Contract to do VA C/P exams

[smalltownpsych]

Look what I got in my linked-in account today. It is definitely not something I want to get involved in for a number of reasons. Just wondering what others think about this. We are having a meeting tomorrow in our department talking about various referrals for evals since I have been saying no to them and others in my department think I am being too rigid.

Good morning, I am Travis Turner with Veterans Evaluation Services and we are in need of help with local Military Veterans in your area. We need quality, licensed Psychologists to perform 1-time compensation and pension exams on these Veterans in which we pay for. Rates are $200-$240.

Thanks.

Travis Turner
Provider recruiter at Veterans Evaluation Services

Houston, Texas Area​

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[WisNeuro]

From what I've heard, pay is neither worth your time or hassle. I'd go be a bartender before I did this. If you're going to be doing forensic work, you should at least be getting paid like you're doing forensic work.

 

[Therapist4Chnge]

It's bad patient care and a bad deal for the psychologist. The amount of time you are given is next to nothing and you have to be super efficient w your summary. I won't call it a report bc it is severely lacking (at least the ones I've reviewed) and the contractors seem to hire anyone who is willing. I've gotten multiple emails/msgs for similar gigs.

These make the SSDI evals look like a payday. These contracts are bad for the field too. It's worse than a rubber stamp bc it dumbs down an evaluation that deserves more than a passing glance. Ethically it's very questionable...at least to me.

 

[Pragma]

Agree with Wis, I did a double-take when I saw the amount. Not worth it.

 

[smalltownpsych]

What about a referral for a psych eval from probation or from DFS? Those are forensic as well, as far as I see it. Those often get billed to medicaid by our department which I also think is a bit dicey.

 

[erg923]

Look what I got in my linked-in account today. It is definitely not something I want to get involved in for a number of reasons. Just wondering what others think about this. We are having a meeting tomorrow in our department talking about various referrals for evals since I have been saying no to them and others in my department think I am being too rigid.

Good morning, I am Travis Turner with Veterans Evaluation Services and we are in need of help with local Military Veterans in your area. We need quality, licensed Psychologists to perform 1-time compensation and pension exams on these Veterans in which we pay for. Rates are $200-$240.

Thanks.

Travis Turner
Provider recruiter at Veterans Evaluation Services

Houston, Texas Area​

"Case rate" payment structure for these types of exams is the dumbest thing ever, and if any of these companies considered basic principles of social psychology and performance psychology, they would realize this is receipe for poor quality and lack of thoroughness.

Our C&Ps here do such good exams because there is no incentive to be paid more for higher volume/productivity.

 

[erg923]

What about a referral for a psych eval from probation or from DFS? Those are forensic as well, as far as I see it. Those often get billed to medicaid by our department which I also think is a bit dicey.

Not "medically necessary." I'm sure these are getting rejected after you submit the bill.

 

[WisNeuro]

It's bad patient care and a bad deal for the psychologist. The amount of time you are given is next to nothing and you have to be super efficient w your summary. I won't call it a report bc it is severely lacking (at least the ones I've reviewed) and the contractors seem to hire anyone who is willing. I've gotten multiple emails/msgs for similar gigs.

These make the SSDI evals look like a payday. These contracts are bad for the field too. It's worse than a rubber stamp bc it dumbs down an evaluation that deserves more than a passing glance. Ethically it's very questionable...at least to me.

What? Are you saying you can't do an adequate full psychiatric differential with adequate psychosocial interview in under 30 minutes? With no opportunity to assess validity or do a thorough chart review? 😉 These evals are how Vets get "diagnosed" and connected with conditions they do not even remotely have.

 

[PsyDr]

Rates are $200-$240.

I doubt you could do one of these evals in a time frame to make this more profitable than a typical Medicare eval. A hour or two face to face and then whatever for writing and records review.

What about a referral for a psych eval from probation or from DFS? Those are forensic as well, as far as I see it. Those often get billed to medicaid by our department which I also think is a bit dicey.

