Settle a disagreement

[Sanman]

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If it's anything like here, nothing. Most of these people get work purely because they will throw out trash diagnoses, especially in the PI IME world.

PI IME?

 

[psych.meout]

PI IME?

Personal injury IME?

 

[Therapist4Chnge]

If it's anything like here, nothing. Most of these people get work purely because they will throw out trash diagnoses, especially in the PI IME world.

95% of the time nothing happens.

For a workers comp case, sometimes the case manager/adjustor will contact me for a one-off case to review, but mostly the bad clinicians still get work, and I get paid $$$ to shred their work. Workers Comp IMEs can be slightly different than traditional IMEs, but that gets a bit too in the weeds for this discussion.

I get a decent amount of referrals from opposing counsels where I shredded their expert(s) in my IMEs in an earlier case, and they track me down to retain me for another case. I’m picky with the cases I choose, but I love whenever a lawyer admits I was on the other side and they settled the case.

PI = Personal Injury
IME = Independent Medical Evaluation (aka generic term for a forensic report)

 

[Sanman]

95% of the time nothing happens.

For a workers comp case, sometimes the case manager/adjustor will contact me for a one-off case to review, but mostly the bad clinicians still get work, and I get paid $$$ to shred their work. Workers Comp IMEs can be slightly different than traditional IMEs, but that gets a bit too in the weeds for this discussion.

I get a decent amount of referrals from opposing counsels where I shredded their expert(s) in my IMEs in an earlier case, and they track me down to retain me for another case. I’m picky with the cases I choose, but I love whenever a lawyer admits I was on the other side and they settled the case.

PI = Personal Injury
IME = Independent Medical Evaluation (aka generic term for a forensic report)

Very familiar with IMEs. The PI threw me for a loop while I was multitasking. Didn't hit me till later.

 

[bluebird-23]

I have a colleague/friend who works for a hospital system. She has a client with cluster b traits that is fairly stable. Her problem has been that you can’t add traits to the problem list. So she added bpd to the problem list since traits weren’t available. Honestly, I had a problem with it. The client fired her and has filed a complaint she will lose. So was my colleague right to add bpd when it was just traits or was I right to say not to add a stigmatizing diagnosis that was not accurate??

Wow, this sounds wildly unethical of the provider. Not because BPD is a stigmatizing diagnosis (although it is, of course) but because it does not sound like the diagnosis was made properly or ethically. Your colleague noticing some cluster B traits does not constitute a BPD diagnosis, it should have been conducted more thoroughly and formally to ensure that client truly does meet full diagnostic criteria along with a rationale about differential diagnosis. Because it is such a stigmatizing diagnosis, I do think the provider owes the client extra caution in ensuring that this diagnosis truly fits, i.e. consulting with an expert (is the provider an expert in BPD/BPD diagnosis?) and then once the diagnosis is made, the provider has an ethical (and professional) obligation to explain the diagnosis, describe rationale clearly and answer any questions, and how this impacts the treatment plan. The client should not find out about this diagnosis in their chart/through indirect means. This provider's behavior is undermining the credibility of clinical psychology licensure.

 

[statsprof]

If it's anything like here, nothing. Most of these people get work purely because they will throw out trash diagnoses, especially in the PI IME world.

All too common.

 

[msc545]

I have a colleague/friend who works for a hospital system. She has a client with cluster b traits that is fairly stable. Her problem has been that you can’t add traits to the problem list. So she added bpd to the problem list since traits weren’t available. Honestly, I had a problem with it. The client fired her and has filed a complaint she will lose. So was my colleague right to add bpd when it was just traits or was I right to say not to add a stigmatizing diagnosis that was not accurate??

Just essentially hiding the Dx by not writing it in the chart would, in my view, been far worse than doing what she did. Bpd is a serious dx with high suicide risk, and even "traits" need to be noted somehow. Perhaps she could and should have made bpd a provisional dx, but *something* about it needed to be in that chart to alert other providers, since people with bpd or even just "traits" are often a danger to themselves and to the people trying to treat them, thus the supposed "stigma". I also want to note that in my view there is nothing inherently stigmatizing about using the bpd dx in a confidential medical document - it is not like this provider posted it on Facebook or that the public has access to it.

 

[msc545]

Wow, this sounds wildly unethical of the provider. Not because BPD is a stigmatizing diagnosis (although it is, of course) but because it does not sound like the diagnosis was made properly or ethically. Your colleague noticing some cluster B traits does not constitute a BPD diagnosis, it should have been conducted more thoroughly and formally to ensure that client truly does meet full diagnostic criteria along with a rationale about differential diagnosis. Because it is such a stigmatizing diagnosis, I do think the provider owes the client extra caution in ensuring that this diagnosis truly fits, i.e. consulting with an expert (is the provider an expert in BPD/BPD diagnosis?) and then once the diagnosis is made, the provider has an ethical (and professional) obligation to explain the diagnosis, describe rationale clearly and answer any questions, and how this impacts the treatment plan. The client should not find out about this diagnosis in their chart/through indirect means. This provider's behavior is undermining the credibility of clinical psychology licensure.

