The 'Long-Game' of Moral/Ethical Decision-Making that Determines Difficult Decisions We Have to Make

[Fan_of_Meehl]

It seems to me that a crucial core principle in any ethical/moral dilemma involves doing what one judges to be 'the right thing to do' even when it flies in the face of the prevailing popular (often emotionally-saturated) paradigm and particularly when doing the 'right' thing causes you to encounter otherwise 'punishing' consequences and is broadly unpopular (according to the herd mentality reasoning).

A couple of cases in point I have encountered recently.

A) Taking the time as a full time compensation and pension examiner in the Department of Veterans Affairs to include formal testing (MMPI-2-RF) to obtain the most accurate clinical picture possible and to detect cases of extreme overreporting of psychopathology--and, importantly, to withhold mental health diagnoses as a result of the evidence suggesting unreliability/invalidity of self-report (upon the basis of which the diagnosis would have been made). Cost = more time/trouble to do each evaluation, cumulative risk over time of this resulting in an incident of violence from a veteran who has been 'denied' compensation; Benefit = being able to sleep at night because at least I was doing something to detect extreme/unsophisticated attempts to obtain benefits fraudulently. I was sometimes baffled by opinions that this is somehow 'victimizing or retraumatizing the veteran' by less scientifically-trained colleagues who don't understand what such extreme scale elevations (on F(p)-r > 100) mean in terms of the credibility of self-report and being seen as 'anti-veteran.' However, I think that my behavior is quite 'pro-veteran' in that it is motivated by a desire to protect the integrity of a process that I can clearly foresee (if things don't change soon) will result in a huge backlash from society down the road and harm veterans who are truly suffering from severe mental disorders and who need and deserve compensation.

B) Saying 'no' to veterans requesting that I write letters to third parties (I refer to these as 'magic letters') to get them out of a bind they and their decision-making has gotten them into. For example, a veteran on an inpatient unit with all the telltale signs of antisocial/psychopathic tendencies cornering me during our one therapy session and 'gently demanding' that I should write a letter (as a doctor) to his landlord certifying that he should be let out of his contract/lease so that he could move to a different location to get treatment (now, the patient had clearly laid out that he had motivation to get out of the lease due to other reasons). I was dumbstruck by, in another instance, seeing in a veteran's chart that a local LCSW had written a strongly worded legalistic letter to the owner of the apartment complex of a veteran (whom the provider had seen exactly twice and who had a working diagnosis of anxiety disorder, NOS) under the auspices of the Fair Housing Act including a 'prescription' for an 'emotional support animal' that was somehow determined to be medically necessary to their ability to function (the apartment had a no pets policy that the patient undoubtedly knew about when they signed the lease). A wise colleague opined that it might get tricky for the provider down the road if, as a result of the letter/threat, the apartment complex owner felt forced into allowing the exception and the 'emotional support animal' happened to bite the face off of a neighbor's kid. It just seemed to me that the provider was being exceptionally cavalier regarding the rights of the property owner in this situation and way off base in arguing the medical necessity of a pet in managing/treating a mental health condition (I agree that it is a good idea for folks who want pets, in general, to have them (can help with anxiety, blood pressure, etc., but I don't think we should use our position in society to force/threaten property owners in this type of situation). In the current sociopolitical context, it may be seen as unpatriotic, 'anti-veteran' and horrifying to take into consideration (and prioritize) the individual rights of the property owner. I then saw a blog post online from a frustrated service-animal owner (where there is medical necessity, e.g., epileptic patient with trained/certified animal to help detect onset of seizures) regarding how the 'emotional support animal' craze (involving untrained pets accompanying owners in stores and causing havoc) is causing resentment and backlash against folks like her.

