Requests for academic accommodations

[Trismegistus4]

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Just when you thought patients had run out of things to request of you other than diagnosis and treatment of psychiatric disorders... you get a request for a form or letter stating that they need academic accommodations. I got my first one of these today. Have you ever gotten this request? How did you handle it?

The frustrating thing for me is that this is one of those phenomena where the patient had something before, so they think it's no big deal for their new psychiatrist to give it to them again--just like the people with history of ADHD, moving in from out of state, who basically waltz into your office for an initial visit and say "yeah, I'm here to get my Adderall, kthxbye." Only this was an established patient whom I've been seeing for more than a year. Since last visit in January, he has taken the PCAT, gotten the result, and gotten accepted to pharmacy school. Then today he comes in for a routine follow-up and throws in the fact that, oh, by the way, he had academic accommodations in undergrad, which his psychiatrist at the time supported, for longer test taking times and a quiet space, and could he get those again for pharmacy school? He claims it was basically because of OCD, in that he would excessively check his work.

In my lay opinion, it would seem this would be an area where formal testing would be appropriate. But I'm not a psychometrician or neuropsychologist. This is yet another request (like ADHD evals) where I'd like to be able to simply say "sorry, I don't do that." But in my current job, I don't have the power to tailor my practice to be what I would like it to be. And I've been just giving in to this kind of thing more and more, because it just doesn't seem worth it to fight with people all day. But a little piece of me dies inside every time I give in.

Also, I have to admit, while this guy doesn't have an arrogant, entitled, or demanding demeanor--he actually comes across a little sheepish, kind of like Woody Allen only Italian and not Jewish--I do have some negative feelings toward him. This is because he is one of these people who comes to a new psychiatrist on polypharmaceutical overkill and wants you to just continue his huge cocktail, saying "I know it's a lot of meds, but it's taken me years of tweaking with my past psychiatrist to get here, and every time someone tries to change one little thing, I go off the rails." In this case, the guy's on gabapentin, an SSRI, Lyrica, propranolol AND Xanax PRN, and probably something else I'm forgetting. And you feel like you're kind of held hostage because this person is saying "please, I just need these meds, these are my meds, and if I don't get exactly this I'll decompensate."

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

 

[splik]

i think its a cop out to say you can't say no to things. your employer is not holding a gun to your head. it is your license and you cannot be forced to practice below your standard of care. if you dont want to prescribe Adderall to everyone, or continue Xanax, or write an ESA letter, or fill in forms for disability accommodations you can decline. You are the physician and it is up to your judgement to decide whether something is medically appropriate or not. Your employer cannot force you to practice below your standard of care or provide suboptimal care. And if they are that micomanagey you should quit. We are in high demand and you can easily find another job that will not make you do things you find personally distasteful. You are doing both yourself and your patients a disservice by being so weak-willed and conflict avoidant.

BTW I am perfectly happy filling in requests for academic accommodations if I believe it to be medically appropriate. I have also opined when doing these as IME that "this person does not have the required level of intelligence requisite for graduate level study," which is often a motivator for accommodations rather than disability. I wouldn't say that to a patient, but would tell them I won't support their request if I don't believe in it.

 

[Stagg737]

As someone with absolutely no experience with this whatsoever (yet), I'd guess that these situations are probably over-prescribed or that people ask for them too much and that your analysis that society and people don't like to tell people they're just not smart enough/don't have the aptitude for something and instead make the "if someone can't achieve it, then there must be something wrong" argument. At the same time, I don't think every one of these cases is just a cop out or excuse to help someone compensate for lack of ability. I'm sure there are times when someone's psychiatric or medical condition truly is a handicap and that appropriate accommodations will "level the playing field". I think it is an interesting conversation though, and one I do hope to get the opportunity to work on/discuss more during residency.

 

[CareBear2018]