Really? Where is the valid research that indicates that BPD is a stigmatizing Dx? Even if stigma exists, is it more severe than a suicide that occurs because the actual disorder was not diagnosed or listed and proper precautions were not taken?

 

[bluebird-23]

Really? Where is the valid research that indicates that BPD is a stigmatizing Dx? Even if stigma exists, is it more severe than a suicide that occurs because the actual disorder was not diagnosed or listed and proper precautions were not taken?

I never said the diagnosis should not be given if it is accurate. The problem is that it sounds like it's simply therapist's conjecture, not a proper assessment. Further, you're talking as if the client is detached from their own care - labeling someone with a diagnosis in their chart without explaining the diagnosis (including rationale for why it was made) or answering any questions that come up could cause harm in itself. Your question of "where is the valid research" shows me a) that you did not search very hard for valid research and b) that you do not have experience working with folk with BPD. But here are some examples of where stigma comes up, just to be thorough: "premature termination of treatment, rationalization of treatment failures, a lower likelihood of forming an effective treatment alliance with patients, emotional and social distancing, difficulty empathizing, a lack of belief in recovery, and perceptions of patients as powerful, unrelenting, dangerous, manipulative and more in control of their behaviors than other patients" (Knack et al, 2015). Since they were citing multiple studies in this statement, to be thorough, I searched into some of these papers to ensure that there was empirical data and not just opinion and indeed there have been plenty of studies showing that clinicians tend to have unfavorable views/negative biases toward individuals who have received a personality disorder diagnosis. THIS IMPACTS CARE. So diagnosing should be done accurately and carefully, as it should with any disorder, regardless of stigma - but the added stigma has added implications for the client.

It's also silly to suggest that you could prevent suicide by diagnosis BPD vs not diagnosing it. If anything, a BPD diagnosis is likely to make clinicians take the client LESS seriously if they report suicidal ideation. A BPD diagnosis does not confer suicide risk on its own. Are you confusing borderline personality disorder and bipolar disorder? The latter has more implications for proper diagnosis-based treatment in the case of depression. No matter the presenting problem, suicide risk should be assessed separately. You don't need a mental illness diagnosis to be at risk for suicide.

 

[bluebird-23]

Just essentially hiding the Dx by not writing it in the chart would, in my view, been far worse than doing what she did. Bpd is a serious dx with high suicide risk, and even "traits" need to be noted somehow. Perhaps she could and should have made bpd a provisional dx, but *something* about it needed to be in that chart to alert other providers, since people with bpd or even just "traits" are often a danger to themselves and to the people trying to treat them, thus the supposed "stigma". I also want to note that in my view there is nothing inherently stigmatizing about using the bpd dx in a confidential medical document - it is not like this provider posted it on Facebook or that the public has access to it.

It sounds as if you have your own stigma against people with BPD. "people with bpd or even just 'traits' are often a danger to themselves and to the people who treat them' - I'm sorry, where does this statement come from? It's certainly true that many with BPD self-harm, have suicidal ideation, and engage in risky behavior. But not everyone with the diagnosis is necessarily a risk to themselves, and you can't know that from the BPD diagnosis, you know that from their behavior, which should be documented in the chart. But how does having a diagnosis of BPD make someone a danger to the people who treat them? That's bull****, and along the lines of clinicians who think that those with BPD are manipulative - a judgmental point of view not in line with leading theories of BPD. Clinicians who have inadequate training or who are not competent in maintaining boundaries may struggle to treat someone with BPD or BPD traits, but that is on them, and their responsibility to refer to someone more equipped. It's not the client being a danger to their clinician.

 

[msc545]

It sounds as if you have your own stigma against people with BPD. "people with bpd or even just 'traits' are often a danger to themselves and to the people who treat them' - I'm sorry, where does this statement come from? It's certainly true that many with BPD self-harm, have suicidal ideation, and engage in risky behavior. But not everyone with the diagnosis is necessarily a risk to themselves, and you can't know that from the BPD diagnosis, you know that from their behavior, which should be documented in the chart. But how does having a diagnosis of BPD make someone a danger to the people who treat them? That's bull****, and along the lines of clinicians who think that those with BPD are manipulative - a judgmental point of view not in line with leading theories of BPD. Clinicians who have inadequate training or who are not competent in maintaining boundaries may struggle to treat someone with BPD or BPD traits, but that is on them, and their responsibility to refer to someone more equipped. It's not the client being a danger to their clinician.

It sounds to me like you have been diagnosed with BPD yourself at some point, given your frantic struggles here to somehow make it a "benign" condition - which it most certainly is not. I am not going to be drawn into your struggle here other than to note that anyone who has attempted to treat a patient with BPD knows empirically and experientially that most if not all of your points are, as you so delicately mentioned, self-serving bull****.

 

[WisNeuro]

 

[statsprof]

Really? Where is the valid research that indicates that BPD is a stigmatizing Dx? Even if stigma exists, is it more severe than a suicide that occurs because the actual disorder was not diagnosed or listed and proper precautions were not taken?

BPD is surely very stigmatizing.

 

[AcronymAllergy]

Mod Note: Reminder to keep all messages professional and respectful. Thanks.