The common denominator to these situations seems to be people failing to take a 'long-term' or 'long-game' view of things. That is, while it may seem emotionally compelling just to 'give the veteran the benefit of the doubt' in a C&P exam or just write the letter to get the veteran out of their lease/contract, the end (probably unintended) consequence of these types of actions over time will be decidedly 'anti-veteran' in their outcome as the public will become increasingly less tolerant of folks with legitimate issues requiring compensation or accommodation. I am wondering if other providers (particularly at VA) are faced with situations like these and to what extent is this an issue at your site or in your practice. I know that among my colleagues there is a general practice to be wary of pointing out the 'elephant in the room' in any kind of public way or with administration due to the highly political climate at these settings and the notion that some people have that 'the veteran is always right.' Things get really polarized/intense when we consider the reality of veterans very often not getting proper service from VA and try to understand that they often are approaching the situation from a history of actual mistreatment or neglect by the organization.

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[cara susanna]

However, I think that my behavior is quite 'pro-veteran' in that it is motivated by a desire to protect the integrity of a process that I can clearly foresee (if things don't change soon) will result in a huge backlash from society down the road

Can you explain more about the reasons why you foresee this? I'm very curious.

 

[erg923]

There is definitely a "savior mentality" in some parts of the VA, especially among some of the OEF/OIF social workers at my facility. I was once asked if I could do an "emergency" substance abuse program intake (with a likely referral to the residential program) on a veteran. I inquired if he was suicidal or something, and they said no. I promptly said, well then its not an emergency and to please call my program scheduler and I will see him in my first available (read non-booked) slot. The SW was clearly agitated that I would not skip my lunch hour to overbook this guy. She said, "but he is said he is afraid he will use if he doesn't see somebody today." To have a trained mental health professional not know what do with such a mentality other than to refer him for an "emergency evaluation" makes me worried.

The savior mentality has of course worked it way into policy too- the 3 phone call no show non-sense, which only takes the onus further away from the patient in a system that is already rife with external locus of control/responsibility, bordering on infantalizing at times. I wrote about this in another post in which I lamented that there is almost a pressure to get veterans into therapy whether they really want to be or not (referrals to MH or PCMHI are often made blindly or done despite ambivalence), all whilst we wonder how to fix our access issues. Hmmm....

I think one has to swallow a few pills in order to work well in the VA health system. One I have had some trouble with is that notion that veteran are "entitled" to the moon and stars....and should be held in different regard than other patients. I obviously respect service to our country, but there is a limit in my mind with what you should be able to milk from that. A monthly service connection pension for "scars" or various other health conditions that were not caused by your service is not really something I think we should be remunerating you for. I am also not really convinced that we should be giving away an unlimited, lifetime supply of free MH treatment services, unless we are treating conditions that are directly resulting from your service. I might be in the minority there, though.

 

[Fan_of_Meehl]

Can you explain more about the reasons why you foresee this? I'm very curious.

There are strong incentives to over-report/exaggerate symptoms of psychopathology in an examination context in which the result directly affects your monthly income. For individuals who are struggling financially, struggling with general psychopathology (depression, anxiety, substance abuse, interpersonal dysfunction), there can be a tendency (and there's research on the frequency/extent of symptom overreporting of psychopathology and/or cognitive dysfunction in medico-legal contexts (e.g., disability examination or as part of a lawsuit). PTSD is a diagnosis that is easy to malinger due to the fact that its core symptoms are self-reported. It is also easy to misattribute common symptoms of psychopathology in general (e.g., insomnia, anxious arousal, avoidance behavior, irritability, memory/concentration problems) to PTSD when they may be attributable to a different mental or medical disorder. Richard McNally (and others) have raised questions regarding 'Why Veterans of OEF/OIF are claiming disability at rates greater than veterans of prior conflicts (http://mcnallylabcom.ipage.com/beta/wp-content/uploads/mcnally-frueh-2013-jad-disability-rates1.pdf) ' and Arthur Russo has a good review article regarding symptom validity in the population (http://www.veteranslawlibrary.com/files/Veterans_Symptom_Validity_Russo.pdf).