I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

I get where this idea comes from & I'm sure these accommodations are given out too easily & ADHD is overdiagnosed. I know too many people who aren't ADD/ADHD but simply like the meds or work in finance and must work around the clock so they ask for them. BUT a lot of people really need accommodations/meds and benefit greatly from them. My quality of life improved dramatically once I was diagnosed & received help. I didn't quite understand ADHD when I was younger & ignored everyone who told me to get tested. I didn't realize it was the reason every aspect of my life was so stressful. I thought it was just for kids who didn't do well in school & wanted better grades. I only finally went and got help when I started averaging Cs on my AP Chem class exams senior year of HS, not because I didn't know the material (I got near 100% of everything I got to), but because they were very long exams & I only could finish about 2/3, since I was slow. Also my AP teacher basically forced me to see someone, lol.
Anyway once diagnosed, my life improved in every aspect, and there were obvious improvements in my self-confidence and general mood (I had comorbid depression diagnosed at the same time). I easily got into the majority of medical schools I applied to, because I had worked so excessively hard before undergrad to just do the basic & now everything in college was so easy it felt like a joke. I did start getting lazy about taking my adderrall during medical school (I started to believe I didn't need it) & I really think that played a big role in my depression returning. It is hard to keep my struggles due to ADHD & depression separate, but I believe if I hadn't gotten help (including accommodations at first), I and probably several other very competent and smart people would not be contributing to society like we do today!
I get what you're saying about someone not being able to work in the real world as efficiently in the allotted time. However, a lot of people learn how to adapt and I honestly think I learned how to be faster & more efficient as I was using the accommodations in college. I never asked for any for the MCAT or med school. I'm on the slower side, I suppose, in medical school with chart reviews & exams, but not so much that it's an issue or anyone notices. I just usually get to the hospital a little earlier 🙂 Even if someone never improves and always needs extended time or whatever for exams, it is unlikely their job will involve taking exams all day. The type of focus required to sit still and finish an exam quickly is much different than that required on the average day at most jobs. There's no reason to hurt someones chances at a future career just because they are slower taking exams in school.

This probably wasn't very helpful lol. I know people on this forum don't need to be taught that ADHD (or OCD or whatever diagnosis) is a real thing. I just disagree with the snowflake comment or the suggestion that if you struggle with test-taking, you don't deserve to go far academically.

 

[erg923]

Just when you thought patients had run out of things to request of you other than diagnosis and treatment of psychiatric disorders... you get a request for a form or letter stating that they need academic accommodations. I got my first one of these today. Have you ever gotten this request? How did you handle it?

The frustrating thing for me is that this is one of those phenomena where the patient had something before, so they think it's no big deal for their new psychiatrist to give it to them again--just like the people with history of ADHD, moving in from out of state, who basically waltz into your office for an initial visit and say "yeah, I'm here to get my Adderall, kthxbye." Only this was an established patient whom I've been seeing for more than a year. Since last visit in January, he has taken the PCAT, gotten the result, and gotten accepted to pharmacy school. Then today he comes in for a routine follow-up and throws in the fact that, oh, by the way, he had academic accommodations in undergrad, which his psychiatrist at the time supported, for longer test taking times and a quiet space, and could he get those again for pharmacy school? He claims it was basically because of OCD, in that he would excessively check his work.

In my lay opinion, it would seem this would be an area where formal testing would be appropriate. But I'm not a psychometrician or neuropsychologist. This is yet another request (like ADHD evals) where I'd like to be able to simply say "sorry, I don't do that." But in my current job, I don't have the power to tailor my practice to be what I would like it to be. And I've been just giving in to this kind of thing more and more, because it just doesn't seem worth it to fight with people all day. But a little piece of me dies inside every time I give in.

Also, I have to admit, while this guy doesn't have an arrogant, entitled, or demanding demeanor--he actually comes across a little sheepish, kind of like Woody Allen only Italian and not Jewish--I do have some negative feelings toward him. This is because he is one of these people who comes to a new psychiatrist on polypharmaceutical overkill and wants you to just continue his huge cocktail, saying "I know it's a lot of meds, but it's taken me years of tweaking with my past psychiatrist to get here, and every time someone tries to change one little thing, I go off the rails." In this case, the guy's on gabapentin, an SSRI, Lyrica, propranolol AND Xanax PRN, and probably something else I'm forgetting. And you feel like you're kind of held hostage because this person is saying "please, I just need these meds, these are my meds, and if I don't get exactly this I'll decompensate."

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

.
Because you don't know if they do or not. This is not a just clinical question, its an educational one. Simple as that. This is the school/school system's obligation to assess and decide. I have always referred people back to their school for this question. Ive actually never talked to a psychologist colleague that wouldn't/doesn't refer this inquiry back to the school system? I would doubt your boss would bat an eyelash at this. I thought this was pretty widespread practice?

 

[hamstergang]

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

The purpose of a test is to see how much of the material the student knows. The test itself is just the artificial scenario we've created to assess this knowledge -- we don't care about the test itself. So if someone has a condition that impairs their ability to demonstrate their knowledge in this specific testing environment, it is reasonable for them to have accommodations to alter the testing environment.

Note that we don't actually give accommodations to address a deficit in knowledge; we don't have them change questions to be easier or make it open book, for example.

The real world is often quite different from the academic setting, so issues at school don't necessarily correspond to issues at work.

 

[Fan_of_Meehl]

Just when you thought patients had run out of things to request of you other than diagnosis and treatment of psychiatric disorders... you get a request for a form or letter stating that they need academic accommodations. I got my first one of these today. Have you ever gotten this request? How did you handle it?

