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Prescribing at visit one has become an unspoken expectation, but is not always a clinical necessity.

First visits ask mental health providers to do too much in too little time, increasing burnout.

A two-step model (rapport first, data-informed planning second) can improve precision.

Immediate prescribing should be the exception, not the default.

Somewhere along the way, behavioral health adopted an unspoken rule: the first visit ends with a prescription. Not because it is always clinically appropriate. Often, simply because it is expected.

Understandably, patients want immediate relief. Systems expect productivity. Employers may expect “decisive action.” And clinicians, caught in the middle, are left trying to meet a stranger, understand a lifetime of context, assign diagnoses, and initiate treatment, all within a single appointment.

It is time to challenge this norm.

The Ethical Tension We Don’t Talk About Enough

Even in systems that encourage or require prescribing at visit one, liability is not transferred upward. Organizations share responsibility, but the prescription still bears the prescriber’s name, license, and ethical obligation. Yet we continue to hear from clinicians who feel pressured, directly or indirectly, to prescribe the first time they meet a patient. This should give our field pause. Prescribing is not a productivity metric. It is a clinical judgment that must belong to the provider, full stop.

The reality is that many clinicians feel they must choose between doing what feels thorough and doing what feels expected. That tension erodes autonomy and, over time, contributes to burnout.

The First Visit Has Become an Impossible Task

Think about what we ask providers to do in a standard intake:

Establish rapport with someone they have never met

Gather psychiatric, medical, developmental, and social history

Synthesize symptoms across multiple potential diagnoses

Often, prescribe a medication

All within 30 to 60 minutes.

We would never expect a cardiologist to diagnose and treat complex cardiovascular disease after a single conversation without testing. Yet in psychiatry, this compressed decision-making has quietly become normalized.

What if the problem is not clinician hesitation, but the structure of the visit itself?

A Different Model, One That Removes the Pressure

Imagine a workflow where the first appointment is not a race to prescribe, but an opportunity to listen.

The clinician’s role is to understand context, hear the patient’s story, and build trust. Then, instead of rushing toward a treatment decision, the process pauses long enough to gather a comprehensive, structured picture of mood, anxiety, ADHD, trauma, sleep, substance use, and overlapping symptom patterns, which come into focus through data, not guesswork.

The follow-up visit becomes something different, a collaborative conversation grounded in insight rather than assumption. Treatment planning shifts from reactive to intentional.

This is not about delaying care. It is about making the care more precise from the beginning.

“Isn’t That a Wasted Visit?”

Some critics argue that patients want medication quickly, and that slowing down risks losing momentum.

But consider the alternative reality many clinicians see every day: medications started quickly, adjusted repeatedly, and sometimes abandoned because the original formulation of the problem was incomplete.

Speed can create the illusion of progress. Precision creates actual progress. The implication is not that assessment replaces clinical judgment, but that it strengthens it.

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Of Course, There Are Exceptions

There are moments when immediate prescribing is the right decision. Acute psychosis. Severe insomnia. Unrelenting panic. Situations where stabilization cannot wait.

But what if those moments were treated as true exceptions, rather than the default expectation?

When every intake carries the assumption of prescribing, clinicians lose the space to practice thoughtfully.

Reclaiming the First Visit

The first appointment does not have to be a transactional exchange where the patient leaves with a prescription and the clinician leaves with lingering uncertainty.

It can be something more deliberate:

A conversation that prioritizes understanding over immediacy.

A process that values data alongside clinical intuition.

A treatment plan that emerges collaboratively, rather than under pressure.

Behavioral health is at an inflection point. Burnout is high, diagnostic complexity is increasing, and patients deserve care that reflects the full picture of who they are.

Maybe the boldest thing we can do is stop asking clinicians to solve everything in 40 minutes.

Maybe the most responsible first step is not prescribing faster, but understanding deeper.

© Psychology Today