Question for outpatient therapy providing VA psychologists

[Fan_of_Meehl]

I am looking for some information/feedback from psychologists providing outpatient psychotherapy in a VA setting regarding a very specific question:

Do you accept referrals/consults specifically for 'R/O PTSD' or 'Assess for PTSD' where the person clearly expresses to a third party (who is making the referral/consult) that they have absolutely no interest in psychotherapy for PTSD? This has historically been something that has been done occasionally in my outpatient (OEF/OIF) setting and a colleague and I are struggling with the issue and how to respond to such requests (some of which, by the way, come from the patient advocate (a non-provider) who is ecouraging vets who, in his opinion, have signs of PTSD to make an appointment with a psychologist to confirm PTSD so that they can get started with the compensation and pension process (a diagnosis from a psychologist or psychiatrist of PTSD is apparently needed to facilitate an expedited claim for PTSD). We obviously have concerns about turning things into a PTSD diagnosis-dispensing service-connection drive through factory operation. Again, we're not talking about situations in which patients are presenting with PTSD symptoms and are open to the possibility of therapy...just situations where they are clear that they are not interested in psychotherapy, just 'ruling in/out' the diagnosis. I have used the analogy of someone asking for a medical doctor to x-ray their hip to confirm a broken him but, at the same time, stating that they are in no way interested in medical intervention.

What I have done is go on record articulating my concerns with these types of referrals (e.g., they are coming from a non-provider (patient advocate) and they are specifically seeking confirmation of a specific psychiatric diagnosis (PTSD) vs. saying that the person is experiencing psychological symptoms and is interested in psychological assessment and treatment recommendations. I have stipulated that, if forced to do so by administration, I would require, at minimum, at least (a) one to two sessions (all my sessions are 50 min) to get general background, military history, employment, developmental, mood/anxiety/psychotic disorder symptom review, etc.; (b) one session broadband (MMPI-2, MMPI-2-RF, or PAI) personality and symptom domain assessment; (c) one to two sessions structured interview (CAPS-5) specific to PTSD symptomatology and relation to claimed stressors/trauma; and (d) one session feedback and treatment recommendations (which I consider to be ethically necessary if I am to assess this level of psychopathology).

I have argued that this would take our time away from our current mission of providing actual treatment to the OEF/OIF veterans who present to our clinic and would, potentially, cause disruption in our ability to serve the local OEF/OIF population of veterans with treatment services since many of them may (after such an extensive assessment) evidence symptom overreporting or other signs that necessitate a 'No Diagnosis' response from us even if they and their family is convinced that they have PTSD. This would obviously complicate any future attempts to develop/maintain effective working alliances with them in service of providing evidence-based treatment for other conditions (depression, substance abuse, personality disorders).

I am interested in what others may have experienced regarding such requests ('R/O PTSD...not interested in treatment) and what their thoughts are on the matter.

Thanks!

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[erg923]

I am looking for some information/feedback from psychologists providing outpatient psychotherapy in a VA setting regarding a very specific question:

Do you accept referrals/consults specifically for 'R/O PTSD' or 'Assess for PTSD' where the person clearly expresses to a third party (who is making the referral/consult) that they have absolutely no interest in psychotherapy for PTSD? This has historically been something that has been done occasionally in my outpatient (OEF/OIF) setting and a colleague and I are struggling with the issue and how to respond to such requests (some of which, by the way, come from the patient advocate (a non-provider) who is ecouraging vets who, in his opinion, have signs of PTSD to make an appointment with a psychologist to confirm PTSD so that they can get started with the compensation and pension process (a diagnosis from a psychologist or psychiatrist of PTSD is apparently needed to facilitate an expedited claim for PTSD). We obviously have concerns about turning things into a PTSD diagnosis-dispensing service-connection drive through factory operation. Again, we're not talking about situations in which patients are presenting with PTSD symptoms and are open to the possibility of therapy...just situations where they are clear that they are not interested in psychotherapy, just 'ruling in/out' the diagnosis. I have used the analogy of someone asking for a medical doctor to x-ray their hip to confirm a broken him but, at the same time, stating that they are in no way interested in medical intervention.

What I have done is go on record articulating my concerns with these types of referrals (e.g., they are coming from a non-provider (patient advocate) and they are specifically seeking confirmation of a specific psychiatric diagnosis (PTSD) vs. saying that the person is experiencing psychological symptoms and is interested in psychological assessment and treatment recommendations. I have stipulated that, if forced to do so by administration, I would require, at minimum, at least (a) one to two sessions (all my sessions are 50 min) to get general background, military history, employment, developmental, mood/anxiety/psychotic disorder symptom review, etc.; (b) one session broadband (MMPI-2, MMPI-2-RF, or PAI) personality and symptom domain assessment; (c) one to two sessions structured interview (CAPS-5) specific to PTSD symptomatology and relation to claimed stressors/trauma; and (d) one session feedback and treatment recommendations (which I consider to be ethically necessary if I am to assess this level of psychopathology).

I have argued that this would take our time away from our current mission of providing actual treatment to the OEF/OIF veterans who present to our clinic and would, potentially, cause disruption in our ability to serve the local OEF/OIF population of veterans with treatment services since many of them may (after such an extensive assessment) evidence symptom overreporting or other signs that necessitate a 'No Diagnosis' response from us even if they and their family is convinced that they have PTSD. This would obviously complicate any future attempts to develop/maintain effective working alliances with them in service of providing evidence-based treatment for other conditions (depression, substance abuse, personality disorders).

I am interested in what others may have experienced regarding such requests ('R/O PTSD...not interested in treatment) and what their thoughts are on the matter.

Thanks!

Short answer: No.

Long answer: If they desire, or are open to treatment of some sort, even if that just seeing what meds can help with symptoms, I will see them. As PCMHI, I serve as the gateway into MHC, thus anyone who wants MH treatment goes through me first. That how my clinic operates anyway.