And there are numerous anecdotes from clinical experience of those within the VA system that the condition is often overdiagnosed or mis-diagnosed for many reasons (the most common reason being that the DSM-5 criteria were not systematically employed in making the diagnosis and co-morbid alternative diagnoses/explanations were not ruled out). Another common questionable practice involves using self-report on an instrument such as the Posttraumatic Stress Disorder Checklist (PCL) to 'make the diagnosis.' If an increasing percentage of veterans are put on disability for PTSD who do not actually meet criteria for the clinical disorder (say, when we get to >50% of veterans) and more people become aware of neighbors, ex-boyfriends, sons-in-law, etc. who are not actually as disabled as their service connected status indicates (there was a recent fraud investigation of former firefighters/police who claimed to be suffering from PTSD post-9/11 in the news), then there will likely be a public outcry due to the inappropriate use of taxpayer dollars. This is assuming that the percentage doesn't level off at a tolerable percentage, however (this may well happen). But what I have seen anecdotally is more and more 'pushing of the envelope' over time as to what, for example, counts as a Criterion A stressor (to be overly inclusive) such that statistically normal life stressors (death of a loved one to cancer, getting yelled at in basic training) are being claimed as bases for the PTSD diagnosis (by veterans and, sadly, mental health professionals alike). As McNally points out, the broader you make Criterion A (to include 'normal' life stressors) the more likely it is that you are talking about a condition involving abnormal responses to normal life stressors (not really the PTSD construct) rather than, properly, a disorder of 'normal' (somewhat) responses to abnormal (victim of rape, killing another person) life stressors.

 

[Fan_of_Meehl]

There is definitely a "savior mentality" in some parts of the VA, especially among some of the OEF/OIF social workers at my facility. I was once asked if I could do an "emergency" substance abuse program intake (with a likely referral to the residential program) on a veteran. I inquired if he was suicidal or something, and they said no. I promptly said, well then its not an emergency and to please call my program scheduler and I will see him in my first available (read non-booked) slot. The SW was clearly agitated that I would not skip my lunch hour to overbook this guy. She said, "but he is said he is afraid he will use if he doesn't see somebody today." To have a trained mental health professional not know what do with such a mentality other than to refer him for an "emergency evaluation" makes me worried.

The savior mentality has of course worked it way into policy too- the 3 phone call no show non-sense, which only takes the onus further away from the patient in a system that is already rife with external locus of control/responsibility, bordering on infantalizing at times. I wrote about this in another post in which I lamented that there is almost a pressure to get veterans into therapy whether they really want to be or not (referrals to MH or PCMHI are often made blindly or done despite ambivalence), all whilst we wonder how to fix our access issues. Hmmm....

I think one has to swallow a few pills in order to work well in the VA health system. One I have had some trouble with is that notion that veteran are "entitled" to the moon and stars....and should be held in different regard than other patients. I obviously respect service to our country, but there is a limit in my mind with what you should be able to milk from that. A monthly service connection pension for "scars" or various other health conditions that were not caused by your service is not really something I think we should be remunerating you for. I am also not really convinced that we should be giving away an unlimited, lifetime supply of free MH treatment services, unless we are treating conditions that are directly resulting from your service. I might be in the minority there, though.

Thank you for your reply. I chuckled reading it as I have recently changed positions to the OEF/OIF clinic and have encountered my own versions of the situations you describe. Regarding the three call rule, since the administrators at VA are so zealous about 'empirically supported whatever,' would it be so hard to do a study where they empirically examine the effectiveness of three different approaches to this?: (1) make one call / leave one message and wait for a reply; (2) make two calls/messages; and (3) make three calls/messages. I would predict very little difference between conditions 1 and 2 and perhaps a small negative effect of condition 3 (which is our current policy).

 

[AcronymAllergy]

There are definitely societal pressures associated with Veteran status, and anecdotally, I particularly see the 'savior mentality' erg mentioned in some clinicians who are Veterans themselves, and/or who have worked in the VA system for quite some time. Heck, I've heard a provider or two tell a patient outright, "you can't and shouldn't work, you're disabled, and you don't have anything to gain from a re-review of your case; all that's gonna happen is they may reduce your benefits." And to an extent, I understand it. VA healthcare honestly wasn't all that great even a decade ago, and I'm sure we've all heard horror stories of VA providers years ago who told patients things like, "all veterans lie." We're also dealing with the pendulum having swung way in the other direction after the snafu that was the lack of care (and societal respect) given returning Vietnam era Veterans.