 

[smalltownpsych]

It sounds as if you have your own stigma against people with BPD. "people with bpd or even just 'traits' are often a danger to themselves and to the people who treat them' - I'm sorry, where does this statement come from? It's certainly true that many with BPD self-harm, have suicidal ideation, and engage in risky behavior. But not everyone with the diagnosis is necessarily a risk to themselves, and you can't know that from the BPD diagnosis, you know that from their behavior, which should be documented in the chart. But how does having a diagnosis of BPD make someone a danger to the people who treat them? That's bull****, and along the lines of clinicians who think that those with BPD are manipulative - a judgmental point of view not in line with leading theories of BPD. Clinicians who have inadequate training or who are not competent in maintaining boundaries may struggle to treat someone with BPD or BPD traits, but that is on them, and their responsibility to refer to someone more equipped. It's not the client being a danger to their clinician.

So many clinicians seem to hold on to this “manipulative patients with borderline” perspective. It is funny that a key component of DBT is to teach interpersonal effectiveness skills to help patients get their needs met from others. In other words, I would say that my patients with Borderline PD are actually not good at manipulation and that is part of their problem. Of course, if you have fears of abandonment as part of your perspective, then the interpersonal needs are like a bottomless pit in some ways, hence some of the difficulties with treatment and patients tendencies to try and push through boundaries. Clinicians that understand this are much better at helping these patients and those that don’t continue perpetuating inaccurate negative stereotypes of mental illness.

 

[WisNeuro]

So many clinicians seem to hold on to this “manipulative patients with borderline” perspective. It is funny that a key component of DBT is to teach interpersonal effectiveness skills to help patients get their needs met from others. In other words, I would say that my patients with Borderline PD are actually not good at manipulation and that is part of their problem. Of course, if you have fears of abandonment as part of your perspective, then the interpersonal needs are like a bottomless pit in some ways, hence some of the difficulties with treatment and patients tendencies to try and push through boundaries. Clinicians that understand this are much better at helping these patients and those that don’t continue perpetuating inaccurate negative stereotypes of mental illness.

Also my experience in the past when I did this work.

 

[R. Matey]

Bpd is a serious dx with high suicide risk, and even "traits" need to be noted somehow

If they're impairing, certainly. If not, there is no need.

 

[msc545]

If they're impairing, certainly. If not, there is no need.

There is absolutely a need since traits may become a reality before you can do anything about the consequences.

 

[psych.meout]

There is absolutely a need since traits may become a reality before you can do anything about the consequences.

What does "become a reality" mean in this context?

 

[R. Matey]

There is absolutely a need since traits may become a reality before you can do anything about the consequences.

I'm uncertain of your meaning. Those with borderline traits may have some problems with affective instability that may be well-controlled with prior intervention or a supportive nurturing environment. See this paper as an example.

 

[msc545]

I'm uncertain of your meaning. Those with borderline traits may have some problems with affective instability that may be well-controlled with prior intervention or a supportive nurturing environment. See this paper as an example.

Apparently you and I have been around different kinds of borderlines. I have watched ones that were diagnosed with "traits" explode behaviorally without much prior warning. I am not inclined to minimize the potential dangers they present to themselves and others even if such warnings hurt their feelings.

The article you referenced seems to have little to do with what we are now discussing, although only the abstract was available.

 

[msc545]

BPD is surely very stigmatizing.

That is the least of the problems with it. Saying it is stigmatizing is like saying that antisocial behavior is stigmatizing and implying that it should not be somehow.

 

[WisNeuro]

This thread is absolutely wild.

 

[smalltownpsych]

Apparently you and I have been around different kinds of borderlines. I have watched ones that were diagnosed with "traits" explode behaviorally without much prior warning. I am not inclined to minimize the potential dangers they present to themselves and others even if such warnings hurt their feelings.

The article you referenced seems to have little to do with what we are now discussing, although only the abstract was available.

I have been working with patients with Borderline PD for years and have not seen this. I did know of one patient who was obnoxious as hell and used emotionality to try and get her way by screaming and throwing fits. Some clinicians would call her Borderline just because she was so obnoxious but she was really just a grown up spoiled child. After two years of poor treatment that consisted of validating her bad behavior and blaming others for not being more understanding, she came to me and made rapid progress because I focused on the maladaptive and immature pattern and she was smart enough to see that there were better ways of interacting that wouldn’t make people hate her.

The only other time I have had patients with Borderline PD blow up is when they are trauma victims and people put hands on them and the situation escalates and then they end up with a biting, scratching, kicking animal response. My attitude is, keep your f’ing hands off my patients.

Also, your language is not very patient centric and borderline demeaning and is characteristic of the type of attitude that will lead to bad patients interactions with highly interpersonally sensitive patients.

 

[R. Matey]

Apparently you and I have been around different kinds of borderlines. I have watched ones that were diagnosed with "traits" explode behaviorally without much prior warning. I am not inclined to minimize the potential dangers they present to themselves and others even if such warnings hurt their feelings.

I encourage you to review your own heuristics before painting all patients with a specific condition with the same brush.

 

[WisNeuro]

I encourage you to review your own heuristics before painting all patients with a specific condition with the same brush.

Broad brushes are sometimes the only brushes some people have.

 

[R. Matey]

Broad brushes are sometimes the only brushes some people have.

