Getting The Nod

The medical student currently rotating on the psychiatry consultation service asked me a very astute question yesterday. He wanted to know how psychiatrists get patients to change.

We have seen quite a few patients on rounds in the general hospital, and he’s getting a pretty good idea about how the psychiatry consultation service can be a lot like a fire brigade, putting out fires. Often one type of fire is the patient who seem stuck in a maladaptive coping style or interpersonal patterns which seem unproductive or counterproductive to healing.

Medical students don’t often ask me difficult questions like that. I’m always impressed when they do. It showed he was paying attention–and thinking about the repeatedly difficult conversations psychiatrists tend to have with some patients.

Among the many reasons why hospitalized patients can appear to be rigid, argumentative, hostile, and even threatening are delirium due to the severe medical problems they’re suffering from, demoralization from long, complicated, painful hospital courses, isolation from family and friends, mystifying and seemingly arbitrary ward rules. It’s not hard to see how demoralized we can get in the frustrating and painful situations that medical hospitalizations can become.

And there are some patients who seem predisposed to suffering more from the challenging hospital environment than the average person. They may have personality disorders or even personality changes from brain injuries. They may just be under a lot of stress at home. Under these circumstances, they may have conflicts with doctors and nurses who are trying to help them heal. Health care professionals don’t always communicate or listen well, either.

So when the medical student asked me how do psychiatrists get people to change, I thought of the many difficult questions I’ve gotten from my colleagues over the years and the many complicated communication problems I’ve encountered. I remembered a conference in Boston about 9 years ago. It was a review of Psychosomatic Medicine and one of the speakers was a guy named C. Gordon, MD [1]. And he talked about the process of “therapeutic negotiation” in situations where there seems to be an impasse between the inpatient health care team (including the psychiatric consultant) and the patient. Gordon divided the therapeutic negotiation into three stages:

  1. Beginning: Getting the Nod
  2. Middle: Finding the edge, generating options
  3. End: Negotiating a path forward

“Getting the Nod” is all about getting enough rapport to get permission from the patient to at least have a place to start negotiating. “Finding the edge” means reaching the place where a patient sort of gets it that a part of the problem may lie within him or her. It’s at that point that an exploration of other choices available for action might begin. Finally, “negotiating a path forward” could mean little more than simply agreeing to meet again.

I told the medical student that I generally spend a great deal of time attempting to “get the nod” from the patient, rather than immediately jumping in and suggesting, cajoling, or insisting on moving him or her more quickly through the Stages of Readiness to Change, Stages of Readiness for Change | Taking Charge of Your Health & Wellbeing. I try to look for the nod, which is often difficult to gauge based on what the patients says to me. More often I get nonverbal clues, and it may be little more than better eye contact as a signal of greater engagement.

I try to remember to give the patient what Stephen Covey called “psychological air”, which is really just respectful, attentive listening without any empty “active listening” techniques which can sound phony. After I get the nod, I may tentatively try to formulate the problem (usually in a questioning attitude, open to correction) to the patient in common, nonjargon terms so that it doesn’t sound like I’m being condescending or pigeon-holing. I could do it in one of several ways:

Biological: “chemical imbalance”

Social: current stressor

Psychological: past stressors, a pattern that might be hard to see and change, or unresolved grief

Spiritual: crisis in life’s meaning, such as the loss of an important person

Another suggestion from Gordon came from somebody named Rubin and it’s that a consultant should try to employ “pull” strategies rather than “push” strategies. Pushing implies trying to influence someone to do what you, the consultant, wants. Pulling means trying to le the patient do what he or she wants. When you pull you listen respectfully, ask questions, and seek to understand and empathize. Pushing involves preaching, exhorting, prescribing, and even inspiring.

I don’t think it’s practical during the usually brief time a patient is medically hospitalized to try to get him to change. I try my best to understand him. It may not be practical to assume I can always teach an old dog new tricks. But I’m open to trying if I get the nod.hound dog elvis


1. Gordon, C., M.D. Difficult and Personality-Disordered Patients. In Psychiatric Care of the Medically Ill. A Review of Psychosomatic Medicine. 2004. Boston, Massachusetts.



  1. I don’t envy you the prospect of trying to help a patient change in the short duration of a hospital stay, and under the duress of whatever put the patient in the hospital in the first place, the possibility of delirium, or pain, or very bad news, and the less-than-ideal conditions of most hospitals.
    Sometimes, a therapy-, or an analytic-patient will say to me, “We’ve already talked about this, and it doesn’t make any difference. I still have the same problems.”
    I try to remind these patients that they didn’t get this way overnight, and that learning, or relearning, or unlearning, takes time, patience, and repetition.
    But try that in a hospital?


  2. I think there are a couple of useful concepts in interacting with people in a therapeutic manner. I remember talking with my very first patient as a medical student. He was not much older than me at the time and our team was in the process of diagnosing him with a life changing illness. I noticed that the communication was open and productive. At the time I had just gone through an interviewing course taught by medical faculty and they were focused on the issue of being a doctor and looking like a doctor because that was what patients expected. I noticed it was important to have open, honest, and neutral communication. I also noticed that it is important to say something useful and later heard Michels say that same thing at an Aspen psychotherapy conference.

    The second issue that confuses a lot of physicians is the idea of the therapeutic alliance. The patient really needs to know what you are working on and that it makes sense to them. That ranges from: “We are going to try to get rid of these voices.” to “We are going to try to figure out why you continue to have extramarital affairs.” At some point there needs to be a common goal. One of the problems that frequently bogs down medical and psychiatric treatment is the lack of an explicit common goal or pointing out that the physician and the patient are at odds with a common goal.

    I also flash back to a moment when I was considering Neurosurgery as a career. I had an NHSC scholarship and learned that they would not defer the payback until after the residency. When I discussed that with the Chief Resident he said (to the surprise of others who knew him): “That’s OK – psychiatrists deal with hard problems that nobody else wants to deal with.” Over the last 28 years of practice I have found that to be very true. I often end up seeing patients with very severe illnesses, chronic pain, or disabling illnesses that have no treatment or cure. They are referred for “depression” or “anxiety” but the problems are a lot more complicated than that. They often see me after another physician has told them: “There is nothing more that I can do for you.” In those cases it is important to not give up and that usually comes down to researching unique solutions and remembering that people benefit from a nonjudgmental discussion.


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