Recently, the parent of a 9 year old patient with an anxiety disorder was discussing with me her experience in the office of a somewhat famous child psychiatrist. I had referred the family there for a medication consultation. I knew when I referred them to the MD that that they were reluctant to consider medication, but I also knew medication might well help the child as an adjunct to the cognitive behavioral therapy (CBT) we were doing together.
The parent reported that she left the doctor’s office not knowing what he thought about medication. She also had not gotten to speak to him without her daughter present, though she thought she had expressly asked to do so.
I asked her what she had learned, and she said that he had confirmed her daughter’s diagnosis – which had never been in doubt! At first, I was inclined to judge the doctor harshly for his communication failure. Then I realized the same thing has happened to me. Occasionally, toward the end of a session, a patient will tell me we never discussed the major thing they had wanted to focus on. Why? What goes wrong?
I have identified at least two factors which affect the success of my communication with patients. The first is whether I have emotionally centered myself before the session to be present for that specific individual. This involves thinking about what we have talked about in the past and what we may want to talk about in the moment, and making sure that my own life is not at the forefront of my mind. Mental health professionals are human, after all, so sometimes we are distracted, tired, or less emotionally available than we want to be.
However, even when I am as perfectly present as I can be – really at the top of my game – I am not always successful. Which leads me to the second factor: conscious and willing participation by the patient.
Sometimes, patients are embarrassed to share things. Others don’t know how to explain their feelings. Sometimes people don’t want to confront the things that need to change. Bottom line – if the patient isn’t prepared to tell me, there’s not much I can do about it.
Children present an added dimension to the difficulties of communication. For example, the child in my example above shared how well she was doing with the psychiatrist, and as long as she was in the room her mother could not openly express fears and worries about her actual progress. Children have both a greater need to be liked than adults do, and less ability to think abstractly. Since children are less able to think about themselves outside of the present moment, there have to be additional sources of information. Balancing communication between the parents, school, and child is challenging.
In addition to using mindfulness to center myself before a session, another tactic which helps me avoid communication problems is setting an agenda. I ask what the patient wants to focus on, and I suggest things I’d like to discuss with them. We go back and forth for a few minutes, ascertaining what is most important so that we use our time together well. With kids I spend time with them and their parent(s) together, without their parent, and with the parent alone – giving me three tries to get the agenda right.
Why did the parents in my first story have such a tough time communicating with the child psychiatrist? It seems like the doctor was too focused on his medical evaluation to recognize that the parents were not getting what they needed, while the parents were too ambivalent and wary of contradicting an authority figure to clearly ask for what they needed. What it boils down to is that mental health professionals are subject to the same failings as anyone else, and effective communication is a skill that needs to be constantly worked on and maintained.
Tamar Gordon, Ph.D., a licensed clinical psychologist, is Voluntary Faculty at NYU School of Medicine and Adjunct Faculty, Ferkauf Graduate School of Psychology, Yeshiva University. She has been a supervisor at a major mental health clinic, an expert consultant on trauma treatment to the United States Veteran’s Association, and is an active member of the Association for Behavioral and Cognitive Therapies. She currently spends most of her working time at her private practice in New York City, and most of her personal time raising her two rambunctious sons.