But as has been said, too much of a "good" thing is also a problem, and we're especially seeing that now with the way the whole C&P situation is being handled (and, in some instances, abused). Heck, part of me just wonders if we might not be better off following the lead of some other countries and given all military service members a lifetime pension of sorts. At least that way, there wouldn't be a perpetual pressure to remain in a sick role, which I've seen become particularly problematic in the case of mild TBI (and which isn't helped by other providers telling folks who may have had a mild TBI that they "won't ever be right again").

At least for me, my way of trying to battle this trend is to focus in my feedback appointments on all the things folks can do to improve themselves and their situation. Even if an individual's entire neuropsych assessment was invalid, I'm still going to have recommendations for them about what they can do to get better.

 

[psych844]

Isn't much of this over-diagnosis connected to the DSM and how we are essentially making any normal human behavior appear to be a mental disorder?

 

[AcronymAllergy]

Isn't much of this over-diagnosis connected to the DSM and how we are essentially making any normal human behavior appear to be a mental disorder?

Honestly, if one follows the DSM's guidelines properly, and really focuses on the necessary presence of significant disruption/impairment in daily life, then the over-pathology can be somewhat minimized.

 

[Fan_of_Meehl]

Honestly, if one follows the DSM's guidelines properly, and really focuses on the necessary presence of significant disruption/impairment in daily life, then the over-pathology can be somewhat minimized.

I'm reminded of a time during a C&P exam when I pulled out a pocket DSM and was looking up some criteria I was uncertain about. The veteran made a comment something to the effect of 'you got it right there in your little book, eh?' To which I replied, 'You know, there are plenty of doctors who are too embarrassed/proud to refer to written criteria for making a diagnosis for fear of appearing human or fallible in front of their patients. I'd hate to be one of their patients.'

 

[erg923]

There was a tragic murder-suicide committed by a vet in Georgia a few weeks ago. All the headlines could focus on was that after missing an outpatient VA mental health appt, the woman committed this act. This then translated into, "why didn't the VA do more to prevent this tragedy?" Seriously? WTF?! How bout actually putting the blame on the murderer for goodness sake!

 

[Fan_of_Meehl]

There was a tragic murder-suicide committed by a vet in Georgia a few weeks ago. All the headlines could focus was that after missing an outpatient VA mental health appt, the woman committed this act. This then translated into, why didn't the VA do more to prevent this tragedy? Seriously? WTF?! How bout actuallu putting the blame on the murderer for goodness sake!

The secretary (McDonald) in a recent testimony before congress reminded them that 17 out of the 22 veterans committing suicide every day were not engaged in VA-related health care and emphasized the importance of finding ways to increase their participation (while also implicitly refuting the commonly seen headline rhetoric that you describe...i.e., if vets are committing suicide, this means that the VA is failing them). There was also a recent journal article in a pretty high-profile medical journal (JAMA?) indicating that suffering from PTSD symptomatology was not driving the increase in suicide (although depression, substance abuse, and financial/social issues were).

 

[erg923]

The secretary (McDonald) in a recent testimony before congress reminded them that 17 out of the 22 veterans committing suicide every day were not engaged in VA-related health care and emphasized the importance of finding ways to increase their participation (while also implicitly refuting the commonly seen headline rhetoric that you describe...i.e., if vets are committing suicide, this means that the VA is failing them). There was also a recent journal article in a pretty high-profile medical journal (JAMA?) indicating that suffering from PTSD symptomatology was not driving the increase in suicide (although depression, substance abuse, and financial/social issues were).

I have an ethical obligation to do my job. Professional due diligence, is you will. If you choose to come see me (or not)..... and i do my job, if you then choose to commit suicide, then you are to blame. Not me.

Is it VA culture influencing society or perhaps the other way around?

 

[Fan_of_Meehl]

I have an ethical obligation to do my job. Professional due diligence, is you will. If you choose to come see me (or not)..... and i do my job, if you then choose to commit suicide, then you are to blame. Not me.

