"What Social Work is"

[DrGero]

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RANT: I'm dreading this upcoming presentation by our facility Social Work service that's coming up, which will be presented to the core clinical staff at our admin meeting. Not because I have a problem with Social Workers in general (in fact I have a close friendship with one of the Social Workers at the very facility I work at), but because one of the other Social Workers is an absolute *****. I can't stand it. She thinks (for some bizarre reason) she can do behavior management with dementia patients which takes the form of weekly sessions, essentially, to talk the patient out of his symptoms. And she insisted I participate in this nonsense (which I didn't do) and refused to listen to me when I tried to explain to her that this patient had DEMENTIA and had no idea what he was doing and weekly meetings to make him stop using foul language (disinhibition of course) is ridiculous and by the way, I do have a behavior plan that should be followed with him? She's an idiot. She insists, "oh, he knows what he's doing." HE HAS VASCULAR DEMENTIA. I've done at least two neuropsych. testing sessions with this guy. She doesn't care - I'm flabbergasted by this person. I have no idea how this person can work in long term care.

This is not the worst about this particular Social Worker by the way, this is just the tip of the iceberg... but probably enough, right?

What do I need to do to survive this meeting without blowing up at this idiot? I'm paranoid that she will stand up and as part of the presentation assert that Social Work can do behavior management with patients. Which, obviously, she's demonstrably incapable of doing.

 

[stigmata]

Ask this person to explain vascular dementia to you...let them sink their own ship.

 

[O Gurl]

I can understand your frustration, but am not sure the title of this thread is fair. This person, as you describe her, is in no way representative of "what social work is."

As for your question, though, I think the real issue is not just surviving her presentation. I would not overly restrain myself. If you have a question about her methods then ask. I think asking for her rationale, understanding of the literature, and approaches with this patient is completely appropriate.

 

[DrGero]

I can understand your frustration, but am not sure the title of this thread is fair. This person, as you describe her, is in no way representative of "what social work is."

As for your question, though, I think the real issue is not just surviving her presentation. I would not overly restrain myself. If you have a question about her methods then ask. I think asking for her rationale, understanding of the literature, and approaches with this patient is completely appropriate.

I wasn't being clear (I was in rant mode) - this is going to be the title of their presentation, as a group. This woman happens to be the senior long term care Social Worker at our facility and I'm just cringing at what her contribution to this upcoming presentation will look like, given the above - she doesn't seem to understand basic interdisplinary models of care, dementia management, much less what "social work is."

It should be said it's fairly clear to a lot of the core clinical staff here that this woman is not particularly competent, so I understand quite well she's not representative of Social Workers. But I'm just flabbergasted she ever got hired at the VA.

 

[O Gurl]

Ah.... I see. Hence the quotation marks.

Well, in any event I do not think you are doing anyone any favors by simply enduring her ignorance. At the end of the day she is a professional (or masquerading as such) and should be able to withstand appropriate inquiry into her practice. I say let her have it.

 

[Therapist4Chnge]

Ah.... I see. Hence the quotation marks.

Well, in any event I do not think you are doing anyone any favors by simply enduring her ignorance. At the end of the day she is a professional (or masquerading as such) and should be able to withstand appropriate inquiry into her practice. I say let her have it.

I would be careful how you handle your inquiries, as you don't want to come off as defensive. I would definitely challenge her wacky ideas, but leave some of the "grey area" stuff alone for now. The VA is an odd place, which tends to tolerate long-standing staff a lot more than other places.

 

[PsyDetective]

Best piece of advise on the matter I ever received: Truly incompetent people, no matter what profession, will eventually sink themselves; they need no help.

The tip I received was to do the opposite of my initial response. That is, be genuinely supportive and positive. Either they will be open and less defensive toward you and demonstrate that they are more competent than you originally gave them credit for, or they will talk themselves into damaging their own professional credibility with others, particularly those that have the power to drop the axe. Either way, you present as a supportive interdisciplinary professional. You could even send her a nice card as she packs up her cubicle 😉

.02

 

[DrGero]

The piece I didn't include about this woman is she's now gone from being a ***** to being objectionable and downright unprofessional - I actually caught her last week telling the nurse manager that I had "refused" to work with this patient in question, and then she included a note in the patient's chart to that effect! 😕

Obviously, of course, what I had "refused" to do was participate in what appears to be a completely contraindicated treatment plan with this patient.