Yeah, that's insurance fraud. Most people who do this say it's fine because the state is the one asking for the eval. IMO, there remains the potential for the state to later audit providers for the last 7 years. I don't know about your state, but I don't trust whoever is in charge of the budget in most states in which I have lived to avoid that type of potential revenue generation.

 

[smalltownpsych]

Not "medically necessary." I'm sure these are getting rejected after you submit the bill.

If so, then at least at that point, the person gets the bill. I think they are coding a psychiatric diagnostic evaluation by a psychologist code (90791.9) for it so then medicaid automatically pays it just like they would for all of my patients who are coming for a psychotherapy referral. I think that is the point that PSYDR is making.

Yeah, that's insurance fraud. Most people who do this say it's fine because the state is the one asking for the eval. IMO, there remains the potential for the state to later audit providers for the last 7 years. I don't know about your state, but I don't trust whoever is in charge of the budget in most states in which I have lived to avoid that type of potential revenue generation.

 

[Fan_of_Meehl]

Look what I got in my linked-in account today. It is definitely not something I want to get involved in for a number of reasons. Just wondering what others think about this. We are having a meeting tomorrow in our department talking about various referrals for evals since I have been saying no to them and others in my department think I am being too rigid.

Good morning, I am Travis Turner with Veterans Evaluation Services and we are in need of help with local Military Veterans in your area. We need quality, licensed Psychologists to perform 1-time compensation and pension exams on these Veterans in which we pay for. Rates are $200-$240.

Thanks.

Travis Turner
Provider recruiter at Veterans Evaluation Services

Houston, Texas Area​

Most of these contracted exams that I see are of pathetically low quality and are (along with 'drive-by' social security mental health disability diagnoses) creating a GINORMOUS problem for society in the decades to come via creation of a permanent underclass of people who will be dependent on a disability check for the rest of their lives and who may or may not actually have had the mental health condition they were diagnosed with in a 25 minute 'drive-by' evaluation consisting of, basically, a mental status exam and one-page self-report instrument (PCL or BDI). It also irks me that most of the pay structure of these schemes involve uneducated 'business' types with impaired ethics making a fortune (taking the bulk of the revenue) from a massive softcore fraud enterprise while breaking off a sliver of pay for a doctoral-level professional doing the demanding and sophisticated (if they care, and try) clinical work.

 

[Justanothergrad]

From what I've heard, pay is neither worth your time or hassle. I'd go be a bartender before I did this. If you're going to be doing forensic work, you should at least be getting paid like you're doing forensic work.

This is exactly what I was saying to others yesterday as we were talking about contract C&P work. Its hardly worth the liability/work for the low pay. Perhaps if its an area someone is competent in, it /might/ be worth a very brief run at it over a few months to build their case load when there are no other folks to see yet if they are trying to go PP without partnering with any sort of already existing practice. Maybe. And even then, seems like a better idea to just take a different business model.

 

[deleted343839]

I've seen similar solicitations for psychologists to do VA C&P and Medicare disability evals and every time I get a little angry, and a little sad.

 

[Sanman]

Have to agree with the others. I get a little worried anytime these contractor positions come up. However, they seem to be becoming ubiquitous.

What is your liability in these situations as a contractor anyway? Seems like you take the risk and the contracting company rakes in the money. Seems like the professional is on the wrong side of this equation.

 

[PsyDr]

If so, then at least at that point, the person gets the bill. I think they are coding a psychiatric diagnostic evaluation by a psychologist code (90791.9) for it so then medicaid automatically pays it just like they would for all of my patients who are coming for a psychotherapy referral. I think that is the point that PSYDR is making.

Not quite. What I meant was that the provider could get paid. Then, years later, the state has a budget problem. They are allowed by both contract and law to audit any Medicaid provider they want. If they find billing errors like "lack of medical necessity", they can take/sue whatever the amount they believe was paid incorrectly. There are contracted auditors called RAC teams which are paid via a percentage of whatever they discover in mispaid funds. The typical length that they can look back is 7 years.

