily emphasize evaluation and do not believe it's ethical to work with anyone until I've conducted a full evaluation regardless of where you're coming from.
The Evaluation Can Increase Treatment’s Effectiveness
The Evaluation Period is tailor-made to quickly and efficiently identify problematic beliefs/behaviors that will likely impede your recovery. These problematic “factors” can occur in either the provider or the patient/client. It’s important to bring these factors to conscious awareness so that they can be dealt with through accountability and commitment. Refer below on how that is done:
Provider Factors and How to Deal With Them: Provider Factors usually revolve around insecurity and skill deficits. Both can be addressed through professional consultation, but one of the best tools for the provider is for them to seek out their own therapy if they keep running into the same issue(s).
Patient/Client Factors and How to Deal With Them: Patient/Client Factors are influenced by age and exposure to (ineffective) treatment. With growing age and exposure to treatment, patients/clients are more likely to develop factors that can impede their recovery. Metaphorically, these factors are like added “layers” to an onion. The layers protect the inner parts from being hurt. These factors are addressed through identification, informed consent, and your provider’s ability to hold you accountable.
List of Provider and Patient/Client Factors that Impede Recovery
These lists are not 100% exhaustive or comprehensive. They are a collection of some of the more common issues that I have noticed throughout my years of practice.
IMPORTANT NOTE: Some of these items can be shocking or accusatory. We usually don’t want to think about these items, but that’s why it’s so important to discuss them anyway! AVOIDING talking about or acknowledging them often makes the issue(s) worse and can lead to frustrating, dissatisfying experiences. None of what is shared in these lists should be construed as formal psychiatric recommendation, advice, or actual evaluation. These lists are purely for educational purposes to give you an idea of the kind of things I might discuss with patients/clients in an evaluation.
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Therapeutic Agnosticism: Believing that there is no “right” approach or “right” philosophy to helping people recover from Depression/Anxiety. There’s always a right and wrong way to do things that is necessarily dependent on the framework people subscribe to. If the provider declines to choose between right or wrong, or avoids subscribing to some kind of framework, they will be as lost as their clients.
Conflict Avoidance: Believing that it’s the provider’s job to always make their patient/client feel good about their experience and avoid any disagreement. Effective treatment requires a mix of agreeable and disagreeable experiences. Striving to provide only positive experiences is like being a paid "yes-man" which won't help.
Aversion to saying “no”: Believing that if the provider says “no” it will harm their patient/client. This is usually not the case. Saying “no” can be very helpful and sometimes life-changing.
Boundary Crossings: The provider has insecurities that drive them to "rescue" their patient/client. This manifests as additional unpaid time, over-involvement in patient/client's life, over-flexibility with policies, over-communication, and/or attempts to cajole the patient/client into treatment.
Boundary Violations: The provider goes a step further and rationalizes their "rescue" behavior(s) until it becomes something more sinister. This can manifest as unprovoked physical touch, intimate relationships, abuse, unethical financial dealings, deceptive sales tactics, or manipulation. Providers who commit violations are taking advantage of their patients/clients. You should report these behaviors to the appropriate licensing board if you ever observe this happening.
Negativity Blindness: Believing that people at their core are "good" and endorsing this even when it's clear that the patient/client is doing something "bad". People are a mixture of good and bad. Effective treatment requires acceptance of both qualities so that appropriate limits can be set and therapeutic experiences can be reinforced.
Aversion to Evaluation: Dedicating only one appointment or a negligible number of appointments to the Evaluation. Evaluation can accomplish 60-70% of the work in effective treatment. Thorough evaluation cannot be ignored.
Failure to Re-Evaluate: Neglecting to re-assess new information, new symptoms, and new understanding that comes up in subsequent appointments. Anything that is new (even symptom improvement) should be evaluated.
Reinforcing Ambivalence: Believing that the provider has the power to motivate an ambivalent patient/client. The optimal thing for the provider to do in these situations is to offer a break from treatment, a referral, or offer to work on something else. Anything else will usually reinforce the ambivalence.
Failure to Refer in Typical Outpatient Settings: Believing it is safe to work with high risk individuals (i.e. chronically suicidal, self-harming, or other-harming). The provider will feel chronically stressed and unhappy. Unhappy providers cannot help their patients/clients recover. High risk individuals do better in intensive programs that have a higher degree of monitoring and more frequent interaction.
Financial Conflict of Interest: Believing that the outpatient practice should be the primary source of income. Providers will be incentivized to: increase their fees, increase frequency/duration of visits, increase expectations, and retain patients/client for longer than necessary. Treating clinical practice as a secondary source of income remedies these financial pressures.
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Aversion to Homework and Self-Help: Believing the assigned homework or self-help aren’t worth doing within treatment. This is a polite way of saying that you’re probably ready for termination or that you do not agree with the provider’s assessment/recommendations.
Aversion to Exposure: Believing that being triggered will be an awful experience that you cannot tolerate. You can tolerate it, and you will do it especially if your intention is to resolve your triggers. Anything less than this approach will reinforce your triggers.
