Clients asking for letters to get out of restrictions

[Sanman]

So, I just had a request from a veteran for a letter stating that he be allowed to take leisurely drives to reduce his PTSD symptoms. Anyone else getting requests for letters to get around shutdown requirements? How are you handling it?

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[PsyDr]

Same as any other request for accommodations that are not based on science.

"No"

"My malpractice insurance does not cover non-science based recommendations. I am not willing to risk my license on this.".

 

[WisNeuro]

Same as @PsyDr , I refuse to write notes for junk requests (ESA's and the like).

 

[Fan_of_Meehl]

So, I just had a request from a veteran for a letter stating that he be allowed to take leisurely drives to reduce his PTSD symptoms. Anyone else getting requests for letters to get around shutdown requirements? How are you handling it?

I don't write letters.

 

[AcronymAllergy]

Same as above. I'll write appointment attendance letters (e.g., "XX attended an appointment at YY clinic today at ZZ time"), if asked. I would not write a letter as described here RE: lifting restrictions. In part in this situation because it's not as though there aren't alternatives to leisurely driving around.

 

[Mama Bear]

Letter aside, I was not aware leisurely driving was banned in places, provided you don’t try to congregate anywhere. Just stay in your car and don’t get out until you’re back home?

 

[erg923]

So, I just had a request from a veteran for a letter stating that he be allowed to take leisurely drives to reduce his PTSD symptoms. Anyone else getting requests for letters to get around shutdown requirements? How are you handling it?

Where is this "banned?" And how are you endangering anyone by doing it?

 

[Sanman]

Where is this "banned?" And how are you endangering anyone by doing it?

It is not technically an "essential activity", so it may fall under a state ban. I have personally been on drives without an issue. The person in question wants to use their motorcycle. While I personally have no issue with the behavior and think they should be fine riding around, I don't feel the need to write letters for b.s. purposes as a general practice.

 

[student til 30]

In addition, a lot of these letters speak to an assessment resulting in a recommendation having to do with administrative law (can I bring a dog to work under ADA?). This changes the relationship from provider-patient, and can work against treatment or affect the therapeutic relationship if there is a recommendation that is different from the desired outcome. As a provider I recommend against stuff that might hold treatment back and cover lack of effectiveness, and I also highlight the difference between the treatment relationship and what they're asking for.

 

[Sanman]

Anyway, I am curious if this is a one off or if others are experiencing this more often as well recently?

 

[WisNeuro]

Anyway, I am curious if this is a one off or if others are experiencing this more often as well recently?

I haven't seen a patient in over a month, so I can't really comment.

 

[Fan_of_Meehl]

Anyway, I am curious if this is a one off or if others are experiencing this more often as well recently?

Not necessarily recently but, over the past several years, I've been a bit surprised at the frequency of requests from patients for me saying that my opinion is X to get them benefit Y. When I worked inpatient, one particularly sociopathic veteran pressured me to write a letter to his landlord saying that because of his PTSD diagnosis (and need to be treated, say, in another town), he needed to be released from his recently signed lease agreement. When I politely/firmly held my boundary, he fumed but, fortunately, didn't assault me.

What I find troubling about these requests is:

(1) 100% of the time, the patient opens the request by telling me what my opinion is that they want me to put on paper (rather than asking me what my opinion ACTUALLY IS or requesting that I do an assessment to determine what my opinion actually is).
(2) I really chafe at the role that this puts me in (as some sort of special aribiter of exceptions to law specific to the circumstances of the patient)
(3) Nearly always, these are requests that have very little to no merit on their face (even in terms of 'common sense' or a lay perspective) and, frequently, would have me opining the exact OPPOSITE of what the decent professionial literature would say is the case

I don't write letters. I don't write letters to your landlord, your parole officer, your girlfriend, your wife, your mistress, your son, your daughter, your boss, the county dogcatcher...I don't write letters.

And, finally, the task of psychotherapy is to help you get better at solving your own problems (and learning from your mistakes). Me writing 'magic letters' to get you out of your poor decisionmaking would be countertherapeutic.