IMO, idiots who bill cms for forensic stuff based upon a gentlemans agreement that they won't be screwed later on... well they are idiots.

Imagine if you did just $30k in these Evans over 7 years. Auditors look through your books and say that these exams were clearly forensic, and that they want the $30k back plus interest and fees. What are you gonna say? No they're medically necessary? No, there was an implied agreement that insurance fraud was okay? Or are you gonna write a check for the $90k they say is due? Because insurance fraud is a one way ticket to lost license town. And defrauding cms is a ticket to federal prison, where parole isn't a possibiiity.

 

[PSYCHEVAL3]

I have a different take on the compensation. It's actually not bad. The rate is $240 for a 90 minute evaluation with veterans evaluation services, which is $160 an hour. Theoretically, $160 an hour times 40 hours a week = $6,400 a week, 47 weeks a year = $300,800. My impression is that most psychologists working for the VA don't make 300 K a year.

 

[Fan_of_Meehl]

I have a different take on the compensation. It's actually not bad. The rate is $240 for a 90 minute evaluation with veterans evaluation services, which is $160 an hour. Theoretically, $160 an hour times 40 hours a week = $6,400 a week, 47 weeks a year = $300,800. My impression is that most psychologists working for the VA don't make 300 K a year.

It's not bad compensation at that rate, to be sure. But my impression (from backchannel communications with folks doing it or knowing people who have done it) is that they are expected to churn them out at a rate of up to 8 exams per day--and you're expected to complete a thorough chart review, maybe some testing, and a good differential diagnostic interview and write up in <1 hour which I don't think is really feasible, even in the case of a straightforward rule in/out PTSD/Depression/Substances (an average case). Having worked in C&P at VA, I know that there are some cases that are much more involved (remand cases) and some of the things that the people making the referral come up with in terms of the opinions they want--whew...if you really tried to deliver that with any standards, it would take a lot more time than they're giving you.

On the upside, the 'no-show' rates are going to be very low (roughly 1 in 20 when I was doing C&P work for VA) because they are pursuing disability status and you can make some good, regular money while the contract lasts. On the downside, there *has* to be a point at which all the folks who supposedly actually have PTSD are already hooked up with service connection or disability...the 'gold rush' can't go on forever.

 

[researchgirl]

On the downside, there *has* to be a point at which all the folks who supposedly actually have PTSD are already hooked up with service connection or disability...the 'gold rush' can't go on forever.

Well, this depends on who we deploy where to do what in the next several years, right?

 

[Fan_of_Meehl]

Well, this depends on who we deploy where to do what in the next several years, right?

Hopefully, we'll avoid unnecessary trauma (including military) exposure in the coming years.

There are plenty of other mental health conditions for me to treat...I'd love to see PTSD rates (and the associated suffering) decrease dramatically in years to come.

 

[WisNeuro]

Hopefully, we'll avoid unnecessary trauma (including military) exposure in the coming years.

There are plenty of other mental health conditions for me to treat...I'd love to see PTSD rates (and the associated suffering) decrease dramatically in years to come.

With the current administration, fat chance. Chances of BOG are pretty high I'd say.

 

[WisNeuro]

Something else to consider with this job, first, you cannot do them in the time provided, the hourly rate is a sham, unless of course you are ok with just providing really poor clinical services. Second, I believe you are a contracted employee and do not receive benefits from this. So, take out everything else you need (health insurance, liability insurance, 401k etc). Last, I don't believe it is full-time regular work, from what I hear, it can be sporadic at times.

 

[erg923]

I have a different take on the compensation. It's actually not bad. The rate is $240 for a 90 minute evaluation with veterans evaluation services, which is $160 an hour. Theoretically, $160 an hour times 40 hours a week = $6,400 a week, 47 weeks a year = $300,800. My impression is that most psychologists working for the VA don't make 300 K a year.

Agree with others. You cant do most C&Ps in that time. 90 minutes is barely enough time to get an MMPI or PAI which are usually essential in 90% of these cases. Its not full-time. You are contractor, so no benefits. They also do not provide the office space, I don't think? So there's that added cost.