The frustrating thing for me is that this is one of those phenomena where the patient had something before, so they think it's no big deal for their new psychiatrist to give it to them again--just like the people with history of ADHD, moving in from out of state, who basically waltz into your office for an initial visit and say "yeah, I'm here to get my Adderall, kthxbye." Only this was an established patient whom I've been seeing for more than a year. Since last visit in January, he has taken the PCAT, gotten the result, and gotten accepted to pharmacy school. Then today he comes in for a routine follow-up and throws in the fact that, oh, by the way, he had academic accommodations in undergrad, which his psychiatrist at the time supported, for longer test taking times and a quiet space, and could he get those again for pharmacy school? He claims it was basically because of OCD, in that he would excessively check his work.

In my lay opinion, it would seem this would be an area where formal testing would be appropriate. But I'm not a psychometrician or neuropsychologist. This is yet another request (like ADHD evals) where I'd like to be able to simply say "sorry, I don't do that." But in my current job, I don't have the power to tailor my practice to be what I would like it to be. And I've been just giving in to this kind of thing more and more, because it just doesn't seem worth it to fight with people all day. But a little piece of me dies inside every time I give in.

Also, I have to admit, while this guy doesn't have an arrogant, entitled, or demanding demeanor--he actually comes across a little sheepish, kind of like Woody Allen only Italian and not Jewish--I do have some negative feelings toward him. This is because he is one of these people who comes to a new psychiatrist on polypharmaceutical overkill and wants you to just continue his huge cocktail, saying "I know it's a lot of meds, but it's taken me years of tweaking with my past psychiatrist to get here, and every time someone tries to change one little thing, I go off the rails." In this case, the guy's on gabapentin, an SSRI, Lyrica, propranolol AND Xanax PRN, and probably something else I'm forgetting. And you feel like you're kind of held hostage because this person is saying "please, I just need these meds, these are my meds, and if I don't get exactly this I'll decompensate."

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

I'd say that if you don't feel comfortable doing it, don't do it. For many reasons. For one, this is just another area that mental health patients (heavily influenced by their personality pathology) are pushing limits (and will continue to push limits) until resistance is met. You/we give in today, the line moves forward to some progressively unacceptable position next month or next year. Another reason for not doing it is that--even though you pay 'up front' with the discomfort of enforcing the boundary--in the long run it pays off because patients and others come to understand that they won't get what they're looking for from you. The third reason is a bit more nuanced an insidious. I think that if we start lying (in the form of writing letters for things we don't believe in) to our patients then it becomes habitual and then we are more likely to lie to others and ourselves. You said it yourself (and I've FELT it myself), when you give in and do something you don't believe in IT MAKES YOU WEAK...a little bit of you dies each time and, I would argue, the world is degraded as well. If no one is telling the truth and everyone is saying things they don't believe, it makes for one hell of a dysfunctional environment (think Veterans Affairs). One of the things that helps me out in similar situations (requests for 'letters' to whomever saying this or that, service animals, endorsing patients' beliefs that 'my mTBI' is the cause of all my life's problems, endorsing PTSD for someone who was yelled at by their sergeant in boot camp, etc.) is taking the following position (with patients who say things like, 'Well, how do you KNOW FOR SURE that 'it isn't my concussion five years ago' causing symptoms x, y, and z'?): There are many complicated answers to that query (and most of them are research, philosophy of science, and methodologically based--which means they'll fly right over the head of the person asking the question). The truth is I don't KNOW FOR SURE (in this case, that the veteran doesn't 'need specific accommodations' for a specific 'invisible disability'), but I'm going to have the discipline NOT TO LIE (in the form of an affirmative statement of cause/effect/need) that I DON'T ACTUALLY BELIEVE MYSELF based on my professional read of the facts before me, sound clinical reasoning, and established standards of care/practice (published and taught) within my field. If there's another professional with the appropriate credentials who 'specializes' in 'determining specific academic accommodations' for mental health concerns, then maybe they need to be referred to them.

As a disclaimer, I don't know what kind of administrative environment you are in so I don't know if any of the above is practicable, it's just how I try to deal with being put in situations where someone is trying to put conclusions into my mouth and expects me to put them down on paper with my name and license number at the bottom under my signature 🙂.

 

[smalltownpsych]

From the other side of this, when I teach I do not give special accomodations for individuals. Instead I give everyone the option to do whatever accomodations work for them. For example, if you want to record the lectures or get someone elses notes, great. Also, my tests are never timed so no one ever needs extra time. What is funny is that when i took away the time limit, the students finish more quickly anyway. If you need to lay on the floor because your back hurts or go to the bathroom every five minutes or even go outside to have a smoke break, be my guest. I don't require a doctor's note or a psychological evaluation for any of it (actually, I definitely don't want it). Now. if you want to cheat or plagiarize then I will fail you. If you can't show up to class and you fail the test, oh well. The entitlement that we breed with this garbage is maddening.

