In preparation for the first appointment with a new psychiatrist, I wrote a careful, 8-page summary of my medical/psychiatric history, the treatment I had recieved, and the (mostly catastrophic or useless) results of the treatments. At the end, I told him what I wanted from a psychiatrist, and I said what I would do in return. It is common for psychiatrists to make their patients sign a list of "patient responsibilities" when they begin treatment, but I was doing the reverse. I wanted him to guarantee that he would provide competent care. I almost think all mental patients should get together and agree on a contract which they would insist their psychiatrists sign before receiving their first fee. Patients in public care would never get away with this, of course, but if all the private psychiatric patients even in one small town or city insisted on a basic standard of care without which they would not pay for psychiatric treatment, perhaps we could insist on greater respect and more competent treatment.

I think I found myself taking the situation into my own hands this way because I have been pretty much without psychiatric care for the past year (although I have gotten some prescriptions from assorted doctors, and I consulted one so-called expert specialist). I had grown unaccustomed to being a patient (I can hear my Philosophy teacher in France explaining the origin of the word, "passion" which is also that of "patient" by saying "patir, en latin, c'est subir" ("The Latin word patir means to submit [or to suffer]." I no longer want to submit, and I certainly do not wantto suffer the treatments of a psychiatrist!

The new psychiatrist was very young and inexperienced, but seemed well-educated. My father was paying for this treatment, so I was able to consult with a highly recommended young squirt. The initial consultation of 1 1/2 hours cost $350. For comparison, my monthly SSI disability check is $471. Subsequent meetings -- for 30 minutes of "medication management" -- will cost $200. I am appalled by these prices, even though I am not paying them myself.

Of course I didn't have the cojones to make the doctor sign my conditions (that would probably have hurt me rather than helped since I would be classed as manipulative and unwilling to accept my proper role as a patient, and I would be treated more harshly...)

Here is what I wrote:

I would like medical advice on how to best manage my illness, and I am especially eager to receive advice which is backed up (ideally) by research on significant numbers of patients chosen in a statistically sound manner (not papers in which a clinician writes about his last nine patients that he tried some drug on casually), although I know this is not usually possible in psychiatry, where there are not many large studies. If your advice is not research-based, I hope it will come from specific clinical experience (which I want to hear about, naturally not in a way that would reveal any private information about other patients you have seen or heard about) and/or logical reasoning based on pharmacology (e.g. “if you were once helped by a 5HT2-inhibitor like Risperdal, then the underlying problem might be X, and drug Y with mechanism Z might therefore help”). I do not want advice based on dogma such as “you have label X and I have been taught that everyone with that label needs treatment Z,” unless it is also based on the kinds of evidence I have laid out.

I also should make clear that I am looking to receive medical advice, not orders. I may or may not act upon your advice depending on my own conclusions about its soundness. I am emphatically not looking for someone who will tell me I must take exactly what he wants me to take because he is the doctor and I am the patient. I have had enough experiences with bad medical advice – and in many instances I wish I had followed my own instincts, which are often good – that I am not willing to accept that a doctor knows better than I do simply because he is in a position of authority.

I understand that, given the nature of psychiatric illnesses, there could be times when I am so ill that I am not in a position to make fully rational decisions about my treatment. I have pretty much always been aware that I am impaired at the time it was happening (I am aware of being too panicked or agitated or distractible or immobilized or confused to think things through) and in those situations I intend to defer to your judgement about what treatment I should pursue, but at the same time I hope you will not take advantage of my impaired state to make me take medications you know I would not normally be willing to take. I do understand that if I am having a psychiatric emergency, I may need – for some weeks at a time – medications which cause bad side effects. In any case, I will do most anything to avoid further hospitalizations or suicide attempts.

In exchange for your allowing me to keep my freedom and make my own medical decisions after receiving your best advice, I can promise that I will be open with you. I will tell you if I take any additional medications (including OTC preparations) or omit the ones you are expecting me to take. I will also not do either in a casual way. I will tell you honestly what symptoms I am experiencing, so that your advice will be based on the best possible knowledge of my condition. If I do not agree with what you advise, I will let you know (not in a hostile way) rather than promise to do what you say when I have no intention of doing so.