Yeah, I probably need to stop assuming that most psychologists have a working knowledge of trait theory.

 

[psych.meout]

Apparently you and I have been around different kinds of borderlines. I have watched ones that were diagnosed with "traits" explode behaviorally without much prior warning. I am not inclined to minimize the potential dangers they present to themselves and others even if such warnings hurt their feelings.

The article you referenced seems to have little to do with what we are now discussing, although only the abstract was available.

Weren't you recently expressing skepticism about BPD being stigmatized? This (as well as calling these patients "borderlines") sure seems like an example of stigmatization, no?

Yeah, I probably need to stop assuming that most psychologists have a working knowledge of trait theory.

There are many domains of knowledge and experience in which many psychologists are lacking.

 

[statsprof]

That is the least of the problems with it. Saying it is stigmatizing is like saying that antisocial behavior is stigmatizing and implying that it should not be somehow.

Well, yes there are other issues to be sure with BPD. Those who meet atleast 5 of the DSM V criteria for BPD will definitely face ups and downs and can potentially be dangerous to them and others. The issue here was originally diagnosing a client with BPD when they do not meet enough if any criteria. That is an ethical concern to day the least.

Next, I do not think it is helpful to minimize BPD based risks, and not to mention common comorbidities with BPD... Also the suicide attempts and successes are higher amongg those with BPD: 70%/10%, respectively and violent crime is higher too among those with BPD. However, diagnosing BPD is not easy, and it takes more time than a plethora of other disorders as it has significant clinical overlap with several other disorders.

I will say that when someone with bipolar disorder and BPD properly diagosed is observed there is far higher rates of violent/self harm behavior, outbursts, and dissociated amnesia. Trying to determine if one has one or the other requires some robust differential diagnosis.

That being said, those with BPD are not inherently manipulative and those who are need to be carefully observed and assessed to figure out why.

 

[statsprof]

Weren't you recently expressing skepticism about BPD being stigmatized? This (as well as calling these patients "borderlines") sure seems like an example of stigmatization, no?


There are many domains of knowledge and experience in which many psychologists are lacking.

Trait theory is only one of a plethora of useful personality psychology methods. I am not sure why mcs545 feels that is the crux of their argument.

 

[statsprof]

This thread is absolutely wild.

Yeah. I see alot of pent up frustration and egoes getting the better of some.

 

[Freud’sMommy]

 

[statsprof]

100%

 

[psych.meout]

I miss Trevor. 🙁

 

[psychma]

There’s no doubt that bpd carries stigma. It’s all over this thread in subtle ways. The problem that I see with the associated stigma is that there are studies suggest that people who are diagnosed with bpd get a lower quality of healthcare and their problems are perceived to be self-created so care is less empathetic. While I’m on the topic, the majority of borderline diagnoses I’ve seen have a significant trauma history and a suicide attempt or gesture. Anecdotally story. Men admitted with this presentation usually got an MDD diagnosis. Women got a bpd diagnosis. I don’t know the research on whether this is a thing and at 2am too lazy to look up. What I do know is that at staff meetings there was a focus on male patients being depressed and female patients looking for attention.

 

[psychma]

Forgive the mistakes. It’s 2am and time for me to go to bed!

 

[statsprof]

There’s no doubt that bpd carries stigma. It’s all over this thread in subtle ways. The problem that I see with the associated stigma is that there are studies suggest that people who are diagnosed with bpd get a lower quality of healthcare and their problems are perceived to be self-created so care is less empathetic. While I’m on the topic, the majority of borderline diagnoses I’ve seen have a significant trauma history and a suicide attempt or gesture. Anecdotally story. Men admitted with this presentation usually got an MDD diagnosis. Women got a bpd diagnosis. I don’t know the research on whether this is a thing and at 2am too lazy to look up. What I do know is that at staff meetings there was a focus on male patients being depressed and female patients looking for attention.

All fair and accurate, I think.

 

[bluebird-23]

It sounds to me like you have been diagnosed with BPD yourself at some point, given your frantic struggles here to somehow make it a "benign" condition - which it most certainly is not. I am not going to be drawn into your struggle here other than to note that anyone who has attempted to treat a patient with BPD knows empirically and experientially that most if not all of your points are, as you so delicately mentioned, self-serving bull****.

No personal diagnosis but professional experience treating young adults with BPD among a team of Linehan-certified clinicians. As a scientist and clinician I am disheartened by the unhindered judgment/bias coming from overconfident clinicians who think they know better than evidence.

 

[Fan_of_Meehl]

The majority of our job is asking questions no one wants to ask and making statements that no one wants to say. I don't understand why a psychologist would be hesitant to ask or say ANYTHING. We are paid to have very difficult conversations.

But I think the sentiment you are identifying is the field's move from therapeutic confrontation, to collusion with the patient. There are some areas in which psychology has not moved towards collusion (e.g., cognitive assessment). But psychotherapy sure seems to have transitioned from helping people overcome their struggles, to colluding with patients to tell them that their struggles make overcoming things impossible.

I am going to provide a hypothetical (but commonly encountered) scenario to enunciate this point.