 

[psych md jd]

I take a forensic, non-judgmental approach to these situations. Whatever the policy is at the school or business is none of my business. My business is to complete the form/letter based on my findings and diagnosis.

Whatever I write is defensible and supported by my records or prior records, testing, and assessment scales. I don't speculate or give into what the patient wants. I don't let the patient dictate to me what to write [cf. Harold Bornstein: Former Trump doctor now 'frightened and sad'].

I don't ignore or refuse these forms. The last thing I need is the licensing board or the patient's attorney asking me why I didn't fill out the form.

 

[OldPsychDoc]

I take a forensic, non-judgmental approach to these situations. Whatever the policy is at the school or business is none of my business. My business is to complete the form/letter based on my findings and diagnosis.

Whatever I write is defensible and supported by my records or prior records, testing, and assessment scales. I don't speculate or give into what the patient wants. I don't let the patient dictate to me what to write [cf. Harold Bornstein: Former Trump doctor now 'frightened and sad'].

I don't ignore or refuse these forms. The last thing I need is the licensing board or the patient's attorney asking me why I didn't fill out the form.

Kudos on the Bornstein example.

 

[thoffen]

In this case, it doesn't sound like a very big accommodation, and you've already invested more time in figuring out whether or not you should do it than it would have taken to write him a letter. Personally, if I felt the request were reasonable I'd do it. Why need fancy psychometric tests for such a small thing? But you do also raise a more important concern, and that is what impact does his perfectionism have on his potential career which also involves the safety of patients? So whether or not you do the accommodations, you need to evaluate and potentially treat that.

The other thing is it seems like your objection really relates more to your countertransference than the reality behind his request. In that case, I'd try to figure out what that's telling you about this patient and your treatment.

 

[Salpingo]

Just when you thought patients had run out of things to request of you other than diagnosis and treatment of psychiatric disorders... you get a request for a form or letter stating that they need academic accommodations. I got my first one of these today. Have you ever gotten this request? How did you handle it?

The frustrating thing for me is that this is one of those phenomena where the patient had something before, so they think it's no big deal for their new psychiatrist to give it to them again--just like the people with history of ADHD, moving in from out of state, who basically waltz into your office for an initial visit and say "yeah, I'm here to get my Adderall, kthxbye." Only this was an established patient whom I've been seeing for more than a year. Since last visit in January, he has taken the PCAT, gotten the result, and gotten accepted to pharmacy school. Then today he comes in for a routine follow-up and throws in the fact that, oh, by the way, he had academic accommodations in undergrad, which his psychiatrist at the time supported, for longer test taking times and a quiet space, and could he get those again for pharmacy school? He claims it was basically because of OCD, in that he would excessively check his work.

In my lay opinion, it would seem this would be an area where formal testing would be appropriate. But I'm not a psychometrician or neuropsychologist. This is yet another request (like ADHD evals) where I'd like to be able to simply say "sorry, I don't do that." But in my current job, I don't have the power to tailor my practice to be what I would like it to be. And I've been just giving in to this kind of thing more and more, because it just doesn't seem worth it to fight with people all day. But a little piece of me dies inside every time I give in.

Also, I have to admit, while this guy doesn't have an arrogant, entitled, or demanding demeanor--he actually comes across a little sheepish, kind of like Woody Allen only Italian and not Jewish--I do have some negative feelings toward him. This is because he is one of these people who comes to a new psychiatrist on polypharmaceutical overkill and wants you to just continue his huge cocktail, saying "I know it's a lot of meds, but it's taken me years of tweaking with my past psychiatrist to get here, and every time someone tries to change one little thing, I go off the rails." In this case, the guy's on gabapentin, an SSRI, Lyrica, propranolol AND Xanax PRN, and probably something else I'm forgetting. And you feel like you're kind of held hostage because this person is saying "please, I just need these meds, these are my meds, and if I don't get exactly this I'll decompensate."

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

From the ethical perspective, I agree with some of the above posters -- most tests are pretty artificial assessments of understanding and knowledge. I'm guessing most time limits are fairly arbitrary, and very few teachers/administrators put them together with the thought "what is the exact time that will accurately simulate the time crunch of filling a prescription." And if those schools do exist, I've had some former pharmacists who definitely do not go there. As others mention, the school ultimately decides if they feel comfortable graduating this kid and putting their name on his diploma. If this were NASA or some nuclear launch facility, he would get a pretty quick boot and "please come back when you fix your OC-whatever."

