Patients and lack of responsibility

[Sanman]

Argghhh, just venting..... I got to an appt today and the patient is not there. He missed yet another appt despite me giving him a date book, making sure it was written down, and making it his goal for the previous session. Not to mention, his wife blamed me for him missing his psychiatry appt also (which she is actually responsible for managing). God forbid you hold someone to the most minor of responsibilities. Consequences for this...none. Will just reschedule. Okay, rant over. Some days it is frustrating to be in the VA system.

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[WisNeuro]

Ah, I love being able to drop patients from my clinic at my own discretion. No more wasting multiple testing slots on malingerers or people who just don't care. Although, my now show rate is pretty low even without dropping people. Probably <5%.

 

[Therapist4Chnge]

No shows are the bain of my existence (in regard to work), as they waste 1 to 6hr that could have gone to patients that really need their assessment. I used to carry a 2% no show rate at my first PP, which is a pipe dream now. I think i’m around 8-15%, depending on the month. It’s not horrible, but it’s a BIG change for me.

 

[Fan_of_Meehl]

Argghhh, just venting..... I got to an appt today and the patient is not there. He missed yet another appt despite me giving him a date book, making sure it was written down, and making it his goal for the previous session. Not to mention, his wife blamed me for him missing his psychiatry appt also (which she is actually responsible for managing). God forbid you hold someone to the most minor of responsibilities. Consequences for this...none. Will just reschedule. Okay, rant over. Some days it is frustrating to be in the VA system.

It's frustrating, to be sure. I once had a veteran client respond to a question about goals for therapy that he wanted 'less responsibility (in his life).' I found a fairly direct yet diplomatic way of socializing him to the reality that professional psychotherapy is actually a place you go to become MORE responsible in your life. He ended up selecting himself out of therapy in the end. At the end of the day, my job is to support the client in taking responsibility for themselves, to help set the occasion for more adaptive responses. Sure, there's an art and a nuance to that, but that's the ultimate aim. I fear that the public perception of therapy is often quite different from the reality. And, yeah, we're human too and it is frustrating when we put in the effort and they fail to follow through.

 

[WisNeuro]

It's frustrating, to be sure. I once had a veteran client respond to a question about goals for therapy that he wanted 'less responsibility (in his life).' I found a fairly direct yet diplomatic way of socializing him to the reality that professional psychotherapy is actually a place you go to become MORE responsible in your life. He ended up selecting himself out of therapy in the end. At the end of the day, my job is to support the client in taking responsibility for themselves, to help set the occasion for more adaptive responses. Sure, there's an art and a nuance to that, but that's the ultimate aim. I fear that the public perception of therapy is often quite different from the reality. And, yeah, we're human too and it is frustrating when we put in the effort and they fail to follow through.

Hard to blame him. The system there does a good job of infantilizing its patients. I think the clinical care is top notch, but the entanglement of the benefits in clinical duties and the caving to the entitlement of the patients leads to some poor outcomes for some.

 

[Fan_of_Meehl]

Argghhh, just venting..... I got to an appt today and the patient is not there. He missed yet another appt despite me giving him a date book, making sure it was written down, and making it his goal for the previous session. Not to mention, his wife blamed me for him missing his psychiatry appt also (which she is actually responsible for managing). God forbid you hold someone to the most minor of responsibilities. Consequences for this...none. Will just reschedule. Okay, rant over. Some days it is frustrating to be in the VA system.

By the way, Linehan used a term that has turned out to be a useful concept for me: 'active passivity.' It goes something like: (a) client complains about a problem, (b) therapist offers/prompts a solution, (c) client expends more energy avoiding/sabotaging proposed solution than it would have taken to simply solve/ address the problem. Something else is going on (beyond the specified 'problem').