Is it VA culture influencing society or perhaps the other way around?

Agreed. Hard to argue that therapy (by the VA practitioner) failed to prevent suicide if the person never enrolled or kept appointments. Medicine that isn't ingested can't possibly work (and it is foolish to consider it 'bad' medicine as a result).

 

[cara susanna]

There are strong incentives to over-report/exaggerate symptoms of psychopathology in an examination context in which the result directly affects your monthly income. For individuals who are struggling financially, struggling with general psychopathology (depression, anxiety, substance abuse, interpersonal dysfunction), there can be a tendency (and there's research on the frequency/extent of symptom overreporting of psychopathology and/or cognitive dysfunction in medico-legal contexts (e.g., disability examination or as part of a lawsuit). PTSD is a diagnosis that is easy to malinger due to the fact that its core symptoms are self-reported. It is also easy to misattribute common symptoms of psychopathology in general (e.g., insomnia, anxious arousal, avoidance behavior, irritability, memory/concentration problems) to PTSD when they may be attributable to a different mental or medical disorder. Richard McNally (and others) have raised questions regarding 'Why Veterans of OEF/OIF are claiming disability at rates greater than veterans of prior conflicts (http://mcnallylabcom.ipage.com/beta/wp-content/uploads/mcnally-frueh-2013-jad-disability-rates1.pdf) ' and Arthur Russo has a good review article regarding symptom validity in the population (http://www.veteranslawlibrary.com/files/Veterans_Symptom_Validity_Russo.pdf).

And there are numerous anecdotes from clinical experience of those within the VA system that the condition is often overdiagnosed or mis-diagnosed for many reasons (the most common reason being that the DSM-5 criteria were not systematically employed in making the diagnosis and co-morbid alternative diagnoses/explanations were not ruled out). Another common questionable practice involves using self-report on an instrument such as the Posttraumatic Stress Disorder Checklist (PCL) to 'make the diagnosis.' If an increasing percentage of veterans are put on disability for PTSD who do not actually meet criteria for the clinical disorder (say, when we get to >50% of veterans) and more people become aware of neighbors, ex-boyfriends, sons-in-law, etc. who are not actually as disabled as their service connected status indicates (there was a recent fraud investigation of former firefighters/police who claimed to be suffering from PTSD post-9/11 in the news), then there will likely be a public outcry due to the inappropriate use of taxpayer dollars. This is assuming that the percentage doesn't level off at a tolerable percentage, however (this may well happen). But what I have seen anecdotally is more and more 'pushing of the envelope' over time as to what, for example, counts as a Criterion A stressor (to be overly inclusive) such that statistically normal life stressors (death of a loved one to cancer, getting yelled at in basic training) are being claimed as bases for the PTSD diagnosis (by veterans and, sadly, mental health professionals alike). As McNally points out, the broader you make Criterion A (to include 'normal' life stressors) the more likely it is that you are talking about a condition involving abnormal responses to normal life stressors (not really the PTSD construct) rather than, properly, a disorder of 'normal' (somewhat) responses to abnormal (victim of rape, killing another person) life stressors.

Thanks for the explanation. I guess I was wondering why you think it will lead to a backlash from the public, given that the public seems to have different views on social services with regards to veterans.

Erg, I've also noticed this working in the VA on internship. I think that a lot of people believe that problems in the VA are endemic to the VA only and not healthcare in general. I've seen veterans who were angry that they couldn't get an appointment the same week or get a refill of a medication they'd lost, when you'd run into that in almost any private healthcare system as well.

 

[WisNeuro]

My wait list for an appointment in the VA hospital for npsych services, 2-4 weeks. When I was at a private hospital, 6 months.

 

[futureapppsy2]

The discussion of suicide and blame reminded me of this article that I recently came across about suicides in college and basically haranguing depressed/possibly depressed students into treatment:

The case workers are generally social workers, nurses, or nurse practitioners -- not the people who will provide the actual counseling, but people who can work with both the primary care and counseling parts of the equation. And who can pester.