I think the bigger issue is that you're taking care of a person that you really don't like, to the extent that you're posting information on a public forum that he could easily see and identify. Like you said yourself, he seems to be holding you hostage with this passive aggressive threat of decompensating, diminishing your role as a physician and making you feel like an accessory. I try to remind myself if I view the patient this way, so does most of the world (I could only imagine what his mother/father/whoever were like to facilitate this behavior). You can try to therapeutically confront him with this information (particularly the "I feel like you're holding me hostage"), but my guess is that's not really the treatment frame.

 

[Fan_of_Meehl]

From the ethical perspective, I agree with some of the above posters -- most tests are pretty artificial assessments of understanding and knowledge. I'm guessing most time limits are fairly arbitrary, and very few teachers/administrators put them together with the thought "what is the exact time that will accurately simulate the time crunch of filling a prescription." And if those schools do exist, I've had some former pharmacists who definitely do not go there. As others mention, the school ultimately decides if they feel comfortable graduating this kid and putting their name on his diploma. If this were NASA or some nuclear launch facility, he would get a pretty quick boot and "please come back when you fix your OC-whatever."

I think the bigger issue is that you're taking care of a person that you really don't like, to the extent that you're posting information on a public forum that he could easily see and identify. Like you said yourself, he seems to be holding you hostage with this passive aggressive threat of decompensating, diminishing your role as a physician and making you feel like an accessory. I try to remind myself if I view the patient this way, so does most of the world (I could only imagine what his mother/father/whoever were like to facilitate this behavior). You can try to therapeutically confront him with this information (particularly the "I feel like you're holding me hostage"), but my guess is that's not really the treatment frame.

"
I try to remind myself if I view the patient this way, so does most of the world (I could only imagine what his mother/father/whoever were like to facilitate this behavior). You can try to therapeutically confront him with this information (particularly the "I feel like you're holding me hostage"), but my guess is that's not really the treatment frame.
"

This is an absolutely critical point and one that is often missed in these kinds of situations. Despite (for many complicated reasons) the reluctance of providers to provide personality disorder diagnoses, personality disorders do exist in the clinical population (quite frequently presenting in certain contexts). In these cases, the patient is in a position of having to come to therapy because, fundamentally, their approach to others, the world, and getting their needs met is largely flawed. In many situations, the flaw involves a belief (or set of beliefs) something along the lines of "I'm always being treated unfairly" or "nothing is ever my fault, I'm always the victim." Patient is having difficulty in their classes. Patient does not adopt a proactive problem-solving and responsible approach by saying, "Hmm...why did I do poorly on my last exam? Was I prepared? How much time did I spend studying? Am I pursuing an educational/occupational path that is practical and attainable for me? What else could be the problem here? What do other people *really* think might be the problem here? Could I benefit from their honest opinions or advice? *What could I do differently to try to solve this problem?*" Nah...patient approaches mental health professional to write them a 'magic letter' to 'address' the problem by legally threatening/forcing their instructor to provide special accommodations. Mental health provider knows, deep down, that they don't feel comfortable just firing off the documentation to empower/legitimize the legal threat but the provider is short on time and energy and doesn't want another headache. Nor can the provider be 'tilting at windmills' all the time and incurring the wrath of the disability bureaucracy or its minions. I get it. I've been there. You have to pick your battles and have your reasons for having and implementing professional boundaries. Coming on boards like these and venting anonymously and asking for other professionals' opinions is healthy, not dysfunctional. What's dysfunctional, I believe, is having your soul, conscience, and professional dignity stripped away, piece-by-piece over several decades to the point that whenever the next obviously personality-disordered patient comes into your office demanding that you issue a 'magic letter' to force other people to do things against their will on behalf of the patient who feels victimized by the demands of the reality of life as an adult...you don't even experience a momentary ripple of hesitation, doubt, or circumspection. You just write the letter, man. To me...that's dysfunctional.

 

[Jules A]

"
What's dysfunctional, I believe, is having your soul, conscience, and professional dignity stripped away, piece-by-piece over several decades to the point that whenever the next obviously personality-disordered patient comes into your office demanding that you issue a 'magic letter' to force other people to do things against their will on behalf of the patient who feels victimized by the demands of the reality of life as an adult...you don't even experience a momentary ripple of hesitation, doubt, or circumspection. You just write the letter, man. To me...that's dysfunctional.

Well said. I have had the unfortunate opportunity, multiple times, to work behind what was once a solid psychiatrist who decompensated to a Schedule II writing machine. In addition to my sadness at a respected colleagues' decline cleaning up the mess is most unpleasant for myself and the disgruntled patients who are attached to high dose benzos and stimulants. This is a phenomenon I have experienced most often with the ancient, needed to retire years before, docs but that isn't always the case. This discussion has been enlightening and reinforces what I have have been taught: better to rip the bandaid off than languish in the mess for years to come.