 

[PsyDr]

I have a different take on the compensation. It's actually not bad. The rate is $240 for a 90 minute evaluation with veterans evaluation services, which is $160 an hour. Theoretically, $160 an hour times 40 hours a week = $6,400 a week, 47 weeks a year = $300,800. My impression is that most psychologists working for the VA don't make 300 K a year.

If you can do a diagnostic interview, record review, and report write up in 90 minutes, you are a better man than I. And I would wonder where testing is crammed in there, or how the lack of said testing is rationalized to be in accordance with Apa forensic guidelines.

IMO, the benefit of forensic work is that you are paid for all services including reading records, reading the research, etc.

When I have come across c&p exams, by physicians and psychologists; everyone is basically doing crappy work. No one uses the gudesljnes for causation. Everyone uses a bunch of stupid clinical myths that are not supported by empirical literature (e.g., the self medication hypothesis). No one appreciates the literature that indicates that the type of payment used by disability systems has been shown to increase health adverse behaviors and decrease life expectancy.

 

[erg923]

When I have come across c&p exams, by physicians and psychologists; everyone is basically doing crappy work. No one uses the gudesljnes for causation. Everyone uses a bunch of stupid clinical myths that are not supported by empirical literature (e.g., the self medication hypothesis). No one appreciates the literature that indicates that the type of payment used by disability systems has been shown to increase health adverse behaviors and decrease life expectancy.

This is not so at my VA. Only because they are scheduled two per day with One day in the middle of week to catch up on reports, records review, and or literature reviews

 

[Therapist4Chnge]

The irony is that if more thorough evals were allowed and paid (w more interview time and required validity measures), it'd likely attract better clinicians and the rate of dx PTSD I suspect would go down. It would also cut down on over-utilization, free up slots for Veterans in dire need of sooner treatment, and the long-term financial cost is less.

Too bad that will never happen bc it's always about short-term thinking and going w. the cheapest route.

 

[erg923]

that are not supported by empirical literature (e.g., the self medication hypothesis).

Can I assume you are you referring to many clinicians tendency to attribute substance abuse to an underlying MH condition instead of the person simply liking to get high/drunk? If so, again, I think out C&Ps here are great about this too...our service line staff not so much unfortunately.

 

[Justanothergrad]

I've not seen a lot of testing for the C&P psych evals that I've come across in my VISN. It's pretty much just record review and interview. C&Ps aren't my thing, but it always struck me as a bit weird given the forensic context. How common is the use of testing explicitly for these? I see folks reference other testing results but rarely administer it themselves for the purpose of this evaluation.

 

[WisNeuro]

I've not seen a lot of testing for the C&P psych evals that I've come across in my VISN. It's pretty much just record review and interview. C&Ps aren't my thing, but it always struck me as a bit weird given the forensic context. How common is the use of testing explicitly for these? I see folks reference other testing results but rarely administer it themselves for the purpose of this evaluation.

Varied wildly by VA. We did it a lot at my old VA, I haven't sen it done once here at my current VA.

 

[PSYCHEVAL3]

I was simply pointing out $160 an hour is a nice compensation. If a clinician feels they cannot do a record review and an interview in 90 minutes and deliver an adequate product, definitely don't do it.

I'm not a fan of any particular contract, I'm just a fan of psychologists getting compensated an appropriate amount given our years of training.

It doesn't look like a mmpi or pai is required with VES so that is not factored into the time/cost.

It is contract work, so benefits are not included. That's not necessarily bad. I love contract work, such as jails, police departments, adult protective services, vocational rehabilitation, pre employment, fitness for duty, competency, child protective services, etc. My malpractice is a nominal $1,200 a year and my health insurance is $400 a month. Benefits can come at a heavy price at some salaried positions. Psychologists can be paid very well with several nice paying contracts. That was my point.