 

[WisNeuro]

I had a physician refer to me to do an evaluation for a patient who wanted an extension on a leave from work for anxiety, after exhausting a 2 month letter from her PCP already. I canceled the referral, of course. PCP asked me what they should do, refuse to write the letter, refer out for treatment, as the patient had thus far refused treatment recs. Additionally, from chart review, it looked pretty clear from other notes that the pt had been planning to file for disability so she could file early for retirement benefits through her job for some time.

 

[cara susanna]

I actually did get a request similar to this (not comfortable giving specifics in this setting but can elaborate via PM if you like). I told the patient that it likely was not necessary as the activity likely fell under essential activity. Plus our state isn't really pulling over individuals and asking.

 

[WisNeuro]

I actually did get a request similar to this (not comfortable giving specifics in this setting but can elaborate via PM if you like). I told the patient that it likely was not necessary as the activity likely fell under essential activity. Plus our state isn't really pulling over individuals and asking.

Yeah, our state here is supposedly one of the more "restrictive" states, and they are only issuing citations for people gathering in large-ish groups.

 

[AcronymAllergy]

I've not had any uptick in letter requests, but like some folks above, I've also not been seeing anyone in-person for a few weeks (and those I do "see" via telehealth are for eval rather than treatment).

The only uptick I'm worried about right now is wait times. Ohhhh my, the wait times (for in-person testing).

 

[Sanman]

Not necessarily recently but, over the past several years, I've been a bit surprised at the frequency of requests from patients for me saying that my opinion is X to get them benefit Y. When I worked inpatient, one particularly sociopathic veteran pressured me to write a letter to his landlord saying that because of his PTSD diagnosis (and need to be treated, say, in another town), he needed to be released from his recently signed lease agreement. When I politely/firmly held my boundary, he fumed but, fortunately, didn't assault me.

What I find troubling about these requests is:

(1) 100% of the time, the patient opens the request by telling me what my opinion is that they want me to put on paper (rather than asking me what my opinion ACTUALLY IS or requesting that I do an assessment to determine what my opinion actually is).
(2) I really chafe at the role that this puts me in (as some sort of special aribiter of exceptions to law specific to the circumstances of the patient)
(3) Nearly always, these are requests that have very little to no merit on their face (even in terms of 'common sense' or a lay perspective) and, frequently, would have me opining the exact OPPOSITE of what the decent professionial literature would say is the case

I don't write letters. I don't write letters to your landlord, your parole officer, your girlfriend, your wife, your mistress, your son, your daughter, your boss, the county dogcatcher...I don't write letters.

And, finally, the task of psychotherapy is to help you get better at solving your own problems (and learning from your mistakes). Me writing 'magic letters' to get you out of your poor decisionmaking would be countertherapeutic.

I agree with this. My other big issue is that I have no standing even if I were to write the letter. Is random cop going to care what some letter says would help with anxiety when the governor says not to do so? Would a cop accept a letter saying that this person needs social interaction with more than 10 people at a time?

 

[WisNeuro]

I agree with this. My other big issue is that I have no standing even if I were to write the letter. Is random cop going to care what some random letter says would help with anxiety when the governor says not to do so? Would a cop accept a letter saying that this person needs social interaction with more than 10 people at a time?

"Can you write me a letter that says I need to be able to carry my AR-15 and congregate with 200 *****s down at the Capitol for my mental health?"

 

[Sanman]

"Can you write me a letter that says I need to be able to carry my AR-15 and congregate with 200 *****s down at the Capitol for my mental health?"

Oh, those I do write. I just sign them Dr. S. Darwin.

 

[Fan_of_Meehl]

I agree with this. My other big issue is that I have no standing even if I were to write the letter. Is random cop going to care what some letter says would help with anxiety when the governor says not to do so? Would a cop accept a letter saying that this person needs social interaction with more than 10 people at a time?

I attribute this to the Oprahfication of the lay perspective on psychology or the Dr. Phil effect. The talking box and popular magazines say that therapists are the new priest class in our society and will be the 'deciders' on what is 'right' vs. 'wrong.' Like ancient Roman arbiters/judges resolving petty disputes among the plebs in the streets. No thanks.