Anyways, so now I'm scheduled (today) to be speaking with this Social Worker's supervisor to address this situation somehow - my hand is forced because obvious falsehoods like this just *can't* go in the chart. I spoke to my own boss about this situation and a report of contact will probably have to happen by me - and if my some bizarre stretch this woman won't remove her idiotic, insulting, and objectionable note about me from this patient's chart, I'm going to have to write my own addendum in the patient's chart pointing out that this note of hers is basically a lie. Which, of course, is terrible because this is not what charting is for, at all.

Sigh. Yes, I think the VA is an odd place. We have some consummate professionals and brilliant people that work for us, as I well know - I work with them. Then there are people like this woman. She's been working there for the past several years. Did I mention she doesn't have her license yet - she's been working under her Service Chief's license since I started working there (3 years ago)? Anyways.

 

[Therapist4Chnge]

Document. Document. Document.

I ran into a couple of treatment differences (obviously not to the extent of your situation)during my time in the VA, and I made sure that for my part I documented my rationale, cited objective data when possible, and kept my boss in the loops if anything wonky was going on. I would definitely want to provide an addendum to that note, as people will not automatically look further into a chart for "the other side".

 

[Neuropsych2be]

The piece I didn't include about this woman is she's now gone from being a ***** to being objectionable and downright unprofessional - I actually caught her last week telling the nurse manager that I had "refused" to work with this patient in question, and then she included a note in the patient's chart to that effect! 😕

Obviously, of course, what I had "refused" to do was participate in what appears to be a completely contraindicated treatment plan with this patient.

Anyways, so now I'm scheduled (today) to be speaking with this Social Worker's supervisor to address this situation somehow - my hand is forced because obvious falsehoods like this just *can't* go in the chart. I spoke to my own boss about this situation and a report of contact will probably have to happen by me - and if my some bizarre stretch this woman won't remove her idiotic, insulting, and objectionable note about me from this patient's chart, I'm going to have to write my own addendum in the patient's chart pointing out that this note of hers is basically a lie. Which, of course, is terrible because this is not what charting is for, at all.

Sigh. Yes, I think the VA is an odd place. We have some consummate professionals and brilliant people that work for us, as I well know - I work with them. Then there are people like this woman. She's been working there for the past several years. Did I mention she doesn't have her license yet - she's been working under her Service Chief's license since I started working there (3 years ago)? Anyways.

One of the beautiful things about social workers is how they can get on their white horse and tilt at windmills. Social work as a profession has an ethos of advocacy and empowerment. IF social work as a profession did not exist, we would need to invent it. Unfortunately, this tendency can lead to them running amok and violating professional boundaries in the name of advocacy. If she is running amok as badly as she seems to be, she will quickly shoot herself in the foot. Also remember that the best way to deal with Axis II pathology is not to inadvertently reinforce it. Not that I am diagnosing anyone with anything

Clearly this woman is invested in the creation and maintenance of conflict. Remain the calm effective interdisciplinary psychologist that you are, respond to accusations and questions about weekly therapy with Socratic questions about evidence based best practices for clients with dementia. You might want to bring up Medicare policies about billing patients with dementia for weekly therapy sessions. I seem to recall that this violates federal Medicare guidelines and constitutes unethical practice.

 

[BSWdavid]

I understand your obvious frustration with this individual, but what does this have to do with social work? Isn't this the exact type of generalization we need to avoid? You don't directly state a bias against social work, but indirectly you are implying that this individual's actions are in some way connected to her professional title. If your issue isn't with social work, why even bother mentioning that she is a social worker? Why not simply refer to her as a colleague? I will be the first one to admit that the social work profession has a its share of problems, and clearly individuals like this give the profession a bad name, however, psychology isn't immune from these kinds of issues either.

 

[stigmata]

Well because we see this a lot with social workers who have no science training, but also think they do and think that psychology doctors only have a few stats courses above their training. I have seen this dynamic 10 times for every 1 time with an MFT or LPC. BTW, when did you become a MD/PhD student? If you are cool.

 

[BSWdavid]

Well because we see this a lot with social workers who have no science training, but also think they do and think that psychology doctors only have a few stats courses above their training. I have seen this dynamic 10 times for every 1 time with an MFT or LPC. BTW, when did you become a MD/PhD student? If you are cool.

I was accepted into a PHD program which I will begin this fall. I didn't see a PhD option without the MD.

 

[FuturePhD2]

Well because we see this a lot with social workers who have no science training, but also think they do and think that psychology doctors only have a few stats courses above their training. I have seen this dynamic 10 times for every 1 time with an MFT or LPC.

Amen - the other day I heard a social worker proclaim that they had more expertise in substance abuse treatment than any of the psychiatrists or psychologists in our clinic (based on having done case management in a substance abuse treatment facility for several years). As I've said before, I think social workers have valuable skills to bring to a treatment team. But it will always bother me that people go get MSW's and then try to function as if they are psychologists.