 

[Fan_of_Meehl]

The irony is that if more thorough evals were allowed and paid (w more interview time and required validity measures), it'd likely attract better clinicians and the rate of dx PTSD I suspect would go down. It would also cut down on over-utilization, free up slots for Veterans in dire need of sooner treatment, and the long-term financial cost is less.

Too bad that will never happen bc it's always about short-term thinking and going w. the cheapest route.

This is not so at my VA. Only because they are scheduled two per day with One day in the middle of week to catch up on reports, records review, and or literature reviews

That's an awesome deal...so they do a total of eight (8) mental health C&P exams per week?

My sense of the average #/wk required at most VA's was somewhere from 3-4/day (15 - 20/wk) with some even higher.

Eight C&P exams per week is quite do-able and would be heavenly as a full-time gig.

 

[psych.meout]

I was simply pointing out $160 an hour is a nice compensation. If a clinician feels they cannot do a record review and an interview in 90 minutes and deliver an adequate product, definitely don't do it.

I'm not a fan of any particular contract, I'm just a fan of psychologists getting compensated an appropriate amount given our years of training.

It doesn't look like a mmpi or pai is required with VES so that is not factored into the time/cost.

It is contract work, so benefits are not included. That's not necessarily bad. I love contract work, such as jails, police departments, adult protective services, vocational rehabilitation, pre employment, fitness for duty, competency, child protective services, etc. My malpractice is a nominal $1,200 a year and my health insurance is $400 a month. Benefits can come at a heavy price at some salaried positions. Psychologists can be paid very well with several nice paying contracts. That was my point.

I think the point most people here are making is that it is not feasible to "deliver an adequate product" with those time restrictions and caseloads. Furthermore, $160 per case (or $240/case assuming your 90 minute figure) is actually not good compensation for the time and effort to actually "deliver an adequate product," which would be far more time than what these kinds of contracts are looking for.

 

[WisNeuro]

I think the point most people here are making is that it is not feasible to "deliver an adequate product" with those time restrictions and caseloads. Furthermore, $160 per case (or $240/case assuming your 90 minute figure) is actually not good compensation for the time and effort to actually "deliver an adequate product," which would be far more time than what these kinds of contracts are looking for.

I'm skeptical of the $240 claim as is, I imagine the truth is the lower end of the range given

 

[erg923]

• Completion of a Compensation and Pension assessment - an objective, one-time, non-treatment psychological assessment as it pertains to the claims that have been filed.

• Review medical history prior to the appointment.

• Gather information from the veteran from a behavioral health assessment and verbal dialogue.

• Interact positively with Veterans.

• Complete Disability Benefit Questionnaires (DBQs) electronically

• No treatment is determined. No follow-up is performed. Assessments only.

• Submit all documentation within 24 hours.

• Doctorate Ph.D. or Psy.D. with a major in the Psychology field.

• Graduation from Doctorate or Post-Doctorate APA Accredited Program.

Good God, these people don't even know what a C&P exam even is is, much less what a psychologist is. Who works for these people?!

 

[PsyDr]

Can I assume you are you referring to many clinicians tendency to attribute substance abuse to an underlying MH condition instead of the person simply liking to get high/drunk? If so, again, I think out C&Ps here are great about this too...our service line staff not so much unfortunately.

The self medication hypothesis was put forward by Duncan and Khantzian in 1974. The former was a behavioralist, the latter was a psychoanalyst. Hypothesized that people suffering from affective disorders would abuse substances in a direction opposite their affective state (e.g., depressive disorders would abuse stimulants; anxiety disorders would abuse sedating substances). The key word is hypothesis. Empirical testing did not support this hypothesis. Some research showed that substance abuse caused affective disorder. I don't know about anyone else, but the concept of null hypothesis was covered in like 5th grade. So why do we hear anything about self medication? Well, old Duncan there ended up working for the Clintons as a consultant. Until he went to prison for child porn. In light of contrary evidence, Khantzian said that maybe people aren't self medicating, per se. Maybe they are using substances to smooth over their ego. And that's the self medication hypothesis. Not the one he said before. Then he complains that no one knows how to operationalize this idea. So his hypothesis must be right....