 

[PikminOC]

From the other side of this, when I teach I do not give special accomodations for individuals. Instead I give everyone the option to do whatever accomodations work for them. For example, if you want to record the lectures or get someone elses notes, great. Also, my tests are never timed so no one ever needs extra time. What is funny is that when i took away the time limit, the students finish more quickly anyway. If you need to lay on the floor because your back hurts or go to the bathroom every five minutes or even go outside to have a smoke break, be my guest. I don't require a doctor's note or a psychological evaluation for any of it (actually, I definitely don't want it). Now. if you want to cheat or plagiarize then I will fail you. If you can't show up to class and you fail the test, oh well. The entitlement that we breed with this garbage is maddening.

Whaf if during the breaks they take they are looking up the questions answers? How would you know?

 

[smalltownpsych]

Whaf if during the breaks they take they are looking up the questions answers? How would you know?

I wouldn't and I wouldn't care either although I was actually referring to regular class as sopposed to tests when I was mentioning breaks. I am not too big on trying to catch people doing bad things. I find that to be a poor strategy anyway. I'm not stupid, naive, or afraid to fail anyone though. Don't mistake my being nice for weakness is one of my favorite sayings.

 

[MacDonaldTriad]

The fire department has a lighter dead weight carry requirement for women as compared to men, but if I were in a burning building I now hope that a male fireman finds my unconscious self. I get the ADA intention, but honestly, I don't want my physician to need more time to complete an examination that is one of the only concrete measures of their competency. I know this sounds terrible, but I can't help it. This is my care I'm talking about. Now feel free to chastise me for this opinion. My reasoning will still meet the "at the end of the day...." argument.

 

[Mad Jack]

Just when you thought patients had run out of things to request of you other than diagnosis and treatment of psychiatric disorders... you get a request for a form or letter stating that they need academic accommodations. I got my first one of these today. Have you ever gotten this request? How did you handle it?

The frustrating thing for me is that this is one of those phenomena where the patient had something before, so they think it's no big deal for their new psychiatrist to give it to them again--just like the people with history of ADHD, moving in from out of state, who basically waltz into your office for an initial visit and say "yeah, I'm here to get my Adderall, kthxbye." Only this was an established patient whom I've been seeing for more than a year. Since last visit in January, he has taken the PCAT, gotten the result, and gotten accepted to pharmacy school. Then today he comes in for a routine follow-up and throws in the fact that, oh, by the way, he had academic accommodations in undergrad, which his psychiatrist at the time supported, for longer test taking times and a quiet space, and could he get those again for pharmacy school? He claims it was basically because of OCD, in that he would excessively check his work.

In my lay opinion, it would seem this would be an area where formal testing would be appropriate. But I'm not a psychometrician or neuropsychologist. This is yet another request (like ADHD evals) where I'd like to be able to simply say "sorry, I don't do that." But in my current job, I don't have the power to tailor my practice to be what I would like it to be. And I've been just giving in to this kind of thing more and more, because it just doesn't seem worth it to fight with people all day. But a little piece of me dies inside every time I give in.

Also, I have to admit, while this guy doesn't have an arrogant, entitled, or demanding demeanor--he actually comes across a little sheepish, kind of like Woody Allen only Italian and not Jewish--I do have some negative feelings toward him. This is because he is one of these people who comes to a new psychiatrist on polypharmaceutical overkill and wants you to just continue his huge cocktail, saying "I know it's a lot of meds, but it's taken me years of tweaking with my past psychiatrist to get here, and every time someone tries to change one little thing, I go off the rails." In this case, the guy's on gabapentin, an SSRI, Lyrica, propranolol AND Xanax PRN, and probably something else I'm forgetting. And you feel like you're kind of held hostage because this person is saying "please, I just need these meds, these are my meds, and if I don't get exactly this I'll decompensate."

Finally, to go a bit deeper into the subject of the thread, though I'm a layman in this area, I'm pretty skeptical of the idea of academic accommodations to begin with. I feel it's an instance of our society's "you are a special and unique snowflake, you can do anything you put your mind to" philosophy which is simply not true. The purpose of a test is to see whether you can pass it or not (or what score you get.) I don't care WHY you can't pass it, or get the score you did--whether it's because your IQ is 70, or you have dyslexia, or you have ADHD, or you have really bad OCD and spend too much time checking your work. If you don't make the cut, you don't make the cut. I mean, when this guy becomes a pharmacist, is he going to get a letter from a psychiatrist saying that the pharmacy he works for has to pay him the same salary as the other pharmacists despite his only doing 2/3 the amount of work, because his OCD makes him slow?