 

[aagman01]

Ahhhh....how about not going????????? 😉

RANT: I'm dreading this upcoming presentation by our facility Social Work service that's coming up, which will be presented to the core clinical staff at our admin meeting. Not because I have a problem with Social Workers in general (in fact I have a close friendship with one of the Social Workers at the very facility I work at), but because one of the other Social Workers is an absolute *****. I can't stand it. She thinks (for some bizarre reason) she can do behavior management with dementia patients which takes the form of weekly sessions, essentially, to talk the patient out of his symptoms. And she insisted I participate in this nonsense (which I didn't do) and refused to listen to me when I tried to explain to her that this patient had DEMENTIA and had no idea what he was doing and weekly meetings to make him stop using foul language (disinhibition of course) is ridiculous and by the way, I do have a behavior plan that should be followed with him? She's an idiot. She insists, "oh, he knows what he's doing." HE HAS VASCULAR DEMENTIA. I've done at least two neuropsych. testing sessions with this guy. She doesn't care - I'm flabbergasted by this person. I have no idea how this person can work in long term care.

This is not the worst about this particular Social Worker by the way, this is just the tip of the iceberg... but probably enough, right?

What do I need to do to survive this meeting without blowing up at this idiot? I'm paranoid that she will stand up and as part of the presentation assert that Social Work can do behavior management with patients. Which, obviously, she's demonstrably incapable of doing.

 

[DrGero]

Ahhhh....how about not going????????? 😉

I'm tempted, except that I think it's my responsibility to see what level of disinformation and misinformation is out there - for example, if this SW's contribution is to state "we are trained to perform behavior management with dementia patients," (which is obviously untrue) I'll either need to respond right there or later to deal with it.

 

[DrGero]

In the way of an update, I finally had my conversation with this woman's supervisor, and I pretty much laid everything on the table. Unfortunately, I'm not sure what, concretely, will be done to reign in this woman's behavior. After all is said and done, regardless of what I would do differently if something like this would happen again, she bald-facedly lied about me to my colleagues (!!!!), apparently thinking despite our (somewhat inexplicable) differences it was appropriate to go to fellow colleagues and go into the chart and state falsehoods about me.

I feel like I'm finally out of the 'honeymoon' at my job - there's a real problem here at my facility. How to move forward....

 

[SingingCow]

In the way of an update, I finally had my conversation with this woman's supervisor, and I pretty much laid everything on the table. Unfortunately, I'm not sure what, concretely, will be done to reign in this woman's behavior. After all is said and done, regardless of what I would do differently if something like this would happen again, she bald-facedly lied about me to my colleagues (!!!!), apparently thinking despite our (somewhat inexplicable) differences it was appropriate to go to fellow colleagues and go into the chart and state falsehoods about me.

I feel like I'm finally out of the 'honeymoon' at my job - there's a real problem here at my facility. How to move forward....

I guess you can only do the best you can and then "move on" and wait for the next storm. Regardless of your setting, there will always be black sheep in the mix. I am fortunate to have excellent social work colleagues at my current job but it doesn't mean there won't be gossipy, unprofessional people show up at some point. It could be a psychiatrist, a nurse, even a fellow psychologist.

You saw the inaccuracy in the chart. You had the means to address it. You were being proactive. That's all you could do. Educating the social worker and other colleagues about what works and what doesn't work may be a much longer and harder battle. Sometimes, the frustration lies in the fact that you know what is wrong with the system and want to do something about it... but you can't. Good luck!

 

[All4MyDaughter]

Anyways, so now I'm scheduled (today) to be speaking with this Social Worker's supervisor to address this situation somehow - my hand is forced because obvious falsehoods like this just *can't* go in the chart. I spoke to my own boss about this situation and a report of contact will probably have to happen by me - and if my some bizarre stretch this woman won't remove her idiotic, insulting, and objectionable note about me from this patient's chart, I'm going to have to write my own addendum in the patient's chart pointing out that this note of hers is basically a lie. Which, of course, is terrible because this is not what charting is for, at all.

I think you'll have to write an addendum b/c I don't think a signed progress note can be deleted from CPRS. Maybe by IMS but not at the provider level.

 

[O Gurl]

I think you'll have to write an addendum b/c I don't think a signed progress note can be deleted from CPRS. Maybe by IMS but not at the provider level.

I agree. There is an option for deleting an "erroneous note" in CPRS but it almost requires an act of congress. Also, the original author of the note has to initiate it and the note has to be seriously flawed, like writing a note in the wrong patient's chart. So yeah, an addendum is probably the bet option for correcting the record.