 

[PsyDr]

I have a hard time understanding how any psychologist would recommend avoidance as a treatment modality. Financial matters seem to be some weird case for psychologists..... They'd never recommend avoiding a phobic stimuli, but work is hard for you? Better take a break! Leased a place where you can't afford the pet deposit? Better get an ESA letter! The Trust literally says such letters are de facto evidence that your treatment is not producing effect/are incompetent.


Typically these requests are evidence of certain personality configurations that enjoy having special standing when confronted with rules. Tends to explain the symptoms more than any axis I stuff.

 

[Fan_of_Meehl]

I have a hard time understanding how any psychologist would recommend avoidance as a treatment modality.


Typically these requests are evidence of certain personality configurations that enjoy having special standing when confronted with rules. Tends to explain the symptoms more than any axis I stuff.

Which direction a practitioner's general advice goes regarding how to address anxiety (avoidance vs. exposure) is probably the best single point predictor of the quality of their professional training and practice.

My favorite days are those when non-clinical staff (including those who administrate over MH departments) consider 'anxiety' to be a medical/psychosocial emergency.

 

[BuckeyeLove]

just as with ESA, this (IMO) represents a psycho-legal issue

 

[Fan_of_Meehl]

just as with ESA, this (IMO) represents a psycho-legal issue

And yet another clinical practice scenario in which the irresistible force of "I'm your patient and your role is to give me what I want" meets the immovable object of "No. I am your treating clinician and my role is to support you in building skills that will help you manage the reality that your prior maladaptive coping patterns (including asking your therapist for 'magic letters') have allowed you the opportunity to avoid (at the expense of your well-being).

 

[Sanman]

just as with ESA, this (IMO) represents a psycho-legal issue

The difference with ESAs is that we somehow got stuck with dealing with that as a legal requirement. Not sure who had that bright idea. Granted, after I hit age 60 or 65, I might start a practice solely on focusing on writing ESA letters. Seems like a nice cash grab.

 

[deleted480308]

"Can you write me a letter that says I need to be able to carry my AR-15 and congregate with 200 *****s down at the Capitol for my mental health?"

Tell them to print the constitution.

(couldn’t resist)

 

[Fan_of_Meehl]

The difference with ESAs is that we somehow got stuck with dealing with that as a legal requirement. Not sure who had that bright idea. Granted, after I hit age 60 or 65, I might start a practice solely on focusing on writing ESA letters. Seems like a nice cash grab.

There are so many problems with the ESA/service animal request. My favorite is the fact that--in the history of therapists making such (pseudo)determinations--the percentage of 'no' determinations is so small or nonexistent that it would probably have to be printed using scientific notation--that is, if it isn't actually zero. Of what use is a 'determination' that aleays only goes one way?

The only 'determination' that is being made is, "Yes, Mr. X (who has PTSD) thinks he needs an animal to manage his anxiety and it is medically necessary and he is paying me to say so."

Is anyone aware of anyone doing these 'determinations' who has actually said 'no?'

It doesn't help that the field has shied away from even properly delineating/ formulating the relevant questions at issue, let alone a valid/ reliable methodology for addressing the question(s).

 

[WisNeuro]

Tell them to print the constitution.

(couldn’t resist)

Meh, I a big fan of personal freedoms, but they end when they put others' lives at risk. Constitutional arguments can be made for that side of things fairly easily as well.

 

[erg923]

Tell them to print the constitution.

(couldn’t resist)

There always seems to be a segment of the population that, when they get upset at the da gubment about this or that, cant wait to show their guns in public, talk about guns, shoot their guns, talk about shooting their guns, fantasize about shooting their fellow citizens, etc.. As if COVID has anything to do with your AR-15. It's bizarre.

 

[WisNeuro]

There always seems to be a segment of the population that, when they get upset at the da gubment about this or that, cant wait to show their guns in public, talk about guns, shoot their guns, talk about shooting their guns, fantasize about shooting their fellow citizens, etc.. As if COVID has anything to do with your AR-15. It's bizarre.

To the MAGA crowd, everything has to do with their misinterpreted 2nd amendment rights.

 

[erg923]

To the MAGA crowd, everything has to do with their misinterpreted 2nd amendment rights.

