A Letter to My Future Mental Health Provider

Dear future provider,

I’m curious to meet you, and also quite wary. There’s so much emphasis on first impressions, but what about all of the past impressions that have led us here? At this point in your career, you have a burgeoning caseload with many former and current clients to track. As for me, in 2017 alone I estimate I had 27 first appointments or intakes with providers while navigating inpatient and outpatient services. Most of these first meetings were neutral experiences, and some led to strong collaborations. But a few were overwhelmingly negative, damaging my ability to trust providers and advocate for myself. Whether we acknowledge it or not, we’re both bringing histories and expectations into this first appointment that will shape our trajectory and ability to working together.

I’ve been wondering about your style and perspective. What are your assumptions, your shortcuts, your strengths as a provider? Do you, or other providers, ever hear what it is like to be shuffled from one intake to the next? Do you consider how my past experiences will shape how I regard you from before we’ve even met? Do you ever have a chance to hear the patient’s perspective on what is and isn’t working in mental health treatment?

If I could offer my perspective to a provider, what would I say?

The following is a reflection of what I wish providers thought more about or did more often.

1. I wish providers thought more about their assumptions.

You can really only learn so much about a person in one hour (or 30 minutes, for example). The rest you fill in with your assumptions, one perhaps being that you are smart and skilled enough to learn every relevant thing in an hour. Together, you and I are relying on your ability to ask the best questions and on my ability to give you the best, most accurate and informative responses.

There is so much that cannot fit into an hour of us doing this, even if we’re giving it our best shot. What is falling through the cracks? The historical context, or lack thereof, for a presenting symptom? How much I remember, or trust you, or can even explain in an understandable way? The amount you can correctly interpret and retain what I tell you? You just can’t get it all.

So, what are your assumptions? If you assume you don’t have any, then start there.

2. I wish providers thought more about their limitations.

A provider recently told me I was out of medication options. I’d been depressed for about 18 months. I had tried a dozen meds. A few helped but did not put me back in remission. When he told me I had no more options, my personal world shifted on its axis. I swung away from “recovery” and the belief I could get better, and toward a confusing, dystopic future of life with depression as a permanent installation.

I saw a second doctor. She laughed (right out loud) at the idea I’d run out of choices, drafted a list of medications in minutes, and together we chose one. My depression lifted within days. I only saw her twice.

Let’s go back and reframe the first provider: he was out of options, not me. He was at the limits of his expertise. What would it look like if he had made this his problem, and not mine?

3. I wish providers thought more about their power.

The definition of gaslighting is to “manipulate (someone) by psychological means into doubting their own sanity.” In the world of mental health treatment, this is actually very easy. You, the provider, are the supposed-neutral expert of psychological experience and thus the arbitrator of reality. There are no x-rays or lab orders that can verify someone’s experience or perception. It’s my word against yours, my mind against yours.

I had a provider who doubted me as a rule, turning my questions around, denying having said things he’d told me minutes earlier, and generally interacting with me in a way that made me feel crazy. It was hell. It made me act differently: scared, defensive. I felt trapped. I came to doubt myself, my instincts, my dignity. I believe this behavior constituted gaslighting: his actions caused me to doubt my sanity.

How often do you doubt, challenge, or subvert what your client is telling you? Why? And at what cost? Because of the power imbalance in the provider-client/patient structure, I hope you have thought carefully about how you use power. I hope you will treat me with respect, even in moments of tension. I hope what I tell you is always believed to be my truth — to be respected as such and considered factually and meaningfully true unless there is a clear and significant reason not to do so. I hope you use your power to create an environment where we can work together, instead of against each other.

4. I wish providers applied diagnostics sparingly.

What’s the point here? Is your primary goal to correctly locate the cause of the presenting symptoms and improve my well-being, or is it to establish a case against me. How I am wrong or deviate from the DSM norm?

To what extent does something “present” and to what extent do you extract it? (See above re: gaslighting). Do you consider the impact on the patient of introducing a heavily-stigmatizing label? How important does that weigh in contrast to “being right?” Research has found that certain diagnoses can lead to less effective treatment for their actual experiences, as well as increased stigma.

5. I wish providers answered my questions instead of responding with more questions.

Just answer my question.

6. I wish providers were honest and direct.

I want to know I can count on you to tell the truth. Convoluted answers — answers that aren’t really answers at all — are confusing and erode trust. Direct and clear answers build trust. And that builds our ability to work together effectively in our hour. See above.

7. I wish providers were able to admit fear — to themselves, at least — instead of scrambling to fix a situation.

I’ve observed (and been told) that providers make mistakes when they are afraid: the situation is intense, they don’t know what to do next, and so on. So the provider does something impulsive, or goes down a stiff and prescriptive path, or just gets angry. My response to this is usually to shut down and disengage from the process, because it feels awkward and desperate and wrong, and because I can see you are grasping at straws. Let’s be real: who enjoys being subject to frantic efforts at “fixing?”

The thing is that I do this to myself too. Over the years of riding the mental health roller coaster and struggling through seemingly unending bouts of severe depression, of course I have gotten scared! Of course, I’ve wanted to fix it! I’ve rushed into my own life the same way providers have. It doesn’t work.

I have been learning to be present with what is “presenting,” to use your language. When someone is suicidal, it’s scary. When the umpteenth medication fails, it’s scary. Both you and I experience moments of powerlessness with this illness. The providers who have been able to meet me there — acknowledge the heaviness in the room, discuss that in a real way, admit their fears or concerns or professional limitations — are the providers who are ultimately successful in finding the path forward. Those are the providers I really respect. And we usually work well together.

When I come into your office, I will be afraid. I will remember the feelings of presumption, of fear and powerlessness from past providers. And I’ll give it another shot anyway because I need your help. I hope you’ll meet me halfway.

Your future patient,
Sage Schick