TCPR: What is the best way to talk about difficult topics with patients?
Dr. Dieringer: Patients want direct communication from their doctors, as do their family and supports. They want more information. They want to exert their autonomy and engage in collaborative decision making. This isn’t easy in high-acuity settings—like inpatient—or when we are rushed during brief medication visits.

TCPR: Should we tell patients their diagnosis?
Dr. Dieringer: Yes. We live in a world where patients have access to their notes, so they already have a direct view. Furthermore, the evidence suggests that sharing diagnostic information with patients is helpful. It’s about transparency. Studies tell us that most patients and their families want to learn about their diagnosis (Maybery D et al, BMC Health Serv Res 2021;21(1):1073). 

TCPR: But many clinicians withhold diagnoses.
Dr. Dieringer: There is this notion that knowledge is harmful and requires us to protect our patients. This belief can lead providers to avoid conversations about diagnosis. To worsen the situation, psychiatrists receive very little training in complex communication around diagnosis and prognosis (Outram S et al, Acad Psychiatry 2015;39(2):174–180). Withholding a diagnosis is very paternalistic, and the evidence doesn’t line up with that. Instead, outcomes improve when we welcome patients and their families into that space and talk openly about diagnosis, prognosis, and treatment options (Wolf D et al, J Nurs Care Qual 2008;23(4):316–321).

TCPR: What if your diagnosis causes conflict with the patient?
Dr. Dieringer: I find there is less conflict when we come at the diagnosis from a place of transparency. They may say, “Bipolar disorder? Are you sure? Don’t you think you’re overreaching? Don’t I need a blood test?” I’ll respond, “I can only imagine how overwhelming this must all be. Let’s take it a step at a time together—I want to answer all your questions.” I’ll allow a lot of silence so they can process the information.

TCPR: Do you ever change your diagnosis if they disagree? 
Dr. Dieringer: Not if I think it’s accurate, but diagnostic formulation is a work in progress, so it’s important to have a dialogue with the patient, particularly when diagnoses are stigma-laden. I’ll say, “You have the right to know this, and we may not agree on it, but I do want you to at least know my perspective and what’s in your chart.” I want the patient to be able to ask questions and share their perspective. Being open to disagreement and discussing diagnoses with patients is a stance that can build rapport and trust.

TCPR: How do you take that stance?
Dr. Dieringer: Let’s say my patient is experiencing schizophrenia and they have a rigid belief that their neighbors are trying to poison them. We may explore how this belief isn’t serving them in the long run. Sometimes they may not want to do this exploratory work, or they may disagree that the belief is unhelpful. However, I do my best to be honest and compassionate. It’s okay to disagree sometimes.

“It’s not that I’m more objective or right. It’s about how each of us sees it, and respecting the other’s perspective.” 

Dana Dieringer, MD

TCPR: It’s almost like you’re saying, “I value my truth, and I value yours as well.”
Dr. Dieringer: Exactly. I want to understand their perspective. It’s not that I’m more objective or right. It’s about how each of us sees it, and respecting the other’s perspective. I also try to use person-centered terms and stay away from words like “delusional” or “paranoid.” And I acknowledge that the DSM is a tool that has its own limitations and evolves over time.

TCPR: What if the ICD code in the chart is “schizophrenia”? 
Dr. Dieringer: I’ll start by asking permission: “Would it be okay if I tell you how I see things, and what I’m worried about in terms of a diagnosis?” If they agree, I’ll ask, “To make sure we are starting from the same place, what have doctors told you about the voices before? What is your understanding of them?” Asking the patient what they have heard or currently understand helps you tailor the next step, which is delivery of the diagnosis. “I’m worried that you may be experiencing something called schizophrenia.” I slow down at this point, as it is a loaded word, and say, “Would it be okay if I tell you what I mean by that?’

TCPR: It’s interesting that you jump right into the medical term “schizophrenia” instead of softening it with words like “rigid thinking.”
Dr. Dieringer: You can do it both ways and, again, assessing the patient’s understanding helps you decide where to start. We have a tendency in medicine to start with easier terms or long summaries, like listing the symptoms the patient came in with. I find it helpful to be more direct, starting with the “headline” and then unpacking it. Now, I’m not jumping into this after meeting them for 15 minutes. I want to make sure I’ve gathered a full history, done my homework, and hopefully gained some trust so they know I care. Then I check in with them. “To make sure I’m being clear, could you tell me what you’re taking away from our conversation so far?” or “I imagine this is a lot of new information. I want to make room for your thoughts or reactions so far.”