Off topic, but:

There is a guy down our street who, when their is something in the news cycle about guns or anything remotely related to the constitution (which I guess is alot of the time actually) is fairly open with comments about shooting people. Not like going on a random shooting spree, but like fantasizing about shooting people or representatives of the government on his property and having it be ok/legally justified. His trigger happiness is bizarre and quite scary for most us normal suburbanites. We know longer let our children hang out with his in the neighborhood and many other people have followed.

 

[Sanman]

There are so many problems with the ESA/service animal request. My favorite is the fact that--in the history of therapists making such (pseudo)determinations--the percentage of 'no' determinations is so small or nonexistent that it would probably have to be printed using scientific notation--that is, if it isn't actually zero. Of what use is a 'determination' that aleays only goes one way?

The only 'determination' that is being made is, "Yes, Mr. X (who has PTSD) thinks he needs an animal to manage his anxiety and it is medically necessary and he is paying me to say so."

Is anyone aware of anyone doing these 'determinations' who has actually said 'no?'

It doesn't help that the field has shied away from even properly delineating/ formulating the relevant questions at issue, let alone a valid/ reliable methodology for addressing the question(s).

I am curious if ESA or medicinal marijuana has fewer denial overall.

 

[cara susanna]

Well, that's the thing. Yes, everyone's mental health would probably be improved if they could get out and do things right now. But we're in extenuating circumstances and right now public and physical health are being prioritized.

 

[thebalmofhurtminds]

My mental health would be better if someone gave me a million dollars and some ice cream.

 

[Sanman]

Well, that's the thing. Yes, everyone's mental health would probably be improved if they could get out and do things right now. But we're in extenuating circumstances and right now public and physical health are being prioritized.

In normal times absolutely. In COVID times, I would say it is 50/50. I am providing support for staff members being asked to come into work and people that are scared to leave home for even essential activities. Then you have the other side being upset that normal activities are interrupted. I feel bad for those that do hold the line on these decisions as no one will ever be happy with you.

 

[BuckeyeLove]

There is a guy down our street who, when their is something in the news cycle about guns or anything remotely related to the constitution (which I guess is alot of the time actually) is fairly open with comments about shooting people. Not like going on a random shooting spree, but like fantasizing about shooting people or representatives of the government on his property and having it be ok/legally justified. His trigger happiness is bizarre and quite scary for most us normal suburbanites. We know longer let our children hang out with his in the neighborhood and many other people have followed.

I've met a few of these, that when you throw booze into the picture all of a sudden they're calling up state senators and talking about how "This is the kind of stuff that leads to people coming into courthouses with guns!" ...then they pick up a terroristic threatening charge.

 

[deleted480308]

There always seems to be a segment of the population that, when they get upset at the da gubment about this or that, cant wait to show their guns in public, talk about guns, shoot their guns, talk about shooting their guns, fantasize about shooting their fellow citizens, etc.. As if COVID has anything to do with your AR-15. It's bizarre.

To them, the gun is just the backbone that let’s them tell the govt they won’t be forced to put up with “x”. In this case, enforce quarantine would likely be “x”

Meh, I a big fan of personal freedoms, but they end when they put others' lives at risk. Constitutional arguments can be made for that side of things fairly easily as well.

if we’re both voluntarily going to a park we’re both responsible for our own actions and accept the risks. I would disagree that anyone owes anyone else self-quarantine if they aren’t sick. I’m not arming myself against the govt over it but I don’t think bans are constitutional even if they are medically advisable

 

[futureapppsy2]

To push back a bit, accommodations are legitimate things. Of course, not every request for accommodations is reasonable, but provider letters for accommodation purposes are a legitimate thing (e.g., for academic accommodations, standardized test accommodations. etc).

 

[PsyDr]

Show a narcissist that he/she is powerless. Watch the the narcissistic rage. Usually by trying to exert the only currency in power they have.

If you like Kohut, the only thing to do is to be empathic. If you like daytime television, the only thing to do is to rile them up further and laugh.


@futureapppsy2 Accommodations are for impairments, not symptoms. There is a key difference.