Chung stressed that the case workers monitor treatment until the counselor and all health professionals involved believe that monitoring isn't needed. Otherwise, he said, the gains from using screening to identify those who need treatment will be easily lost.

“If you think about the lessons of Virginia Tech, we can’t allow any student to drop out [of treatment]," he said. "That sounds awfully Big Brother. If a student doesn’t come back, we use case managers and they call, and they call again and they pester, and they try to ask some questions on the phone and talk about getting care." Many of those students are eventually seeking treatment, he said. They aren't making progress as quickly as those who are better within 12 weeks, but they are receiving outreach regularly. "That's the safety net we are creating."

https://www.insidehighered.com/news/2009/05/29/depression

I'm not sure how I feel about some of these campus approaches to suicide, tbh. I mean, yes, the liability drives a lot of it and of course, no one wants people to commit suicide, but some of them seem to almost be crossing a line. See that thread was had a few months ago about a student getting a code of conduct violation for attempting suicide (that's actually illegal on the part of the university) or campus threat assessment teams that treat sucidality, homicidality, and NSSI as the same thing and thus end up literally sending the cops to escort a student who has expressed suicidal ideation--in the eyes of faculty, not health/mental health professionals-- to be assessed. I mean, there's a point where your attempt to strong arm people into treatment through punishment seems like it creates more fear and stigma than it helps people.

As for assessment, I think it's difficult any time there are outside pressures that influence diagnosis. I've been doing a prac in an outpatient, private (though subsidized) assessment clinic, and even then, there's an implicit pressure to diagnose because if we don't the clients a) feel like we've "wasted" their money and b) don't have any access to services if they have no diagnosis (or not the "right" diagnosis, in some cases). Fortunately, everyone I work with is really ethical and openly tries to account for this, but pressure is pressure. In schools, there's also sometimes implicit pressure to recommend or not recommend certain services on the basis of finances, although that legally shouldn't be a basis for such decisions.

 

[Rivi]

I really like this discussion. As far as the "society backlash," I don't see it happening on a large scale for the reasons mentioned above. Historically speaking, denying or minimizing legitimate claims has been a much bigger sin of our field, followed by over-medicating veterans with PTSD while failing to provide adequate psychotherapy or supportive services. I think that this and advocacy groups/lawsuits have caused the pendulum to swing in the opposite direction and caused a "err on the side of giving them service-connection" mentality. Regardless, as fan_of_Meehl mentioned above, we have to stick to evidence-based practice and try our best to minimize the influence of politics and administration on the compensation and pension system.

Another fundamental issue is that social problems, when unaddressed, eventually get dumped onto mental health, and our field does not have an effective way of sorting this out. I see this with the disability/SSDI evaluation system as well. I suspect that these are the main reasons why we see an increase in individuals seeking service-connected pensions:

-There are a higher percentage of individuals living in poverty fighting our wars; these individuals return home to the same social conditions and poor job prospects
-Recruiters having a tendency to make unrealistic promises about job prospects following military service, which causes some individuals to get frustrated and not care about "gaming" the system that they feel lied to them
-Exploitative "for profit" schools who are targeting veterans to get GI bill money and saddling vets with debt without jobs, which leads to individuals seeking SC pensions
-Shame from loss of social status, going from being a solider, etc. to being broke

 

[futureapppsy2]

There are definitely societal pressures associated with Veteran status, and anecdotally, I particularly see the 'savior mentality' erg mentioned in some clinicians who are Veterans themselves, and/or who have worked in the VA system for quite some time. Heck, I've heard a provider or two tell a patient outright, "you can't and shouldn't work, you're disabled, and you don't have anything to gain from a re-review of your case; all that's gonna happen is they may reduce your benefits." And to an extent, I understand it. VA healthcare honestly wasn't all that great even a decade ago, and I'm sure we've all heard horror stories of VA providers years ago who told patients things like, "all veterans lie." We're also dealing with the pendulum having swung way in the other direction after the snafu that was the lack of care (and societal respect) given returning Vietnam era Veterans.