 

[cara susanna]

Argghhh, just venting..... I got to an appt today and the patient is not there. He missed yet another appt despite me giving him a date book, making sure it was written down, and making it his goal for the previous session. Not to mention, his wife blamed me for him missing his psychiatry appt also (which she is actually responsible for managing). God forbid you hold someone to the most minor of responsibilities. Consequences for this...none. Will just reschedule. Okay, rant over. Some days it is frustrating to be in the VA system.

And you get to call him 3 times! Hurray!

 

[Fan_of_Meehl]

And you get to call him 3 times! Hurray!

Not twice...not four times...but exactly three (the holy number) times, per the infallible and divinely-inspired VA policy.

 

[Sanman]

By the way, Linehan used a term that has turned out to be a useful concept for me: 'active passivity.' It goes something like: (a) client complains about a problem, (b) therapist offers/prompts a solution, (c) client expends more energy avoiding/sabotaging proposed solution than it would have taken to simply solve/ address the problem. Something else is going on (beyond the specified 'problem').

It is a great term and definitely is useful in referring to this patient. Without going into too much detail, this guy has severe anxiety issues that he manages through avoidance. He can afford to do this as a 100% SC veteran with a doting wife. Trying to teach him even basic coping skills is fighting the system the VA has set up for him. Trying to set boundaries and create accountability is hard in a system with White House hotlines.

 

[Sanman]

Not twice...not four times...but exactly three (the holy number) times, per the infallible and divinely-inspired VA policy.

And then send a letter... Didn't need to do all that. Got a call back from his wife. Patient didn't feel like meeting with me and couldn't be bothered to call me ahead of time to tell me. Just went out instead.....sigh

 

[Fan_of_Meehl]

So how would you handle this? Point it out?

Much would depend on our history and strength/quality of our therapeutic alliance. Mostly, I would try to avoid being emotionally/ cognitively reactive (or at least not let it show in session). I would generally adopt a motivational interviewing perspective and focus on open-ended questions, affirmations (where appropriate), reflections, and summaries. When/if the patient is open for help/guidance, I wouldn't withhold it, but I would point out (as a process issue) the actively passive pattern and try to help them identify any thoughts/beliefs supporting the behavioral pattern so we could evaluate them together. "I ask for help but no one ever helps me, they just get mad" is a likely dysfunctional belief that could be non-defensively and collaboratively approached by the therapist. All this depends on the willingness of the client to 'go there' of course. I would also imagine that this pattern was likely prevalent in their other relationships and is unsatisfying to them and others.

 

[cara susanna]

It is a great term and definitely is useful in referring to this patient. Without going into too much detail, this guy has severe anxiety issues that he manages through avoidance. He can afford to do this as a 100% SC veteran with a doting wife. Trying to teach him even basic coping skills is fighting the system the VA has set up for him. Trying to set boundaries and create accountability is hard in a system with White House hotlines.

That's a lot of the patients that we see in the VA, I think. You summarized the core issue nicely.

 

[Fan_of_Meehl]

It is a great term and definitely is useful in referring to this patient. Without going into too much detail, this guy has severe anxiety issues that he manages through avoidance. He can afford to do this as a 100% SC veteran with a doting wife. Trying to teach him even basic coping skills is fighting the system the VA has set up for him. Trying to set boundaries and create accountability is hard in a system with White House hotlines.

So true. The struggle is real and much the VA system does is iatrogenic in the extreme.

 

[Therapist4Chnge]

I would not do well in the current VA system. I trained in it, but it was 90% assessment and consultation and 10% intervention. I could boot ppl for non-compliance on the intervention side, which ended up being a pretty effective move bc most of the time the Veteran would ask back in, and that would be when I hammered home expectations and got buy-in. Now with the 3 calls and punitive feedback opportunities it seems like providers have their hands tied in many scenarios.

 

[deleted343839]

It is a great term and definitely is useful in referring to this patient. Without going into too much detail, this guy has severe anxiety issues that he manages through avoidance. He can afford to do this as a 100% SC veteran with a doting wife. Trying to teach him even basic coping skills is fighting the system the VA has set up for him. Trying to set boundaries and create accountability is hard in a system with White House hotlines.