And this BS is taught day in, day out.

 

[psych.meout]

• Completion of a Compensation and Pension assessment - an objective, one-time, non-treatment psychological assessment as it pertains to the claims that have been filed.

• Review medical history prior to the appointment.

• Gather information from the veteran from a behavioral health assessment and verbal dialogue.

• Interact positively with Veterans.

• Complete Disability Benefit Questionnaires (DBQs) electronically

• No treatment is determined. No follow-up is performed. Assessments only.

• Submit all documentation within 24 hours.

• Doctorate Ph.D. or Psy.D. with a major in the Psychology field.

• Graduation from Doctorate or Post-Doctorate APA Accredited Program.

Good God, these people don't even know what a C&P exam even is is, much less what a psychologist is. Who works for these people?!

It's like one of those gags where you use Google Translate to translate English into another language and then reprocess the resulting text back into English.

The self medication hypothesis was put forward by Duncan and Khantzian in 1974. The former was a behavioralist, the latter was a psychoanalyst. Hypothesized that people suffering from affective disorders would abuse substances in a direction opposite their affective state (e.g., depressive disorders would abuse stimulants; anxiety disorders would abuse sedating substances). The key word is hypothesis. Empirical testing did not support this hypothesis. Some research showed that substance abuse caused affective disorder. I don't know about anyone else, but the concept of null hypothesis was covered in like 5th grade. So why do we hear anything about self medication? Well, old Duncan there ended up working for the Clintons as a consultant. Until he went to prison for child porn. In light of contrary evidence, Khantzian said that maybe people aren't self medicating, per se. Maybe they are using substances to smooth over their ego. And that's the self medication hypothesis. Not the one he said before. Then he complains that no one knows how to operationalize this idea. So his hypothesis must be right....

And this BS is taught day in, day out.

Ok, that hypothesis is pseudoscience, but don't some people with psychiatric issues abuse controlled substances related to their psych symptoms, e.g. depressed people with insomnia abusing alcohol or benzos to sleep?

 

[deleted343839]

It's like one of those gags where you use Google Translate to translate English into another language and then reprocess the resulting text back into English.

Not to totally derail the thread but that reminds me of this woman on YouTube who seems to do this as a full time job.



Looks like way more fun than doing back-to-back, half-baked C&P evals.

 

[PsyDr]

Ok, that hypothesis is pseudoscience, but don't some people with psychiatric issues abuse controlled substances related to their psych symptoms, e.g. depressed people with insomnia abusing alcohol or benzos to sleep?

What you are talking about IS the self medication hypothesis. That's how pervasive this idea is. Unless new evidence comes out, we have to accept the null hypothesis.

In your example: There's evidence of comorbidity, but not of causation in that direction. In the other direction, there is evidence of substance abuse causing affective symptoms. And sleep problems. And concentration problems. and..........

 

[psych.meout]

What you are talking about IS the self medication hypothesis. That's how pervasive this idea is. Unless new evidence comes out, we have to accept the null hypothesis.

In your example: There's evidence of comorbidity, but not of causation in that direction. In the other direction, there is evidence of substance abuse causing affective symptoms. And sleep problems. And concentration problems. and..........

Sorry, I wasn't meaning to imply directionality more generally outside of my example, I just worded it poorly. I meant it more in terms of comorbidity, as you wrote, that they are coexisting and potentially intertwined.

But since my example came out that way, couldn't diagnostic interviewing and assessment shed at least some light on that from a case study perspective? If that depressed person says that they never drank to excess before their depression and insomnia started and they only began drinking heavily in order to sleep (obviously, the quality of this sleep would be poor), wouldn't this be at least somewhat indicative (though by no means definitive, as they could be a poor historian, malingerer, etc.) of directionality in their particular case?

 

[Justanothergrad]

What you are talking about IS the self medication hypothesis. That's how pervasive this idea is. Unless new evidence comes out, we have to accept the null hypothesis.