TCPR: How do you unpack it?
Dr. Dieringer: I focus on what the diagnosis means to them. What can they expect down the road? What is their perspective? What do the symptoms mean in their culture? I have to tread lightly when discussing psychosis as these kinds of symptoms carry so much meaning within different family or cultural systems. I want them to know that their spiritual faith is important. I want them to trust that I will share my medical opinion and what is in the chart. I’ll connect the diagnosis to their experience, such as by saying, “Schizophrenia looks different for everyone. You have this intense concern that someone’s poisoning your food, and I’m worried this belief is making it hard for you to know who to trust. I’m worried it isn’t protecting you in the long run and may be getting in your way.”

TCPR: What if they press you about whether you think the delusions are true?
Dr. Dieringer: I do my best to redirect and focus on how those beliefs are affecting their functioning. “Let’s think about what you want to do and how can we you help get there.” Using a cognitive behavioral therapy framework can be really helpful. For example, sometimes hypervigilance just eats up all their time, but sometimes it is helpful to them, like if they are experiencing homelessness.

TCPR: How do you explain borderline personality disorder?
Dr. Dieringer: The criteria often resonate more than the stigma-laden term. Before I use the diagnostic term, I’ll discuss each criterion and explore how it fits or doesn’t fit with their life or experience. Once you understand which criteria resonate with them, it’s easier to explain the diagnosis in a way they understand.

TCPR: How do you engage patients in treatment decisions?
Dr. Dieringer: First, I’ll say off the bat that medications should never be the only available tool. That’s true for any psychiatric disorder. When we discuss meds, I want to hear their honest experience—positive or negative. So if they say aripiprazole gave them terrible akathisia, I’m not going to discount their experience with “but,” as in “but we can treat that with propranolol.” Instead, I’m going to reflect that back and ask for more: “Any other problems with aripiprazole?”

TCPR: Talking about propranolol can give hope, but it also shuts down the conversation.
Dr. Dieringer: Yes, because you’re the doctor. You’re the authority. The patient may be sharing the side effect to relay a feeling or an “emotion cue.” They are expressing frustration, dissatisfaction with care, and I need to pay attention to that before jumping into a problem-solving mode. So I’ll validate: “That sounds miserable. Tell me more.”

TCPR: What are other examples of emotion cues?
Dr. Dieringer: In a family meeting, when I introduce the possibility of schizophrenia, the parent might jump in with, “What if it’s just that they’re smoking too much pot?” Usually, the parent is not looking for a medical lecture on substance-induced psychosis in that moment. Instead, it’s an emotion cue that a schizophrenia diagnosis is hard to accept. So I’ll respond to the emotional undertone behind the question: “I can imagine how hard this is to hear right now.”

TCPR: Do you find that introducing nonpharmaceutical approaches enhances the trust with meds?
Dr. Dieringer: Yes. If they’re not interested in taking medications, they probably have good reasons that I need to understand. Maybe they’ve had side effects or traumatic experiences in the mental health care system.

TCPR: What are ways to phrase things that empower the patient?
Dr. Dieringer: Asking permission. For example, I’ll ask, “Would this be an okay time for us to talk about treatment?” I’ll give them space to share. I might say, “Before I start spouting ideas, I want to hear what you think is best.” If I know what they are interested in first, I can craft better options for treatment. Then, I’ll offer two or three treatment options and give some context so the patient understands each one.

TCPR: How do you talk about long-acting injectables?
Dr. Dieringer: That depends on the patient. I may say, “I’d like to go out on a limb a little bit with you. There are medications that we can give to you once a month through an injection form. Have you heard about this?” Then I’ll ask what they’ve heard and gauge their reaction. I’ll use a similar approach with clozapine and lithium, seeking their permission every step of the way. If they reject it, that’s okay. We may just plant a seed and come back to it later.

TCPR: How do you elicit feedback from the patient?
Dr. Dieringer: When I find myself rattling on a lot, I’ll slow down and say, “Hey, I’m giving you a lot of information. Can I check in on how this is sounding so far? What are you taking away? What are you worried about?”

TCPR: What are warning signs that the discussion is going the wrong way? 
Dr. Dieringer: Having the same conversation over and over is a sign that the communication isn’t working. At that point, I’ll step back and look at what the barriers to communication might be. Maybe there are cognitive barriers or I’m not picking up on emotion cues. Then I’ll address that: “I feel like we’ve been having this conversation a lot. What are your thoughts on why we keep revisiting this?”

TCPR: What if anger erupts?
Dr. Dieringer: Hopefully, I can anticipate and plan ahead. For example, if we’re going to have a family meeting to talk about something the patient and I often disagree on, I’ll say, “There have been times when we see things differently. What should we do if things get intense?” We might plan to take a break, but empowering them ahead of time can help defuse the conflict.

TCPR: Thank you for your time, Dr. Dieringer.