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Join Holly MacKenna, an integrative psychiatrist, as we explore the challenges and nuances of acknowledging goodbyes in the world of mental health treatment and professional relationships. Discover why patients often “ghost” their providers, the impact of business dynamics, and how to foster open conversations about therapy termination.

Holly MacKenna is an integrative psychiatrist.

She discusses the KevinMD article, “Ghosting in mental health.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Holly MacKenna. She’s an integrated psychiatrist. Today’s KevinMD article is titled “Ghosting in mental health.” Holly, welcome back to the show.

Holly MacKenna: Thanks so much for having me.

Kevin Pho: So go to KevinMD.com/podcast to hear Holly’s first episode, to hear her story. But today let’s jump right into your most recent article, and it’s about ghosting in mental health. So tell us what it’s about.

Holly MacKenna: So mental health as a whole, our exchanges with our patients, whether it be in therapy or even medical management, is really a microcosm of what’s going on outside of that therapeutic space. And so there’s a lot of repetitive patterns, and that’s part of the process, that’s really why people seek us out. They may not realize that’s why, but it’s to help them break those patterns.

And something that is a part of human behavior that we try to manage and kind of be ready for is the goodbye, and the human tendency to avoid the goodbye. I had a friend who, after reading my article, laughed, because I’m of Irish descent, my parents are both from Ireland, and she was laughing because people talk about the Irish goodbye, where Irish people kind of tend to just leave and not really make a big fuss. Although if you listen to my mother on the phone, they say bye, bye, bye, bye for like 20 minutes before they actually leave the conversation. That might be why people tend to leave parties without doing all that.

But anyway, in the mental health space we try to anticipate that by talking about it from the start, and talking about preparing for when the person is going to no longer need us, and that being the goal. I mean, that’s really, we want them to get to that better space. But in the business world it doesn’t always translate, and I’ve kind of learned that as someone who’s now a small business owner firsthand. And so that’s part of the article as well.

Kevin Pho: So what would that conversation look like when you’re talking to a client or a patient in your office, and you’re, I wouldn’t say preparing them for a goodbye, but what would that conversation about what the end point would be, what’s that like?

Holly MacKenna: Well, as people are getting better, I mean, I’m in an integrative medicine psychiatry practice, so a lot of folks come to see me to lessen traditional medications, or oftentimes because they want to avoid them. So there is more of an end point when they see me than maybe if they were seeing someone traditionally, although I do have folks who see me long term for things like bipolar or what have you.

But as people are starting to get better and we’re starting to wean that medication that they’ve been on for 20 years, we do talk about what will things look like after this. Well, they are allowed to come back, if they feel like what we’ve been doing with the combination of diet, exercise, supplements isn’t quite hitting the mark, if it’s six months from now because something unfolds, that it’s OK to take steps, and it’s not steps backwards, it’s just part of the journey, to go in and out of relationships.

I really love having those final sessions, and I get kind of bummed out when people ghost out on those, because those are the times when you can really take a pause and look back at the relationship, the therapeutic relationship, but also their journey. Where they were when they first came to me, oftentimes in crisis, how much they’ve grown, how much strength they’ve taken on, all the skills they’ve gained, all the changes they’ve made outside of that little area of space that we share together. And I really feel like it’s a disservice to both of us to not take that pause and be able to acknowledge the growth that they’ve gone through, and the relationship, how it’s evolved.

Kevin Pho: How often does that happen, where a patient would ghost you and just simply not show up in the middle of therapy?

Holly MacKenna: When I was in traditional, more organizational medicine, I was at the VA for over a decade. It would be maybe not VA world, because they have a lot more support there, but when I worked more in the state and more in that kind of space, it wouldn’t be uncommon for folks to just stop coming.

I made a practice that’s not only membership based but primarily membership based, like people can kind of come and go as they want to, but most of my folks do engage in a membership, which is a monthly fee that kind of reminds them, like, hey, I’m supposed to be engaging with this person, and they have a lot of support that’s part of that. So that usually, and part of the reason I have that in place, that usually allows for them to have that conversation with me of, hey Doc, I think I’m doing a lot better, either stepping down from membership, stepping out of it and just seeing me as needed, or ending the relationship and moving on to just seeing primary care.

But still people find ways out of it. They still find ways to just kind of let their credit card expire and not respond when I let them know that happened, or cancel it in the middle of the night and not reply to emails. It’s a lot less, probably more in like the single percentage range now, versus when I was more in that traditional space of only having like 20 minutes with them.

Kevin Pho: And when people just stop showing up, what would be some of the reasons that you could speculate why that happens?

Holly MacKenna: Well, I mean, it ranges from, they’re just doing better. I am more of a consultant in a lot of ways, so when they do see me to maybe do an overall wellness check and see what they can do to kind of make things a little better for them, when that helps a great deal, and if I’m lucky they’ll kind of let me know. Yeah, that’s one reason.

But then very recently I had someone who I was seeing weekly almost for a year ghost, but he actually passed away. Part of that loss was that families go through grieving in different kinds of ways, but I had to find that out through Google, which was really unfortunate. I was spoiled when I was with the VA, in that we tended to find out when our veterans died. So it can range from each extreme.

Kevin Pho: Yeah. And if someone stops showing up, are you curious why? Do you take steps to find out what happened?

Holly MacKenna: I do, yeah. I’m human. And part of why I like doing the integrative medicine model is that it is a relationship, it is a partnership. It’s not that paternalistic, like, I’m telling you what to do and you do it or else you can move on. I really like to try to meet people where they’re at, and if I’m not doing that in a way that’s effective, I appreciate that feedback so I can try to do better. I’m by no means perfect, I would have nothing to write about if I was. But that’s always the goal, is to try to be a better human, right?