Say a veteran has an extensive history (going back about 15 years) of encountering MANY mental health providers (many doctoral-level) in the VA system and NONE of them have ever diagnosed PTSD or a trauma- or stressor-related disorder. Instead, they diagnose disorders like major depressive disorder, 'anxiety' (not a disorder, I know), substance abuse. Then veteran has an extensive, thorough psychological assessment/ workup (say, by an intern or a provider who knows what they're doing) utilizing such things as structured interview (CAPS-5 or SCID-5), objective psychological testing (MMPI-2-RF, or PAI, or MCMI), extensive interviewing around Criterion A, actually attempting to examine the 'association' (if present) between the putative stressors and current symptoms, examining co-morbid conditions and their association with current symptoms, etc., etc. Takes several sessions, several reports/notes, and a good deal of time and effort. They fail to uphold a diagnosis of PTSD and, instead, rule it out.

Veteran turns around and complains, 'fires' the clinician who ruled out PTSD and another therapist in the same service enters a consult for assessment/treatment for 'therapy.' Then a therapist slaps a PTSD diagnosis (first one for that patient, ever) on the chart (with absolutely NO justification whatsoever...not even a PCL-5...literally just the four letters 'P' 'T' 'S' and 'D' all capitalized and in order. That's the justification for the diagnosis. As a result of that 'diagnosis,' a consult is entered for the PCT (specialty clinic) for treatment of PTSD.

Let's assume that we may be dealing with a (not uncommon) scenario that a patient with non-PTSD psychopathology (substance abuse, personality dysfunction, depression/anxiety/neurosis) has actual psychopathology that needs to be honestly and accurately worked up and treated psychotherapeutically, but said type of patient may be seeking 'an answer' to the question 'WHY?' as in 'why do I get angry and mean and aggressive with people.' Obviously fishing for the collusive lying response from a clinician ('because of your PTSD.'). Parenthetically, if I never heard the phrase 'I had a PTSD episode' as a referent for an episode of emotion dysregulation and inappropriate/aggressive outburst again...that'd be awesome.

 

[ccpsych16]

I am going to provide a hypothetical (but commonly encountered) scenario to enunciate this point.

Say a veteran has an extensive history (going back about 15 years) of encountering MANY mental health providers (many doctoral-level) in the VA system and NONE of them have ever diagnosed PTSD or a trauma- or stressor-related disorder. Instead, they diagnose disorders like major depressive disorder, 'anxiety' (not a disorder, I know), substance abuse. Then veteran has an extensive, thorough psychological assessment/ workup (say, by an intern or a provider who knows what they're doing) utilizing such things as structured interview (CAPS-5 or SCID-5), objective psychological testing (MMPI-2-RF, or PAI, or MCMI), extensive interviewing around Criterion A, actually attempting to examine the 'association' (if present) between the putative stressors and current symptoms, examining co-morbid conditions and their association with current symptoms, etc., etc. Takes several sessions, several reports/notes, and a good deal of time and effort. They fail to uphold a diagnosis of PTSD and, instead, rule it out.

Veteran turns around and complains, 'fires' the clinician who ruled out PTSD and another therapist in the same service enters a consult for assessment/treatment for 'therapy.' Then a therapist slaps a PTSD diagnosis (first one for that patient, ever) on the chart (with absolutely NO justification whatsoever...not even a PCL-5...literally just the four letters 'P' 'T' 'S' and 'D' all capitalized and in order. That's the justification for the diagnosis. As a result of that 'diagnosis,' a consult is entered for the PCT (specialty clinic) for treatment of PTSD.

Let's assume that we may be dealing with a (not uncommon) scenario that a patient with non-PTSD psychopathology (substance abuse, personality dysfunction, depression/anxiety/neurosis) has actual psychopathology that needs to be honestly and accurately worked up and treated psychotherapeutically, but said type of patient may be seeking 'an answer' to the question 'WHY?' as in 'why do I get angry and mean and aggressive with people.' Obviously fishing for the collusive lying response from a clinician ('because of your PTSD.'). Parenthetically, if I never heard the phrase 'I had a PTSD episode' as a referent for an episode of emotion dysregulation and inappropriate/aggressive outburst again...that'd be awesome.

I am so sick of hearing “my PTSD” this or that, “it’s because of my PTSD”, etc. It’s like a badge of honor that many keep coming in to therapy for to “work on”, but they don’t actually want to get rid of. Relatedly, I’ve been “fired” by several Vets who did not like that I told them that a diagnosis at one time does not mean that they always meet criteria, forever. They attribute everything to PTSD even when not remotely related (e.g., “I can’t handle the stress of losing my job and my parent dying….it’s because of my PTSD from 30 years ago”).

 

[Fan_of_Meehl]

I am so sick of hearing “my PTSD” this or that, “it’s because of my PTSD”, etc. It’s like a badge of honor that many keep coming in to therapy for to “work on”, but they don’t actually want to get rid of. Relatedly, I’ve been “fired” by several Vets who did not like that I told them that a diagnosis at one time does not mean that they always meet criteria, forever. They attribute everything to PTSD even when not remotely related (e.g., “I can’t handle the stress of losing my job and my parent dying….it’s because of my PTSD from 30 years ago”).