@sb247 You only have it partially right. The gun is symbolic. But these individuals are not acting on those convictions. Because they enjoy the safe holding of the structure of the government. It's like watching what happens when a parent walks out of the room after a child starts throwing a fit. The kid follows, because it's an act. An act designed to show, "I don't like that". Everyone knows that the chances of the toddler deciding to walk out of the house and ride the rails are about nill. They can't get by without the parent . So they need it. But they need to show they are unhappy with not getting ice cream.

 

[erg923]

To them, the gun is just the backbone that let’s them tell the govt they won’t be forced to put up with “x”. In this case, enforce quarantine would likely be “x”

if we’re both voluntarily going to a park we’re both responsible for our own actions and accept the risks. I would disagree that anyone owes anyone else self-quarantine if they aren’t sick. I’m not arming myself against the govt over it but I don’t think bans are constitutional even if they are medically advisable

So, the message being "I want to remind that I am able to shoot you (people)?" LOL. Thats not how I would teach my child (or student, intern, fellow, friend) to confront a conflict in their beliefs.

I think the only thing that does it push mainstream individuals to view them as paranoid, potentially violent, and/or mental abberrants. And thats indeed what happens. These people don't seem to realize that their presentation overshadows and then ruins their overall message. And I am actually sympathetic to some of their concerns. I am actually positive more people would attend these protests if you didn't have all these nutcases carrying automatic weapons around hundreds of people in small, densley compacted areas.

 

[PsychPhDone]

I don't have any strong political or philosophical commentary to add but just wanted to add an additional data point: I don't write letters except to confirm appointment attendance.

It's not hard to find another provider that will though.

I agree, my job is to help patients develop coping skills that don't require breaking laws. Here, people are reporting getting pulled over but not an issue if you're within a certain radius of home.

 

[deleted480308]

So, the message being "I want to remind that I am able to shoot you (people)?" LOL. Thats not how I would teach my child (or student, intern, fellow, friend) to confront a conflict in their beliefs.

I think the only thing that does it push mainstream individuals to view them as paranoid, potentially violent, and/or mental abberrants. And thats indeed what happens. These people don't seem to realize that their presentation overshadows and then ruins their overall message. And I am actually sympathetic to some of their concerns. I am actually positive more people would attend these protests if you didn't have all these nutcases carrying automatic weapons around hundreds of people in small, densley compacted areas.

I'm totally with you on the public relations tactics

But yeah, the whole point of the 2nd amendment is so govt keeps in the back of their mind that the populace can shoot tyrants. It's how we lost britain. As a matter of semantics, those were likely not automatic (probably semi-automatic) and being around a bunch of people with guns isn't dangerous unless one of them wants to shoot people. I've been to a lot of gun shows and ranges, generally felt just fine.

 

[futureapppsy2]

@futureapppsy2 Accommodations are for impairments, not symptoms. There is a key difference.

I fail to see your point, here? Symptoms can cause impairments that rise to the level of disability. Not all symptoms can be treated to the point where disability is not present, and accommodations may be helpful while treatment is ongoing. The ADA/504 are civil rights laws, not philosophies you can choose to agree with or not. Certainly, many accommodations requests are unreasonable but not all are, and it seems really ableist to say that accommodations are always unreasonable or "cheating." Or should we not allow blind people to use screen readers or Deaf people to use sign language? There are reasonable accommodations for psychiatric disabilities (the ADA definition of which should not be confused with SSI/SSDI/VA disability definitions).

 

[Seven_Costanza]

I'm totally with you on the public relations tactics

But yeah, the whole point of the 2nd amendment is so govt keeps in the back of their mind that the populace can shoot tyrants. It's how we lost britain. As a matter of semantics, those were likely not automatic (probably semi-automatic) and being around a bunch of people with guns isn't dangerous unless one of them wants to shoot people. I've been to a lot of gun shows and ranges, generally felt just fine.

But people at gun shows and ranges aren’t actively in rage mode and feeling like they need to fight because they think their civil liberties are being taken away from them.