Pain Management: Depression/Anxiety is sometimes expressed as referred pain. It can manifest as gut issues, back pain, headaches, fever, cough, or any other type of physical pain. Radically treating the pain through medical-surgical options can counter-intuitively reinforce the pain, worsen it over time, and reinforce the underlying Depression/Anxiety.
Suicidality: Believing suicide is a legitimate option for Depression/Anxiety. Suicide for Depression/Anxiety is the ultimate act of ignorance. All living things exist to experience both the pain and joy of being alive. Believing suicide is an option for Depression/Anxiety is a rejection of this basic truth and will reinforce the Depression/Anxiety.
Physical Self-Harm: Believing that harming yourself (cutting, hitting, whipping, burning, starving, purging, etc.) is a legitimate coping mechanism for Depression/Anxiety. If you harm your body, you will harm your mind.
Depression/Anxiety as “Disorders”: Believing that your Depression/Anxiety results from a biological defect that must be “corrected”. There is nothing to “correct” in Depression/Anxiety. They are natural phenomenon extending from who you are and what you want. Depression/Anxiety requires understanding, NOT correction.
Bipolar/Psychosis Treated “Naturally”: Believing medications are NOT necessary for Bipolar/Psychosis. These are genuine, biological disorders in Psychiatry that only respond to medications. They will usually get worse over time, and the medications are the only effective treatment to slow that down. Before these medications existed, the “natural” treatment was institutionalization because we didn't have any effective treatments back then.
Rescue/PRN Medications: Believing that you need rescue medications like Xanax, propranolol, and other meds. These medications all operate on the principle of emotional numbing which practically never helps people and will reinforce the Depression/Anxiety.
Two-Hour Cure: Believing that you will recover in less than 2-3 hours or 2-3 sessions when that is very unlikely. This belief is common in those who’ve listened to David’s Feeling Good Podcast. The “Two-Hour Cure” does happen but is very rare in a typical outpatient clinic!
Hopelessness: Believing that your Depression/Anxiety will not respond to typical treatment. Hopelessness is effectively a shield to avoid accepting disappointment and failure. Recovery requires you accept both as necessary and sufficient for your recovery.
Doubt: Questioning the capabilities of your provider(s) despite asking for help. This is a tricky subject because sometimes, your provider definitely deserves to be questioned especially if they’re acting unethically or against your interest. Assuming the provider is acting ethically and within your interests, continuing to doubt them is a tactic to avoid facing your own insecurities.
Substance Use (includes marijuana, alcohol, and nicotine): Dependence or addiction to substances as a method of numbing away or avoiding your symptoms. Recovery cannot happen if you numb your ability to understand yourself or avoid doing it.
Blaming: This is common in a majority of Personality Disorders and a hard pill to swallow for these individuals. This is the tendency to believe that your problems are due to external factors or others when the reality is the complete opposite - it’s always your problem.
Decision Paralysis: Decisions realistically come down to two choices even if it seems like there are more than two. What many people choose to do instead is a secret third option: be undecided and choose neither. You’ll end up stuck with the decision and stuck with the associated Depression/Anxiety.
Truancy (middle school to high school): Choosing to skip out on going to school because you’re Depressed/Anxious. You’ve effectively reversed the problem - you’re now Depressed/Anxious because you’re choosing to skip out on going to school.
Family Interference (any age): You allow your family member(s) to be overly involved in your treatment. This is a conflict of interest. Your treatment goals no longer belong to you, and your family member(s) has rendered you helpless. They will complain (like they have before) about your helplessness. Everyone will leave disappointed.
ADHD (Stimulant) Dependence: Believing that if you solve your focus and concentration issues with stimulants, your associated Depression/Anxiety will also be solved. Nothing ends up being solved by stimulants. You end up a lifelong customer and further away from why you were having poor focus/concentration to begin with.
Chasing Methods: Believing that finding the “best” technique or “best” provider will solve your Depression/Anxiety. You chase after more techniques and pressure your provider(s) to teach you more as opposed to sitting down and understanding yourself.
Depression/Anxiety as “alien”: The belief that the symptoms related to Depression/Anxiety are “not me”. Believing this will makes enemies out of yourself. The Depression/Anxiety are you - no one else is putting the Depression/Anxiety within you. They are your responsibility to understand and your burden to accept. If you can do both, you will be able to recover.
Disability for Depression/Anxiety: The belief that Depression/Anxiety warrant as a disability and deserves financial compensation. You trap yourself in a feedback loop. You’re financially incentivized to resist your recovery. If you remain Depressed/Anxious, then you will continue to receive disability income. When you’re no longer Depressed/Anxious, you will lose this income.
FMLA for Depression/Anxiety: The belief that having Depression/Anxiety warrants a leave from your job. This is an avoidance tactic. FMLA for Depression/Anxiety weasels you out of the choice you realistically need to face at your job. The two choices are: 1 - stay at your job and learn to accept/solve your problems OR 2 - leave your job and learn to accept/solve the risks.