What do you all think?

Tests of this nature are designed to determine competence. If you cannot complete the test on time because of OCD, that doesn't mean you're incompetent, it just means you're slow compared to an arbitrary time they decided to allow for the exam. The questions are objectively correct or incorrect, but the timing standards and environment for testing are arbitrarily established and have no objective contribution with regard to determining competence in a given domain. In this regard I think that accommodations are reasonable, but that they should be noted in a student's file, as they may have an adequate domain of knowledge and ability to use it, but will not be up to the standards set by some employers for efficiency.

 

[Mad Jack]

The fire department has a lighter dead weight carry requirement for women as compared to men, but if I were in a burning building I now hope that a male fireman finds my unconscious self. I get the ADA intention, but honestly, I don't want my physician to need more time to complete an examination that is one of the only concrete measures of their competency. I know this sounds terrible, but I can't help it. This is my care I'm talking about. Now feel free to chastise me for this opinion. My reasoning will still meet the "at the end of the day...." argument.

I wouldn't care if my physician took longer to examine me, I'd more care about whether they could come to the right conclusions regarding their examination. Their employer, on the other hand, might not be so thrilled with their lack of output.

 

[thoffen]

Tests of this nature are designed to determine competence. If you cannot complete the test on time because of OCD, that doesn't mean you're incompetent, it just means you're slow compared to an arbitrary time they decided to allow for the exam. The questions are objectively correct or incorrect, but the timing standards and environment for testing are arbitrarily established and have no objective contribution with regard to determining competence in a given domain. In this regard I think that accommodations are reasonable, but that they should be noted in a student's file, as they may have an adequate domain of knowledge and ability to use it, but will not be up to the standards set by some employers for efficiency.

That is one possibility and it sounds a reasonable interpretation of the described scenario, however it is not the only one. What if the patient does not have OCD? What if a series of accommodations approved by you allows him to graduate school, practice as a pharmacist, and ultimately harm a patient as a result of whatever illness is there that drove the accommodation requests in the first place?

Separately, it is possible that this patient has a significant personality disorder and the dynamic he is engaging in is causing the OP to experience negative countertransference and yet the intervention itself is appropriate. When a pathologic dynamic is operating within a psychiatric treatment choice as is often the case with medicines, hospitalization, accommodation requests, etc., this does not mean that we restrict ourselves from providing the intervention because what's really going on is the patient's personality disorder. What we need to do is our best (sometimes requiring consult with colleagues or transfer of care) to look at the interventions we provide separate from our countertransference and do or not do the interventions based on whether they are actually the right treatment. And we also need to do something with that countertransference, hopefully using it in a therapeutic way that allows for identification of and treatment of an important and neglected site of pathology.

 

[Mad Jack]

That is one possibility and it sounds a reasonable interpretation of the described scenario, however it is not the only one. What if the patient does not have OCD? What if a series of accommodations approved by you allows him to graduate school, practice as a pharmacist, and ultimately harm a patient as a result of whatever illness is there that drove the accommodation requests in the first place?

Separately, it is possible that this patient has a significant personality disorder and the dynamic he is engaging in is causing the OP to experience negative countertransference and yet the intervention itself is appropriate. When a pathologic dynamic is operating within a psychiatric treatment choice as is often the case with medicines, hospitalization, accommodation requests, etc., this does not mean that we restrict ourselves from providing the intervention because what's really going on is the patient's personality disorder. What we need to do is our best (sometimes requiring consult with colleagues or transfer of care) to look at the interventions we provide separate from our countertransference and do or not do the interventions based on whether they are actually the right treatment. And we also need to do something with that countertransference, hopefully using it in a therapeutic way that allows for identification of and treatment of an important and neglected site of pathology.

It was just an example, and not meant to be illustrative of the particular scenario at hand. The most common reasons I've seen for test accommodations are anxiety (environment), dyslexia or other learning disabilities that require extra time, and ADHD (environment/sometimes time). Accommodations should be both reasonable for the condition and appropriate for the test being administered, which is at the discretion of the individual writing for the accommodations so I can't speak for OP.

 

[PikminOC]

Well said. I have had the unfortunate opportunity, multiple times, to work behind what was once a solid psychiatrist who decompensated to a Schedule II writing machine. In addition to my sadness at a respected colleagues' decline cleaning up the mess is most unpleasant for myself and the disgruntled patients who are attached to high dose benzos and stimulants. This is a phenomenon I have experienced most often with the ancient, needed to retire years before, docs but that isn't always the case. This discussion has been enlightening and reinforces what I have have been taught: better to rip the bandaid off than languish in the mess for years to come.