.....and this is why I would not consider a clinical job in the VA. Just reading this makes me tired.

 

[smalltownpsych]

I don't typically go with religious sayings, but at times they are fitting. The one that comes to my mind is "the Lord helps those who help themselves." If a patient is coming to me for help, they have to be willing to do something. They don't even have to meet me halfway, but they do have to do something and showing up is the absolute minimum expectation. If they are not, then I am acting out an unhealthy relationship dynamic. It is kind of like the relative of the addict who is always trying to control the addict to make them "get better" and at the same time shielding them from the consequences of their behavior. This is spreading past the VA and mental health and into the entire health system. Instead of trying to figure out the best way to ensure healthier choices in a population and recognize that part of that means letting some people suffer the consequences of their own behavior. When I work with family members of addicts we talk very concretely about what that means. The loved one might not get better and they might end up dead. I have found that helping the family member accept this and recognize where the responsibility lies for the life actually has led to less deaths and more involvement in treatment. I have had a number of patients become quite amazed when this happens. Not sure exactly how to apply this to systems, but just musing about possible connections and alternative perspectives.

 

[Fan_of_Meehl]

I don't typically go with religious sayings, but at times they are fitting. The one that comes to my mind is "the Lord helps those who help themselves." If a patient is coming to me for help, they have to be willing to do something. They don't even have to meet me halfway, but they do have to do something and showing up is the absolute minimum expectation. If they are not, then I am acting out an unhealthy relationship dynamic. It is kind of like the relative of the addict who is always trying to control the addict to make them "get better" and at the same time shielding them from the consequences of their behavior. This is spreading past the VA and mental health and into the entire health system. Instead of trying to figure out the best way to ensure healthier choices in a population and recognize that part of that means letting some people suffer the consequences of their own behavior. When I work with family members of addicts we talk very concretely about what that means. The loved one might not get better and they might end up dead. I have found that helping the family member accept this and recognize where the responsibility lies for the life actually has led to less deaths and more involvement in treatment. I have had a number of patients become quite amazed when this happens. Not sure exactly how to apply this to systems, but just musing about possible connections and alternative perspectives.

I think there's quite a bit of useful distilled wisdom to be gleaned from many religious traditions that too often gets overlooked or tossed aside. The fundamental existential/ spiritual challenges associated with the problems of being, meaningfulness (or meaninglessness), responsibility, and the appropriate posture to adopt toward a life full of pain/suffering are not somehow rendered moot due to technological or scientific advances.

 

[smalltownpsych]

I think there's quite a bit of useful distilled wisdom to be gleaned from many religious traditions that too often gets overlooked or tossed aside. The fundamental existential/ spiritual challenges associated with the problems of being, meaningfulness (or meaninglessness), responsibility, and the appropriate posture to adopt toward a life full of pain/suffering are not somehow rendered moot due to technological or scientific advances.

 

[futureapppsy2]

Related to that, the more I learn about Buddhism, the more I think they should call ACT “This is Pretty Much Just Buddhism” (joking, but also not really joking).

 

[cara susanna]

I would not do well in the current VA system. I trained in it, but it was 90% assessment and consultation and 10% intervention. I could boot ppl for non-compliance on the intervention side, which ended up being a pretty effective move bc most of the time the Veteran would ask back in, and that would be when I hammered home expectations and got buy-in. Now with the 3 calls and punitive feedback opportunities it seems like providers have their hands tied in many scenarios.

Yeah, you can't do that at a lot of clinics anymore (kick people out of treatment for non-compliance). Or, you can, but you have to deal with a lot of headaches like patient advocate complaints, threats of congressional inquiries, etc. It all depends on how supportive your local administration is, of course.

 

[psychRA]

Over the last few years a few of my patients have dabbled in non-VA mental healthcare. It was a rough adjustment for some of those patients; people love to trash the VA, but I doubt that many other health care systems (if any) are as generous and patient with the mental health care they provide. I'm fairly certain that Kaiser doesn't cover multiple stints in residential treatment, regular ongoing individual therapy, or indefinite inpatient stays.