So to have those conversations is helpful. And that also translates to the business side. If a contract is ending, to know that it’s just due to a budget, or is it because the services I was providing weren’t a good fit, or whatever that may be. I’m sure folks listening can relate to that on all different types of levels, whether it be physicians or people in business, that sometimes relationships end, and that’s OK. But it is helpful to have that pause, that recognition of the relationship, and acknowledgement of maybe what you could do better or what you did well.

Kevin Pho: Now, are there any warning signs that you can discern, any patterns that you can see from people who do suddenly stop treatment and ghost their clinician?

Holly MacKenna: I mean, suddenly not making follow-ups. Like there’s the, oh I forgot, or, oh I’ll schedule. A lot of my folks like to schedule appointments at the end of their session, and, oh I’ll get to it, and then not getting to it. Then not replying to emails when you send reminders.

Not refilling medication, if you’re able to have a look at that. I have a way of seeing if supplements are ordered, if they use the site that I order it through. Not necessarily traditional medicines, unless they happen to be on a stimulant or something of that nature, where you can kind of do that and we have to, for the DEA. But sometimes I can see in that space if they order that from a different provider, and I’m like, OK, well, I guess they’ve made a choice to move in a different direction, which is OK.

But again, the conversation is one that I think would benefit both of us, to kind of know why that is, if there was something different I could do, and again just to kind of acknowledge the period of time that we spent together.

Kevin Pho: Now you mentioned that you’re in an integrative psychiatry practice, I believe you said it’s a membership based model, is that correct? So would you say that your relationships with clients or patients in this model is a deeper one in contrast to the traditional model that you left?

Holly MacKenna: Yes. I mean, this is a big reason why I do what I do. I definitely make a lot less money than I did when I was in a salaried position, but I’m also a lot happier. I spend 90 minutes to two hours with each evaluation I have.

As part of the membership, I’m available. I do keep boundaries because I have children, I have a life, so I don’t answer 2 a.m. phone calls, but I let them know, like, hey, if you email me at 2 a.m. I’m not going to judge you, I just won’t reply till business hours. So I am more available.

I’m Reiki certified, so I’m able to offer that as a benefit. I have relationships with other integrative providers, so we’re able to share patients, like they see an integrative nutritionist or integrative physical therapist or what have you, we’re able to kind of share that model together, which is super fun. And I find resources from one patient to share with another, because folks that are kind of in this space, a space of wellness, are excited about it and they want to share and grow the community.

So it is kind of more of a conversation and more of a back and forth and a partnership, than maybe when I was behind a desk with a computer that I had to look at more than my patient because there were so many boxes to check. Which unfortunately is kind of where traditional medicine has gone in a lot of ways.

Kevin Pho: Now, when patients suddenly stop treatment in the middle unexpectedly, that’s obviously not the ideal outcome, and even for me in primary care, if patients just suddenly stop coming, that’s not ideal as well. What are some things that you do to prevent that outcome and really foster and build that relationship?

Holly MacKenna: As part of my membership, I try to survey them every so often and see what’s beneficial, what’s not beneficial, what are you using, what are you not using. I try to send out weekly skills, meditations. I send out a regular email to my folks in my practice just to keep that connection. And also I’ve learned to have, like I have a scheduling area of my website, to have that button everywhere.

I work with folks with traumatic brain injuries, and with chronic pain and chronic fatigue, chronic inflammation, and so the brain fog is real. And they’ve given me the feedback that, hey, when you don’t hear from me it’s not necessarily that I don’t want to hear from you, it’s just that I need that reminder.

So I’ve tried to find ways to kind of be more present as much as I can, whether it be through social media. I’m a teacher on Insight Timer, I make sure they know that I’m doing lives on there, and just for that connection. And then again, just being able to have those conversations in real time if they need it.

I trained in dialectical behavior therapy, and so part of that training is, you learn when people trust that you’re available, they actually use you less, because it’s like you’re the safety blanket there. It’s like, I have a seven-year-old, as he gets more independent, knowing mom is still in the other room is still a thing for him.

And in a lot of ways in this relationship, when I’m seeing someone as a patient, it’s the same. Like as they get more independent and able to advocate for themselves within the medical system, just kind of knowing I have their back, and I’m willing to give them ideas, help them rehearse if they’re talking to a specialist about something they’re nervous about or what have you, is oftentimes all they need. They just like having and need that relationship of a healer to help them kind of move forward as human beings outside of the space that we’re in together.

Kevin Pho: We’re talking to Holly MacKenna. She’s an integrated psychiatrist, and today’s KevinMD article is titled “Ghosting in mental health.” Holly, let’s end with some of your take-home messages that you would like to leave with the KevinMD audience.

Holly MacKenna: I think acknowledging relationships, whether it be as a physician or healer, or a business person, or just a human being, is super important. A part of my integrative medicine training is acknowledging the importance of ritual and of ceremony.

Anytime I meet with my integrative colleagues, or in that kind of space that we’re sharing a designated period of time, we do have some type of ceremony to end that together. And that doesn’t have to be the, like, woo woo, which I love, of lighting candles and sharing a meditation, what have you. It can be that final session of acknowledging your time together, talking about what you’ve learned from each other, thanking each other for sharing that period of time, that journey, and then moving on.

And that again is translatable to all areas of life, whether it be ending a contract in business, or ending a relationship, knowing that someone is dying, knowing that you are at the end of your journey in some type of way. Just giving some ceremony to that, I think, serves everyone that’s involved, in ways that we’re still figuring out.

Kevin Pho: Holly, thanks again for coming back on the show and sharing your time and perspective.

Holly MacKenna: Thank you so much for having me.