How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?

This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care while the patient sought another provider.

While perhaps appropriate in situations where the patient is threatening or abusive (in a way not attributable to mania, psychosis, severe frontal lobe injury, and best addressed by hospitalization) toward the provider, staff, or other patients, I do not think that cessation of care is an appropriate (or, arguably, ethical) approach to non-adherence.

That said, continuing ineffective care in an unchanged ...

There are some patients whom I decide I can no longer help. Not sure if this is one or not? But I’m a bit of a stickler when it comes to compliance. I might suggest to a patient that we’re not working together well, and solicit some suggestions from him or her as to how best to improve the situation. There is, for me, also the idea of self-preservation, i.e., how much more can I do for a patient without becoming preoccupied so much it’s a distraction and creates cognitive dissonance. I’ve decided that I can’t help everyone, and I must avoid spending too much mental gymnastics on one or two patients while maintaining my usual jovial attitude for my other, let’s say 200 patients. I usually try and do everything I can to help folks, but I am a...

In the changing world of medicine, we are moving away from the "doctor knows best" model to a shared decision-making model. When we work under the model that our patients have autonomy over their bodies and have the right to make decisions regarding whether or not to take medication (in all but our most ill patients when safety takes precedence over autonomy), then noncompliance simply means that the patient is telling us no thank you.

If we can move away from the position that we know what's best for our patients and work towards understanding our patients' decisions about their bodies and treatment goals, we can achieve better compliance by being open to our patients' treatment decisions through a more direct means of communication.

What ...

I don’t believe a physician has to be “held hostage“ by a patient. There have to be rules and boundaries. It is not even a favor necessarily to the patient to continue along with the situation that is not productive. Termination of a relationship, so long as it is done compassionately and correctly, is not equivalent to abandonment.

There are parts of both of these approaches that are beneficial to the therapist and the patient. The contract approach brings the problems to the forefront and disrupts the heretofore unsuccessful behavioral pattern. However, limiting the patient to basically "sign or not sign" sidesteps the verbal resolution process which is probably more beneficial to the patient. I have found that patients in these positions have typically come from families in which authoritarian parents dominated decisions with the this-or-that choices (that really weren't choices at all). Thus, the process of compromising on the needs of both parties is a new and important skill for the patient to learn.

What an interesting topic and so relevant as well! I can share some of the points made about the psychiatrist's duty, ethical concerns, liability, abandonment concerns, etc., but we are not talking about the patient's autonomy and ability to make decisions which is manifested at many points in the treatment relationship. So as long as the provider has delineated a treatment plan that the patient agreed on but then becomes not compliant with the visits, the psychiatrist can make efforts to re-engage the patient but always be aware that patients are also accountable within the relationship and their choices and preferences can change and might not be relayed to the psychiatrist.

There are different reasons for this scenario. I think the psychodynamic approach can help understand:

Why does the patient want to stay attached to me if they don't think what I suggest is reasonable or doable for them? Is there friction or passivity?

Also, I have had a few cases over the years where I did medication management (plus some brief add-on therapy) and then slowly realized that the patient had no intention to change and was not attached to me.

It became clear that they thought they needed to keep seeing a Psychiatrist to justify continued disability status. If I figured that out sooner, then I might have explored things differently with the patient and found a way to do some motivational work.

I agree that treatment “contracts” can feel aggressive to the patient, but if done well and thoughtfully, it can presented as a way that the provider is making a commitment to the patient as well. A treatment contract provides a structure for the relationship to be more successful when a patient may be presenting barriers, especially if they are struggling with BPD.

I find this best dealt with via a goal-oriented treatment approach that is based on the patient's goals, not mine. Once they are clear about what improvements they hope for in their lives, we can discuss options about how to get there. They always have the choice about what options to pursue. If they do not follow through with a plan, we return to how things are progressing with their goals, I wait for their dissatisfaction with their progress to be the driving force behind future action. This in turn can lead to discovering impediments within them toward making progress, as mentioned in a previous answer.

If the patient is noncompliant, I pick a simple task that they are failing to do (e.g., clean up their room) if this is part of therapy. I suspend them (won't see them in therapy) until they can report that they have accomplished the task. I continue to prescribe medications for a few months.