I'm not suggesting that we should be more like Kaiser or provide less treatment. I do think that many folks would be less critical of the system if they were aware of how difficult it can be to get mental health services just about anywhere else.

 

[Therapist4Chnge]

The VA continues to be a political football, and as such every “improvement” seems to be big on aspirational goals that have zero scientific backing and often in direct contrast to what providers are saying is needed. The no suicide initiatives seem like the perfect example of how to do it the completely wrong way.

 

[Fan_of_Meehl]

Yeah, you can't do that at a lot of clinics anymore (kick people out of treatment for non-compliance). Or, you can, but you have to deal with a lot of headaches like patient advocate complaints, threats of congressional inquiries, etc. It all depends on how supportive your local administration is, of course.

Plus...they just...like...come back and re-present for care . So, in my clinic (post-deployment), 'terminating' with them would be essentially meaningless. I just try to make it non-reinforcing for them to show up and not work--i.e., persistently and consistently redirect the discussion to goals, skills-building, worksheets, assuming responsibility for your life, etc. Most of the folks who don't want to actually work get tired of showing up and having me socialize them to the task of therapy and/or enforcing boundaries with them time and time again.

 

[smalltownpsych]

Plus...they just...like...come back and re-present for care . So, in my clinic (post-deployment), 'terminating' with them would be essentially meaningless. I just try to make it non-reinforcing for them to show up and not work--i.e., persistently and consistently redirect the discussion to goals, skills-building, worksheets, assuming responsibility for your life, etc. Most of the folks who don't want to actually work get tired of showing up and having me socialize them to the task of therapy and/or enforcing boundaries with them time and time again.

i use the same tactics, but over time the unmotivated masses wore me down! They just kept coming! Two more weeks and I am outta here. They call it short-timers syndrome in the military. "I'm so short...(fill in the blank)" Actually on a more serious note, I do have patients who have done some good work and we both appreciated the work that we did together and it is very difficult to say goodbye. A whole different type of emotional toll.

 

[Sanman]

i use the same tactics, but over time the unmotivated masses wore me down! They just kept coming! Two more weeks and I am outta here. They call it short-timers syndrome in the military. "I'm so short...(fill in the blank)" Actually on a more serious note, I do have patients who have done some good work and we both appreciated the work that we did together and it is very difficult to say goodbye. A whole different type of emotional toll.

That's the trick though isn't it. I think we all know what the right thing is for treatment in a vacuum, but trying implement change in the real world and being able to do that over years and years without burning out is what makes you successful. That last part I am still working out for myself. The one thing I do notice is that I generally put in more effort than the lifers around me. However, I have yet to decide if I am a lifer or if this is a simply an extended professional break for me (in terms of work hours) in order to attend more to my personal life before I take on my next time intensive venture. Personally, the nagging thoughts in the back of my mind that I won't be happy unless I am working for myself may get to me eventually.

 

[WisNeuro]

Personally, the nagging thoughts in the back of my mind that I won't be happy unless I am working for myself may get to me eventually.

I'm getting there. Which, may be why I am laying the groundwork for PP now, while I can comfortably collect a paycheck while making some of those tentative steps and networking.

 

[cara susanna]

The past few days I've been daydreaming about starting my own full model DBT practice (to my knowledge, we don't have any in the area). But I'm so lazy and bad with money...

 

[DynamicDidactic]

The past few days I've been daydreaming about starting my own full model DBT practice (to my knowledge, we don't have any in the area). But I'm so lazy and bad with money...

I, too, am lazy but not so bad with money. I have a plan to do so in the next 5 years unless some hiccup (another kid, another new job) occurs.

 

[foreverbull]

Related to that, the more I learn about Buddhism, the more I think they should call ACT “This is Pretty Much Just Buddhism” (joking, but also not really joking).