In your example: There's evidence of comorbidity, but not of causation in that direction. In the other direction, there is evidence of substance abuse causing affective symptoms. And sleep problems. And concentration problems. and..........

Because I'm always trying to build a better and better reference library, do you know any good review articles that pick this apart by chance?

 

[smalltownpsych]

So I had my meeting with the department regarding various evals. The head of the department stated that they did not think that a referral for a psych eval from probation or DFS would be a forensic eval. I debated it a bit since I see it differently especially since the report goes to these parties and is clearly intended to be used for legal purposes. Anyway, the upshot of it was that if anyone doesn't feel comfortable doing these, then they don't have to. I barley touched on the financial issue and that appeared to be a third rail anyway so at this point, I know that I can feel more comfortable saying no to assessment referrals that I feel are inappropriate.

 

[smalltownpsych]

Sorry, I wasn't meaning to imply directionality more generally outside of my example, I just worded it poorly.

But since my example came out that way, isn't that what the diagnostic interviewing and assessment are for? If that depressed person says that they never drank to excess before their depression and insomnia started and they only began drinking heavily in order to sleep (obviously, the quality of this sleep would be poor), wouldn't this be at least somewhat indicative (though by no means definitive, as they could be a poor historian, malingerer, etc.) of directionality in their particular case?

If I have a patient tell me this, I think, "Hmmm. Sounds like denial." I continue to use MI techniques and four or five sessions later the truth begins to come out. It isn't always going to be the case, there are always exceptions, but this is one of the few situations in psych where I would be willing to bet real money on it.

 

[PsyDr]

Sorry, I wasn't meaning to imply directionality more generally outside of my example, I just worded it poorly.

But since my example came out that way, isn't that what the diagnostic interviewing and assessment are for? If that depressed person says that they never drank to excess before their depression and insomnia started and they only began drinking heavily in order to sleep (obviously, the quality of this sleep would be poor), wouldn't this be at least somewhat indicative of directionality in their particular case?

So this is where stuff gets exceptionally more complex.

The short answer is: no, that it started around the same time is basically meaningless. If you started a drug trial in early fall, you would not conclude that the drug caused everyone to end up wearing coats.

The longer answer is: There is a fairly involved process to determining causation. It's long, arduous, and requires a significant familiarity with the literature. The first thing one needs to know is if X is know to cause (not correlate, but cause) Z. In your example, there is no causative effect known (that I recall).

In criminal proceedings, ill advised novices often opine that "XYZ diagnosis made the defendant do the crime.". It is always met with, "Doctor, do all people with XYZ commit the same crime? So it's not the diagnosis then is it?" This goes on for hours until the attorney has shown the jury that the expert is just making crap up.

So I had my meeting with the department regarding various evals. The head of the department stated that they did not think that a referral for a psych eval from probation or DFS would be a forensic eval....

ABFP has both of those types of evals on their stuff as forensic practice.

 

[smalltownpsych]

ABFP has both of those types of evals on their stuff as forensic practice.

On their stuff? I searched around various sites and struggled with finding anything specific to this. Not that I am going to argue with them, but I would like to have documentation to support my position next time someone tries to pressure me.

 

[Pragma]

What you are talking about IS the self medication hypothesis. That's how pervasive this idea is. Unless new evidence comes out, we have to accept the null hypothesis.

In your example: There's evidence of comorbidity, but not of causation in that direction. In the other direction, there is evidence of substance abuse causing affective symptoms. And sleep problems. And concentration problems. and..........

Yay, someone else is on this soapbox too!

There IS some more recent evidence for this concept within the PTSD and some anxiety disorders literature. But otherwise, it's mostly bogus and just something that people like to say for a variety of reasons (e.g., to reduce stigma).

 

[PsyDr]

Yay, someone else is on this soapbox too!

There IS some more recent evidence for this concept within the PTSD and some anxiety disorders literature. But otherwise, it's mostly bogus and just something that people like to say for a variety of reasons (e.g., to reduce stigma).