I don't see veterans in therapeutic settings challenged appropriately/professionally enough on this type of reasoning--which I think is our job. As personally frustrating as it can be, we can certainly 'challenge' this way of thinking by offering an alternative perspective on what may be a better way to think about or change a clinical problem like anger and associated behavior that has negative consequences. Unfortunately, we work in a system that--frankly--includes a number of people who either should or do know better who would label this type of therapeutic intervention as being 'problematic' or not being an 'advocate' for veterans. They are generally unskilled or unethical clinicians who want to capitalize on the social capital gained by ostentatiously transmitting a social message of 'look at me, look at how much I DEEPLY CARE about veterans' (while they actually offer substandard care) and 'look at how much this other provider (who offers standard of care and therapeutic honesty that may upset a veteran) does not.' I'm sorry, but if we are going to survive as an organization (yeah, I know, we may not want to), we're going to have to stop pretending that this isn't a problem.

'I blew up at my wife and got in her face and screamed at her because of my PTSD' isn't a helpful way of thinking about it and won't generally lead to therapeutic solutions or progress going forward. I hate to use the word 'excuse' but basically 'I acted this way because of my diagnosis (or because certain stressors occurred 15 years ago)' serves functionally as a way of deflecting responsibility to 'causes' or 'explanations' that are fixed, immutable, and impossible to change. It is also, of course, an example of tautological (circular) reasoning that is all too common in MH circles. "anger/irritability" is one of the symptoms (criteria) of PTSD. I 'have PTSD' because I have the symptoms of PTSD (one of which is anger). 'I get angry because of my PTSD' is simply a re-discription masquerading as an explanation. This is one (of a million) examples of why training in the philosophy of science and scientific reasoning is so crucial in the training of mental health professionals and why (thankfully) grad programs are starting to formally train on this stuff.

Rather (of course), a psychotherapeutic approach involves a focus on self-evaluation and self-change within the context of an individualized cognitive-behavioral case formulation that has the purpose and hope of helping a client develop increased awareness of and potentially control over the chain of events (in terms of patterns of thought/emotion/action) resulting in the behavior that the client is motivated to change. I am reminded of an exchange with a veteran years ago (one that I will never forget) when, in response to my question of what his goals for therapy might be, he responded, "I want to have less responsibility." I won't go into what happened after that but...well...we basically had an honest conversation the upshot of which is that--if you are seeking to engage in a course of effective psychotherapy--you are actually REQUESTING (and had better be expecting) to take more responsibility.

Successfully engaging the veteran population, especially the non-cherry-picked-cases that present to mental health clinics at VA is an incredibly complex and nuanced endeavor but one which the organization greatly seeks to over-simplify to the detriment of all involved.

 

[smalltownpsych]

As far as the indiscriminate validation leading to collusion, 100% agree this is a rampant problem. I do believe in healthy validation and validate patients when they are wrong all the time. I even validate that it is okay to be wrong. I just won’t agree with them and point out that it is okay to agree to disagree. If they don’t want to explore alternative perspectives, then they are with the wrong clinician and hey can stay as sick as they want to be. Since I don’t engage in the arguments and debates and just stick to my perspectives and separate from the outcome, it usually goes pretty well. In other words, they tend to not get too upset since I won’t fight with them. I just won’t do or say what they think they want me to.

Patient comes to mind with Borderline PD that no one seems to want to diagnose. Patient wants DID, parents want Bipolar and former testing says Bipolar. Patient reports multiple sexual assaults and molestation and significant symptoms of PTSD so thats what I put in the chart. Former testing said trauma disorder NOS or something to that effect because of inability to confirm trauma actually happened and tendency of patient to make inconsistent and exaggerated or false reports. Also, I think they were giving diagnoses parents would agree with.

This brings to mind an interesting distinction between an objective assessment as opposed to a collaborative diagnosis for use in treatment. This is a distinction that our field should endeavor to clarify in some way. One way I answered the distinction is that I base my treatment diagnosis on self report of symptoms and it is not based on a formal assessment with validity checks. The other point is in treatment I don’t just tell the patient everything directly right away because they can’t handle the truth. It is a process. I think about how Motivational Interviewing works. I could tell them what they have to do to deal with their problem from day one and since they are in denial, they aren’t going to come back and received no help or I could work with them on evakuating their use and determining if it is problematic for them and then how to deal with it. The diagnosis is going to reflect some of this process and not necessarily what I think is the “truth”.

 

[Sanman]

I don't see veterans in therapeutic settings challenged appropriately/professionally enough on this type of reasoning--which I think is our job. As personally frustrating as it can be, we can certainly 'challenge' this way of thinking by offering an alternative perspective on what may be a better way to think about or change a clinical problem like anger and associated behavior that has negative consequences. Unfortunately, we work in a system that--frankly--includes a number of people who either should or do know better who would label this type of therapeutic intervention as being 'problematic' or not being an 'advocate' for veterans. They are generally unskilled or unethical clinicians who want to capitalize on the social capital gained by ostentatiously transmitting a social message of 'look at me, look at how much I DEEPLY CARE about veterans' (while they actually offer substandard care) and 'look at how much this other provider (who offers standard of care and therapeutic honesty that may upset a veteran) does not.' I'm sorry, but if we are going to survive as an organization (yeah, I know, we may not want to), we're going to have to stop pretending that this isn't a problem.