Of course! Hayes talked about using Buddhism to cope with anxiety as a precursor to "creating" ACT. Isolating parts of eastern philosophy/Taoist/Hindu/Buddhist principles, reframing them in psychological jargon, and then let the psychological community embrace it as a "new" approach/intervention has been par for the course for a few scholars, and others at least pulled a little from it (MBSR, ACT, DBT's radical acceptance, etc.). I think even Perls used some of the same ideas in Gestalt Therapy with the "I and thou, here and now" (present focus) and his own ideas about the need to integrate/accept all parts of ourselves (radical acceptance).

Been there, done that....for over 2,000 years.

 

[Fan_of_Meehl]

Of course! Hayes talked about using Buddhism to cope with anxiety as a precursor to "creating" ACT. Isolating parts of eastern philosophy/Taoist/Hindu/Buddhist principles, reframing them in psychological jargon, and then let the psychological community embrace it as a "new" approach/intervention has been par for the course for a few scholars, and others at least pulled a little from it (MBSR, ACT, DBT's radical acceptance, etc.). I think even Perls used some of the same ideas in Gestalt Therapy with the "I and thou, here and now" (present focus) and his own ideas about the need to integrate/accept all parts of ourselves (radical acceptance).

Been there, done that....for over 2,000 years.

And Socratic questioning is at the heart of cognitive therapy. Unfortunately, we are in a paradigmatic phase in our field (owing largely to the, I would say, near-religious worship of the medical model) where attention to philosophy (or philosophical principles) is poo-pooed by the powers-that-be as 'unscientific' or a 'soft' or muddled approach to psychology. I see glimmers of a revolution in the other direction beginning (see, for example, the new book by Hayes and Hofman on 'Process-Based CBT'). The battle is completely lost in many applied mental health settings, however (such as the VA).

 

[PsyDr]

And Socratic questioning is at the heart of cognitive therapy. Unfortunately, we are in a paradigmatic phase in our field (owing largely to the, I would say, near-religious worship of the medical model) where attention to philosophy (or philosophical principles) is poo-pooed by the powers-that-be as 'unscientific' or a 'soft' or muddled approach to psychology. I see glimmers of a revolution in the other direction beginning (see, for example, the new book by Hayes and Hofman on 'Process-Based CBT'). The battle is completely lost in many applied mental health settings, however (such as the VA).

IMO:

1) I have considered psychotherapy as being bifurcated into illness treatment and self improvement, much like most of health. The former depends on how the illness is defined. The latter has been addressed since the time of Mesopotamians. All areas of medicine are struggling with this. Preventative health is a thing. Health insurance covers gyms. Cms damn near requires smoking cessation counseling. Why is marital counseling covered by medical insurance? It’s not as clear cut as some claim. I believe the danger is in finding where ones professional education stops. And many do not limit their opinions to such.

2) You might be late to the revolution. FAP is a process based cbt that’s been around for approximately 20 years.

 

[smalltownpsych]

IMO:

1) I have considered psychotherapy as being bifurcated into illness treatment and self improvement, much like most of health. The former depends on how the illness is defined. The latter has been addressed since the time of Mesopotamians. All areas of medicine are struggling with this. Preventative health is a thing. Health insurance covers gyms. Cms damn near requires smoking cessation counseling. Why is marital counseling covered by medical insurance? It’s not as clear cut as some claim. I believe the danger is in finding where ones professional education stops. And many do not limit their opinions to such.

2) You might be late to the revolution. FAP is a process based cbt that’s been around for approximately 20 years.

As far as FAP goes, if that is Functional Analytic Psychotherapy which is something I wasn't familiar with, a quick read on wikipedia tells me that I already do it at least to some extent. That is one of the challenges of the different models is that a psychological practitioner will be using various various psychological principles (operant conditioning, classical conditioning, social learning, attachment theory, etc. ) to inform their treatment and so there will often be a lot of overlap.