I sort of wonder if we're going to see a similar type of pendulum swing with culturally and linguistically diverse (CLD) kids in schools. There's been so much written about these students being incorrectly diagnosed with disabilities due to poor identification of their primary language for testing, practitioners ignoring the fact that they were CLD, testing not taking into account their abilities across both/all languages, etc., that I wonder of we're going to see people refusing to diagnose any disability in CLD students, despite the fact that some CLD students will, in fact, have disabilities.

 

[erg923]

Thanks for the explanation. I guess I was wondering why you think it will lead to a backlash from the public, given that the public seems to have different views on social services with regards to veterans.

Erg, I've also noticed this working in the VA on internship. I think that a lot of people believe that problems in the VA are endemic to the VA only and not healthcare in general. I've seen veterans who were angry that they couldn't get an appointment the same week or get a refill of a medication they'd lost, when you'd run into that in almost any private healthcare system as well.

Indeed. I have seen it written, and explicitly stated, that some are "incensed" about having to wait for an appt at all. My honest first reaction is: Who the **** do you think you are? You choose an honorable path and you have been rewarded with a lifetime of free healthcare. So. settle. the ****. down. Last time I checked, cops, firemen, teachers, and priests have to wait for medical appts too.

Sorry, I think I am in a venting mood tonight. Much of this is directed at the media and it portrayal, not really at veteran population.

 

[Fan_of_Meehl]

Agreed...the media are a big part of the problem and the way that they cover things (and the slant/bias in their coverage) fuels inappropriate behavior and expectations of a minority of veterans who have what may (by comparison with non-veteran patient counterparts) be considered unrealistic. For every article or news story calling attention to cognitive and behaviorally oriented therapies to treat PTSD, you'll see at least 10-20 stories regarding 'support dogs' and the role that they played in saving a veteran's mental health. If the mainstream (non-professional) sources were your guide, it would be understandable for you to have the impression that VA is denying you appropriate care for PTSD by not supplying support dogs.

 

[Engali]

Your point is well-taken, but research on moral reasoning and cognitive moral development suggests that it is actually very weakly related to moral action. Many times people *know* the "right" thing to do, only to find it beyond their current moral constitution to do so. Then this failure to act in accord with what is ethical or moral is probably rationalized away post-hoc.

 

[smalltownpsych]

Agreed...the media are a big part of the problem and the way that they cover things (and the slant/bias in their coverage) fuels inappropriate behavior and expectations of a minority of veterans who have what may (by comparison with non-veteran patient counterparts) be considered unrealistic. For every article or news story calling attention to cognitive and behaviorally oriented therapies to treat PTSD, you'll see at least 10-20 stories regarding 'support dogs' and the role that they played in saving a veteran's mental health. If the mainstream (non-professional) sources were your guide, it would be understandable for you to have the impression that VA is denying you appropriate care for PTSD by not supplying support dogs.

Dogs make for much more compelling TV. Run of the mill treatment for PTSD is just so boring. If I could combine cute dogs with flashing lights and maybe hook someone up to an EEG, then we would have a really impressive looking treatment.

 

[psych844]

How about the moral dilemma of wanting to sleep with some of the veterans? lol
Sorry I had to say it, this thread got me thinking back to when erg said that some of the veterans wives are really attractive.

 

[smalltownpsych]

How about the moral dilemma of wanting to sleep with some of the veterans? lol
Sorry I had to say it, this thread got me thinking back to when erg said that some of the veterans wives are really attractive.

I never had any problem with that one, the vets I knew were male and not that attractive! My biggest moral dilemma was trying to keep the vets from calling me doc because i wasn't one yet. Sounds like Erg has a lot more fun where he works. At the VA I was at, even the psychologists were unattractive.

 

[AcronymAllergy]

I never had any problem with that one, the vets I knew were male and not that attractive! My biggest moral dilemma was trying to keep the vets from calling me doc because i wasn't one yet. Sounds like Erg has a lot more fun where he works. At the VA I was at, even the psychologists were unattractive.

Haven't run into yet myself, either. Just have to learn to develop and maintain appropriate boundaries, although doing so is admittedly a bit different for a neuropsych assessment than a therapy patient.