That stuff is only in people who have a trait disposition to alcohol abuse and in specific PTSD etiologies. That's an exacerbation, not a cause. I know it sounds stupid, but it's like saying

"The loss of a parent caused the pararsiucidal behavior in that person with borderline personality disorder.".

It's very reasonable to assume that the loss didn't help. And that is was probably extremely distressing and awful. And that it probably pushed the person over. But in a person without the underlying personality structure, it is not likely for that to occur. There are specific reasons to reason this way in forensics, drug design, and clinical stuff.

There's a difference between exacerbation, causation, proximate cause, etc.

 

[erg923]

I am aware of this too, and I try to do too espouse the myth to further treatment, but I work with alot of SUD folks, so I hope we aren't suggesting that in some cases substance abuse is NOT a means by which our patients attempt to regulate or cope with negative affective states that are independent of the physiological effects of substance use?

Maybe "cause" isn't the right word, or is too strong of a word, but there alot people who see this as the function of their use and subsequent intoxication...even we do know that this then causes alot of the symptoms that they then the chalk up to their psychiatric disorder. Can we really discount their perception completely?

 

[PsyDr]

Can we really discount their perception completely?

Yes. Think of it like a delusion. You wouldn't tell someone with a delusion that their belief that they could fly is accurate. The potential for harm is high. Positively reinforcing the delusion is against their best interest.

edit: Alternately, think of it like smoking. Smokers frequently say that smoking calms them down. But its a stimulant. The nicotine dependence is what is making them anxious/mad/etc.

 

[erg923]

Yes. Think of it like a delusion. You wouldn't tell someone with a delusion that their belief that they could fly is accurate. The potential for harm is high. Positively reinforcing the delusion is against their best interest.

edit: Alternately, think of it like smoking. Smokers frequently say that smoking calms them down. But its a stimulant. The nicotine dependence is what is making them anxious/mad/etc.

Not ready to relinquish my points per se, but I agree its astonishing how much our patients underestimate basic influences and principles of mental health and what contributes to it.

 

[psych.meout]

That stuff is only in people who have a trait disposition to alcohol abuse and in specific PTSD etiologies. That's an exacerbation, not a cause. I know it sounds stupid, but it's like saying

"The loss of a parent caused the pararsiucidal behavior in that person with borderline personality disorder.".

It's very reasonable to assume that the loss didn't help. And that is was probably extremely distressing and awful. And that it probably pushed the person over. But in a person without the underlying personality structure, it is not likely for that to occur. There are specific reasons to reason this way in forensics, drug design, and clinical stuff.

There's a difference between exacerbation, causation, proximate cause, etc.

Are you referring to something like urgency traits and impulsive behavior?

Yes. Think of it like a delusion. You wouldn't tell someone with a delusion that their belief that they could fly is accurate. The potential for harm is high. Positively reinforcing the delusion is against their best interest.

edit: Alternately, think of it like smoking. Smokers frequently say that smoking calms them down. But its a stimulant. The nicotine dependence is what is making them anxious/mad/etc.

What about opponent processes? Wouldn't the endogenous processes to restore homeostasis in response to stimulants like nicotine produce something like "depressant (for lack of a better term)" effects? I'm not saying that I agreeing with what smokers are saying, I'm just asking if there is somewhat of a biological basis for part of this misconception about long-term nicotine use.

 

[smalltownpsych]

Yes. Think of it like a delusion. You wouldn't tell someone with a delusion that their belief that they could fly is accurate. The potential for harm is high. Positively reinforcing the delusion is against their best interest.

edit: Alternately, think of it like smoking. Smokers frequently say that smoking calms them down. But its a stimulant. The nicotine dependence is what is making them anxious/mad/etc.

I don't agree with the self-medication hypothesis at all, but I am a bit comfused by what you are saying. Substance users do use drugs to regulate their emotions in various ways. Sometimes these are direct effects of the substance themselves, sometimes they can be other aspects of life. At times, they are mistaken in their perspectives at others they are accurate, but either way if they have an addiction the overall effect outweighs any potential beneficial reason for use.