 

[DrGero]

I agree. There is an option for deleting an "erroneous note" in CPRS but it almost requires an act of congress. Also, the original author of the note has to initiate it and the note has to be seriously flawed, like writing a note in the wrong patient's chart. So yeah, an addendum is probably the bet option for correcting the record.

Actually, I've made errors in notes before and then had them deleted - I just Vista email "doc track" or "g.doc" on Vista GUIMail and request a deletion, and it's usually done within the same business day. Pretty easy. Although, knowing what I know about the VA at this point, there may be significantly different policies and procedures in different VISNs (or even within VISNs) when it comes to getting notes struck from CPRS.

 

[nitemagi]

Actually, I've made errors in notes before and then had them deleted - I just Vista email "doc track" or "g.doc" on Vista GUIMail and request a deletion, and it's usually done within the same business day. Pretty easy. Although, knowing what I know about the VA at this point, there may be significantly different policies and procedures in different VISNs (or even within VISNs) when it comes to getting notes struck from CPRS.

g.doc works for us as well in our VA (SD).

 

[Therapist4Chnge]

The only time I've seen a note "deleted" in CPRS was when a note was entered into the wrong record, and even then I'm not sure it was actually deleted. An addendum is definitely the way to go.

 

[All4MyDaughter]

Been thinking about this today and I'm not 100% sure that you can make an addendum to a note you aren't a listed cosigner on. Can you?

I am also (after more reflection) not sure that a patient's chart is the appropriate place to handle this interprofessional squabble/disagreement. Of course, I don't know exactly what the social worker said or how it was worded, but what precisely will you accomplish by posting an addendum to her note? So what if she said you refused to work with the patient? You did, and you did so for reasons of professional judgment. Posting an argumentive addendum might just escalate the situation beyond what is appropriate. And you'd be doing it in a patient's permanent medical record. What do you hope to accomplish? Just give it some thought.

 

[DrGero]

Been thinking about this today and I'm not 100% sure that you can make an addendum to a note you aren't a listed cosigner on. Can you?

I am also (after more reflection) not sure that a patient's chart is the appropriate place to handle this interprofessional squabble/disagreement. Of course, I don't know exactly what the social worker said or how it was worded, but what precisely will you accomplish by posting an addendum to her note? So what if she said you refused to work with the patient? You did, and you did so for reasons of professional judgment. Posting an argumentive addendum might just escalate the situation beyond what is appropriate. And you'd be doing it in a patient's permanent medical record. What do you hope to accomplish? Just give it some thought.

Well, first of all, no need to write addendums. Notes can be effectively deleted and altered in CPRS. I didn't want to do that because it would just essentially stoop to the level of this social worker.

But more importantly, I *did* *not* "refuse" to work with this patient - what I refused to do was work with this patient in the way the SW demanded I do - by participating in her hackneyed approach that apparently has as it's fundamental premise this demented vet has some sort of volition or awareness of his behavior comparable to an intact, non-demented person.

I just read one of her notes today where she described her approach with this patient. It was terrible. Essentially, as far as I can gather, she sat with the patient and "educated" him as to why it was inappropriate to use racial slurs in a working environment. At the very least, she managed to do it in a way that was not confrontational with him, but at best, what she's doing with this patient is a 1) waste of time, 2) condescending (the patient is a former manager at a large California firm - I think he's been well aware his entire life that it's inappropriate to make racist comments at work). Her approach doesn't appear to be based on any evidence base I can see.

The worst part about this approach is it continues to be based on this premise that the patient knows what he's doing - I've done the neuropsych. testing. He doesn't. So, what she's doing is perpetuating the falsehood that he knows what he's doing and thereby confusing the nursing staff members she works with every day. I used this as an analogy with a nurse earlier today - if you assumed that every time a patient was incontinent he did it on purpose in order to spite you, how would you feel? Angry, of course - tense, on edge, keyed up, perhaps even combative. Which is exactly the kind of thing this SW is encouraging in her unit nurses. And how helpful would it be to approach demented patients when you're angry, tense, keyed up, and perhaps combative? Of course, it's completely inadviseable. This is driving me a little nuts - basically because I know that a Social Worker of all people, one with supposedly relevant education and training, would know better.

Anyways, I sent an email to the clinical staff to request a care planning meeting to address all this. I anticipate having to confront this woman about this and pretty much straightforwardly ask her as to what the basis of her approach, exactly, is - I think the "hoist by her own petard" approach perhaps is the best tack for me to take here.