This is the one benefit of privatization. There will be no special treatment and bending over backwards. Just " get out of my office if you cannot control yourself. I don't really care if you are a veteran".

That said, quality of care will not improve unless reimbursement for such things does as well. So, shoddy diagnosis will exist as long as flat rate payment does.

'I blew up at my wife and got in her face and screamed at her because of my PTSD' isn't a helpful way of thinking about it and won't generally lead to therapeutic solutions or progress going forward. I hate to use the word 'excuse' but basically 'I acted this way because of my diagnosis (or because certain stressors occurred 15 years ago)' serves functionally as a way of deflecting responsibility to 'causes' or 'explanations' that are fixed, immutable, and impossible to change. It is also, of course, an example of tautological (circular) reasoning that is all too common in MH circles. "anger/irritability" is one of the symptoms (criteria) of PTSD. I 'have PTSD' because I have the symptoms of PTSD (one of which is anger). 'I get angry because of my PTSD' is simply a re-discription masquerading as an explanation. This is one (of a million) examples of why training in the philosophy of science and scientific reasoning is so crucial in the training of mental health professionals and why (thankfully) grad programs are starting to formally train on this stuff.

Rather (of course), a psychotherapeutic approach involves a focus on self-evaluation and self-change within the context of an individualized cognitive-behavioral case formulation that has the purpose and hope of helping a client develop increased awareness of and potentially control over the chain of events (in terms of patterns of thought/emotion/action) resulting in the behavior that the client is motivated to change. I am reminded of an exchange with a veteran years ago (one that I will never forget) when, in response to my question of what his goals for therapy might be, he responded, "I want to have less responsibility." I won't go into what happened after that but...well...we basically had an honest conversation the upshot of which is that--if you are seeking to engage in a course of effective psychotherapy--you are actually REQUESTING (and had better be expecting) to take more responsibility.

Successfully engaging the veteran population, especially the non-cherry-picked-cases that present to mental health clinics at VA is an incredibly complex and nuanced endeavor but one which the organization greatly seeks to over-simplify to the detriment of all involved.

Engaging folks that are avoidant and unwilling to address concerns is a large part of the job. It is also thankless, uncompensated and easily avoided by requesting a different provider.

 

[WisNeuro]

This is the one benefit of privatization. There will be no special treatment and bending over backwards. Just " get out of my office if you cannot control yourself. I don't really care if you are a veteran".

I love this aspect of PP. In the height of the pandemic, husband of a patient went on a MAGA rant outside of my office door about "I ain't never wearing a mask..." Just said that's his choice and I'd send them a list of other docs for referral, but that they'd likely have the same policy and shut the door on him. All of a sudden he was willing to wear a mask and shut the **** up.

 

[Fan_of_Meehl]

As far as the indiscriminate validation leading to collusion, 100% agree this is a rampant problem. I do believe in healthy validation and validate patients when they are wrong all the time. I even validate that it is okay to be wrong. I just won’t agree with them and point out that it is okay to agree to disagree. If they don’t want to explore alternative perspectives, then they are with the wrong clinician and hey can stay as sick as they want to be. Since I don’t engage in the arguments and debates and just stick to my perspectives and separate from the outcome, it usually goes pretty well. In other words, they tend to not get too upset since I won’t fight with them. I just won’t do or say what they think they want me to.

Patient comes to mind with Borderline PD that no one seems to want to diagnose. Patient wants DID, parents want Bipolar and former testing says Bipolar. Patient reports multiple sexual assaults and molestation and significant symptoms of PTSD so thats what I put in the chart. Former testing said trauma disorder NOS or something to that effect because of inability to confirm trauma actually happened and tendency of patient to make inconsistent and exaggerated or false reports. Also, I think they were giving diagnoses parents would agree with.

This brings to mind an interesting distinction between an objective assessment as opposed to a collaborative diagnosis for use in treatment. This is a distinction that our field should endeavor to clarify in some way. One way I answered the distinction is that I base my treatment diagnosis on self report of symptoms and it is not based on a formal assessment with validity checks. The other point is in treatment I don’t just tell the patient everything directly right away because they can’t handle the truth. It is a process. I think about how Motivational Interviewing works. I could tell them what they have to do to deal with their problem from day one and since they are in denial, they aren’t going to come back and received no help or I could work with them on evakuating their use and determining if it is problematic for them and then how to deal with it. The diagnosis is going to reflect some of this process and not necessarily what I think is the “truth”.

Absolutely. I should also say that--for me--the 'line in the sand' is simply that I do not tell the patient things that I know not to be true (e.g., I do not say, 'I think you have PTSD' when I don't actually think they have PTSD. If the patient thinks he has PTSD and/or Dr. X thinks he has PTSD, fine. We can agree to disagree. I'm not even going to say that my goal is to express or point out 'THE TRUTH' to the patient (I am fallible, and I may not have a clue as to what 'THE TRUTH' is)...but I know when *I'm* saying something to the patient that I do not believe to be true (for purposes of manipulating the situation, the patient, or the system to give me rewards or avoid punishing me) and I simply will not do that. You'd be surprised (or not) how much trouble this can cause. I also consistently try to help patients adopt more of an emphasis on functionality of beliefs (e.g., the belief 'I have PTSD and it explains why I am suffering and cannot control my behavior and so my wife is leaving me') vs. absolute notions of 'am I right/correct?' I may invite them to explore and test out an alternative belief, 'Over time, I can learn to better observe and modify my patterns of thinking/feeling/acting in order to make it more likely my wife and I develop a better relationship and I/we experience less suffering and more joy.' Even if you 'have PTSD,' you can learn to modify your own thinking/feeling/acting in ways that are more functional and that's the entire point of engaging in a course of psychotherapy, PTSD or no PTSD.

