From an email I got:

“I have told the following to patients who’ve tried to place the responsibility on whether they commit suicide or not on me, “If you really want to kill yourself, you CAN outsmart me. I cannot know what’s in your mind and your heart unless you choose to share that with me. I cannot know everything you do during the week, unless you tell me. I’m here to help you and I can better help you the more we’re able to work together. But I cannot fix these problems for you.”

Here’s another example. I had a 22 year male patient with really severe OCD. He responded very well to high dose fluoxetine. The problem was he would skipped 2/3 of his doses and with (what sounded like pride) tell me about this during our med admin sessions. I did not get anywhere with him by encouraging and cajoling him to be more compliant or by giving him a pill box or by involving his mother. Then I noticed how angry I was getting at him for being so stubborn, for defying me! How dare he!

That’s when I started to understand the dynamic and changed my approach. In subsequent visits, I’d ask him how things were going. After some brief generalities, he would tell me how bad his OCD was and how he was skipping doses. Then he’d show me his hands, red and raw from washing with harsh chemicals – he had germ obsessions and washing compulsions. I’d say, “Boy they look bad… That must hurt… You’ve been on 80mg of fluoxetine. Let me write you a prescription unless you would like to take a different approach.” I stopped identifying with whatever his daddy projection was. I made it clear – not explicitly – that he wasn’t hurting me by hurting himself. After all, my life was good. I was here to help but I wasn’t going to shove fluoxetine down his throat or get angry at him if he chose not to take a medication we both knew helped him a lot. Guess what – after I released myself for the responsibility of his outcome, he started to take his med and his OCD improved. He even enrolled in school. So this story had a happy ending. Not all of them do, of course. Let me know what you think. Consider what – if anything – I wrote about my attitude would work for you. If you read what I wrote, you will notice that there are limits to this approach. Please consider what they are.”