 

[PsyDr]

I fail to see your point, here? Symptoms can cause impairments that rise to the level of disability. Not all symptoms can be treated to the point where disability is not present, and accommodations may be helpful while treatment is ongoing. The ADA/504 are civil rights laws, not philosophies you can choose to agree with or not. Certainly, many accommodations requests are unreasonable but not all are, and it seems really ableist to say that accommodations are always unreasonable or "cheating." Or should we not allow blind people to use screen readers or Deaf people to use sign language? There are reasonable accommodations for psychiatric disabilities (the ADA definition of which should not be confused with SSI/SSDI/VA disability definitions).

Professional terms have definitions that you can't choose to agree with or not. Terms like "symptoms", "impairment", and "disability" have established definitions. Symptoms, by definition, are always subjective. If you understood those definitions, then you'd also know that the interaction between blindness and/or deafness in the specific occupational or educational environment can cause impairments. It is the impairments that require can require reasonable accommodations not the symptoms.

But thanks for calling me names and taking my point somewhere completely negative.

 

[deleted480308]

But people at gun shows and ranges aren’t actively in rage mode and feeling like they need to fight because they think their civil liberties are being taken away from them.

We have differing standards for “rage” apparently

 

[BuckeyeLove]

Symptoms can cause impairments that rise to the level of disability.

SSA would fail to agree (..I'm not being facetious, it just has been ingrained in me to the point of indoctrination)

 

[erg923]

Well, symptoms can certainly cause impairments, but that can't be assumed without some formal assessment of functional abilities and the ultimate conclusion that limitations/impairments of said abilities are judged to be caused by those symptoms. Some systems used the "at least as likely than not" criteria (e.g., VA) and others are much more strict. Many doing this will tend to ignore Hill's model of causation/causal relationship.

I used to do disability reviews for AETNA, Metlife, Lincoln Financial, etc, and they tend to folllow a pretty strict range/defintion here. When you are actually doing disability reviews or assessments/determinations for these for large companies that adhere to strict definitions, vague academic musings on the matter won't get you very far.

 

[futureapppsy2]

Professional terms have definitions that you can't choose to agree with or not. Terms like "symptoms", "impairment", and "disability" have established definitions. Symptoms, by definition, are always subjective. If you understood those definitions, then you'd also know that the interaction between blindness and/or deafness in the specific occupational or educational environment can cause impairments. It is the impairments that require can require reasonable accommodations not the symptoms.

But thanks for calling me names and taking my point somewhere completely negative.

Not sure where I called you names? I'm not really sure that anyone in this thread seems to understand disability law outside of SSI/SSDI/VA disability, which is a very different thing with its own definition of disability. Yes, functional impairment depends on the context for sure (legally and practically), but saying that you will never write accommodation letters for clients (which don't actually establish disability, but do establish impairment) because its a medicolegal thing is sketchy from a disability/civil rights point of view. Yes, treatment can work in a lot of cases--but it's not a cure-all, and if those clients want to access reasonable accommodations (which is a legal term and not up to the provider to determine), I don't think it's entirely ethical to not provide documentation, ever, on principal of "they should get better, so no accommodations."

Also, I' m baffled that people in this thread truly don't seem to realize that "disability" is a very different legal term outside of beneficiary laws and confers actual, federally protected, extensively legislated civil rights and protections. This is making me realize that we need some integrated rehab psych education somewhere in the APA-mandated curriculum, because I was honestly assuming that this was common knowledge.

 

[futureapppsy2]

Well, symptoms can certainly cause impairments, but that can't be assumed without some formal assessment of functional abilities and the ultimate conclusion that limitations/impairments of said abilities are judged to be caused by those symptoms. Some systems used the "at least as likely than not" criteria (e.g., VA) and others are much more strict.

I used to do disability reviews for AETNA, Metlife, Lincoln Financial, etc, and they tend to folllow a pretty strict range/defintion here. When you are actually doing disability reviews or assessments/determinations for these for large companies that adhere to strict definitions, vague academic musings on the matter won't get you very far.

Again, "disability" in a benefits context is NOT the same as "disability" in an accommodations context. The legal definition is literally not the same. Also, the ADA/504 are NOT "vague, academic musings"--they are federal civil rights laws with lots of expensive, detailed case law behind them.