 

[ccpsych16]

I also consistently try to help patients adopt more of an emphasis on functionality of beliefs (e.g., the belief 'I have PTSD and it explains why I am suffering and cannot control my behavior and so my wife is leaving me') vs. absolute notions of 'am I right/correct?'

I’ve been integrating ACT (or just straight up using a structured protocol) a lot more in the last several months. I really enjoy the emphasis on language and verbal and mental representations. I ask some variation of “How is it helping/serving you to tell yourself that?” or “What is the purpose if saying/believing that?” very often. It’s worked very well for me with PTSD. Though every now and then I get the all around stubborn, argumentative person who thinks they’ve been right about everything since birth. And then they wonder why they’re lacking meaningful relationships!

 

[PsyDr]

I am going to provide a hypothetical (but commonly encountered) scenario to enunciate this point.

Say a veteran has an extensive history (going back about 15 years) of encountering MANY mental health providers (many doctoral-level) in the VA system and NONE of them have ever diagnosed PTSD or a trauma- or stressor-related disorder. Instead, they diagnose disorders like major depressive disorder, 'anxiety' (not a disorder, I know), substance abuse. Then veteran has an extensive, thorough psychological assessment/ workup (say, by an intern or a provider who knows what they're doing) utilizing such things as structured interview (CAPS-5 or SCID-5), objective psychological testing (MMPI-2-RF, or PAI, or MCMI), extensive interviewing around Criterion A, actually attempting to examine the 'association' (if present) between the putative stressors and current symptoms, examining co-morbid conditions and their association with current symptoms, etc., etc. Takes several sessions, several reports/notes, and a good deal of time and effort. They fail to uphold a diagnosis of PTSD and, instead, rule it out.

Veteran turns around and complains, 'fires' the clinician who ruled out PTSD and another therapist in the same service enters a consult for assessment/treatment for 'therapy.' Then a therapist slaps a PTSD diagnosis (first one for that patient, ever) on the chart (with absolutely NO justification whatsoever...not even a PCL-5...literally just the four letters 'P' 'T' 'S' and 'D' all capitalized and in order. That's the justification for the diagnosis. As a result of that 'diagnosis,' a consult is entered for the PCT (specialty clinic) for treatment of PTSD.

Let's assume that we may be dealing with a (not uncommon) scenario that a patient with non-PTSD psychopathology (substance abuse, personality dysfunction, depression/anxiety/neurosis) has actual psychopathology that needs to be honestly and accurately worked up and treated psychotherapeutically, but said type of patient may be seeking 'an answer' to the question 'WHY?' as in 'why do I get angry and mean and aggressive with people.' Obviously fishing for the collusive lying response from a clinician ('because of your PTSD.'). Parenthetically, if I never heard the phrase 'I had a PTSD episode' as a referent for an episode of emotion dysregulation and inappropriate/aggressive outburst again...that'd be awesome.

You’re avoiding the entire thing. Let me rephrase your question:

Veteran can get $3k/month in tax free income, free college for their kids in some places, and other things, IF someone says they have PTSD. Why is the person, who self selected into a violent profession, aggressively seeking that diagnosis? Maybe it’s the money. Maybe it’s because society will “give” them a mulligan for domestic violence/dui, if they have that diagnosis.

Name another profession that has its own criminal justice system.

 

[smalltownpsych]

You’re avoiding the entire thing. Let me rephrase your question:

Veteran can get $3k/month in tax free income, free college for their kids in some places, and other things, IF someone says they have PTSD. Why is the person, who self selected into a violent profession, aggressively seeking that diagnosis? Maybe it’s the money. Maybe it’s because society will “give” them a mulligan for domestic violence/dui, if they have that diagnosis.

Name another profession that has its own criminal justice system.

It would make less sense to not to try and get extra cash tied to distress about serving in the military. If there was a payout for that in our line of work, it would be easy to justify having witnessed, experienced, and heard criterion A trauma. Inpatient psych unit and covering the ED provided a lot of that. Sometimes I even remember the bad things and sometimes I can’t sleep very well. I could easily make/feign a case for that.
Of course, usually when I can’t get to sleep I’m either thinking about business stuff or mulling over perplexing case that gets stuck in my head for whatever reason. It has nothing to do with any of the scary stuff and the only reason I remember that stuff is because it stands out and was emotionally intense and sometimes it’s helpful for training purposes.

 

[Therapist4Chnge]

Name another profession that has its own criminal justice system.

1. Politician
2. Oligarch / Billionaire

 

[Sanman]

1. Politician
2. Oligarch / Billionaire

Does it count if you are convicted but face no sentence?