Yes, they become pill mills to pay off the lake house and boat

 

[Salpingo]

"
I try to remind myself if I view the patient this way, so does most of the world (I could only imagine what his mother/father/whoever were like to facilitate this behavior). You can try to therapeutically confront him with this information (particularly the "I feel like you're holding me hostage"), but my guess is that's not really the treatment frame.
"

This is an absolutely critical point and one that is often missed in these kinds of situations. Despite (for many complicated reasons) the reluctance of providers to provide personality disorder diagnoses, personality disorders do exist in the clinical population (quite frequently presenting in certain contexts). In these cases, the patient is in a position of having to come to therapy because, fundamentally, their approach to others, the world, and getting their needs met is largely flawed. In many situations, the flaw involves a belief (or set of beliefs) something along the lines of "I'm always being treated unfairly" or "nothing is ever my fault, I'm always the victim." Patient is having difficulty in their classes. Patient does not adopt a proactive problem-solving and responsible approach by saying, "Hmm...why did I do poorly on my last exam? Was I prepared? How much time did I spend studying? Am I pursuing an educational/occupational path that is practical and attainable for me? What else could be the problem here? What do other people *really* think might be the problem here? Could I benefit from their honest opinions or advice? *What could I do differently to try to solve this problem?*" Nah...patient approaches mental health professional to write them a 'magic letter' to 'address' the problem by legally threatening/forcing their instructor to provide special accommodations. Mental health provider knows, deep down, that they don't feel comfortable just firing off the documentation to empower/legitimize the legal threat but the provider is short on time and energy and doesn't want another headache. Nor can the provider be 'tilting at windmills' all the time and incurring the wrath of the disability bureaucracy or its minions. I get it. I've been there. You have to pick your battles and have your reasons for having and implementing professional boundaries. Coming on boards like these and venting anonymously and asking for other professionals' opinions is healthy, not dysfunctional. What's dysfunctional, I believe, is having your soul, conscience, and professional dignity stripped away, piece-by-piece over several decades to the point that whenever the next obviously personality-disordered patient comes into your office demanding that you issue a 'magic letter' to force other people to do things against their will on behalf of the patient who feels victimized by the demands of the reality of life as an adult...you don't even experience a momentary ripple of hesitation, doubt, or circumspection. You just write the letter, man. To me...that's dysfunctional.

I find that to be the most challenging but rewarding aspect of psychiatry - getting the patient from the paranoid-schizoid position that there troubles stem from an external source, to the depressive state that they are now ultimately responsible for their own suffering, giving them agency to grow.

Unfortunately, I’ve gone through a parallel process as a psychiatrist, believing there are too many external forces stacked against that shift, that there’s too much incentive towards disability and away from wellness, with medicalization of mental illness partially removing stigma but also a sense of personal agency.

Which is why being in therapy myself is helpful.

 

[thoffen]

I find that to be the most challenging but rewarding aspect of psychiatry - getting the patient from the paranoid-schizoid position that there troubles stem from an external source, to the depressive state that they are now ultimately responsible for their own suffering, giving them agency to grow.

Unfortunately, I’ve gone through a parallel process as a psychiatrist, believing there are too many external forces stacked against that shift, that there’s too much incentive towards disability and away from wellness, with medicalization of mental illness partially removing stigma but also a sense of personal agency.

Which is why being in therapy myself is helpful.

Melanie? Is that you? 🙂

I think your conclusion is a powerful one, and it may reflect which side most frequently wins in our system. But it's my belief that all people enter treatment in some state of ambivalence. They want growth to escape their pathology. And they also want external reinforcement to keep responsibility off their shoulders. Regardless of which they are asking for, everyone wants both.

 

[MacDonaldTriad]

before growth, there is always that part that makes you feel like a Christian Scientist with an appendicitis.

 

[erg923]

To the physicians who are doing this:

Why are you doing this? You don't know if this is the case or not? What are you even basing your opinion of this this on? The diagnosis? Observation of unrelated behaviors in an obviously artificial setting?

 

[AcronymAllergy]

I'll almost always defer to the university/school or testing organization on this. If I'd conducted an actual psychoeducational evaluation, then I'd make recommendations if appropriate (high-stakes reports generally suck to write, btw). If not, in some instances (e.g., if I have evidence of objective impairment), I'll suggest that accommodations may be beneficial due to X or Y; without evidence, I'll encourage the patient to talk to the school. If the patient requested a letter specifically about accommodations and I wasn't sure they were warranted (or that recommendation wouldn't appear supported by/didn't relate to my assessment), I'd essentially give them a letter saying I'd assessed/treated them for X, and that the results of my assessment indicated Y.

When in doubt, you can also always consult the literature (e.g., does research suggest accommodations are helpful for OCD in an academic setting?)