 

[All4MyDaughter]

You can't delete or alter her progress note. You can try requesting it, but I doubt it will be done on the basis of what what amounts to professional disagreement.

I think the approach of letting her hang herself is the best choice. But don't be surprised if little or nothing happens to her. At the end of the day, it's her supervisors who have to evaluate her, and they are likely to circle the wagons if they perceive she is being attacked, regardless of the merits of the criticisms you are raising.

I've been with the VA for almost five years and have been frustrated a number of times when other departments "protected" people that I saw as incompetent or neglectful or stupid or whatever. I figured out that there's not much I can do about other people, so I just focus on my own work and doing the best I can for my patients.

Good luck!

 

[DrGero]

You can't delete or alter her progress note. You can try requesting it, but I doubt it will be done on the basis of what what amounts to professional disagreement.

I talked to her supervisor - although I wasn't happy with how little in terms of concrete action she seemed willing to take, she at least agreed to get her supervisee to change the note....

As a point of fact, again, the really offensive part of the note to me wasn't that her approach seems to be so nonsensical - it was that it erroneously described me as "declining" to work with the patient. NOT "declining" to participate in her treatment plan, no - but "declining" to work with the patient, period.

 

[aventurine]

In situations where it's been my opinion that the requested intervention is inappropriate, I discuss why with the treatment team and document my rationale. I would not want anything in a record suggesting that I just refused to work with a patient.

(Something similar happened to me once, and I learned my lesson!)

 

[SingingCow]

I've also had psychiatrists tell me to "educate" patients who have moderate to severe cognitive impairment to behave themselves. The social worker and I looked at each other. Often times, the most effective way to tackle this was to "educate" the team why it was not going to help.

 

[DrGero]

So after multiple discussions a special "behavioral IDCP" was called to, as I framed it, make more explicit our process of deciding on behavioral plans as a group, for this patient (the dementia patient with the foul language issue). In other words, as I put it, when there are two or more practitioners doing independent interventions with a patient at best, this confuses staff, patient and/or family, and at worst, the interventions cancel each other out. This was my polite, nonconfrontational way of saying it.

I recommended we move the patient to another unit (I framed my reasons for this, again, nonconfrontatively but my reasons were that I had serious doubts that this social worker and a close colleague of hers, the ward clerk, were able to work with this veteran appropriately). I also voiced my deep concern that the approach the social worker was taking with this colleague was at best a waste of time, but more than likely at worst was counterproductive in that it encourages an inaccurate and inappropriate understanding of this patient (e.g., that his behavior is somehow volitional), which only encourages his behavior problems. I elaborated (again) what the neuropsych. testing showed for this patient. I cited the fact that if this social worker's notes were submitted to medicare for reimbursement, they would likely be flagged as potentially fraudulent due to the patient's established dementia. I elaborated on the evidence basis for my approach.

Through it all, this social worker did the 'broken record' technique, "it's worth a try, I want to try it my way," made several isolated and irrelevant observations about the patient obviously made to try and argue he was somehow more intact than he was (to the effect of, 'I saw him on Saturday and he remembered my name, sooo....' and etc.) Initially, I had talked to the physician and she seemed very supportive of my position, and I thought she would back me in the meeting.

In the end, the team apparently got tired out by this woman's repetitions and they folded. They're going to allow her (or, at least, not prevent her) from seeing this patient and doing something completely nonsensical and potentially counterproductive (e.g., essentially meeting with a demented person weekly to try and teach him to not use racist comments in the workplace), basically because they feel "it probably won't hurt."

I, myself, have no choice but to withdraw from working with this patient. It's completely contradictory to everything I've been trained in when it comes to doing behavior management with dementia patients. Worse, I have no idea why this social worker is interested in doing this with him - I personally called this behavior of my supposed colleague a form of "dullard's dicksizing" (pardon the expression) on her part with the team psychologist.

I have learned a couple of things in this - first, I can no longer encourage a nuanced view of behavior management with dementia patients in this facility. If they're demented, you do it by the book - I used to occasionally try and work in insight-oriented or educative approaches with dementia patients with my interventions with patients as part of my recommendations or team approaches, but no longer - it encourages staff, apparently, to take license that is completely unwarranted. They simply do not have the training or sophistication to handle that kind of nuance.

Anyways, this has all been frustrating and is essentially a systemic failure at my facility that's resulted in a patient getting substandard care, with all of us apparently colluding somewhat. I suppose I could have been more confrontational - I could have really let her have it in the meeting but I just couldn't do it ("oh, that mean old psychologist picking on that poor social worker!") I almost wish I did, now. But this is the way it stands. If this keeps happening, I certainly will be more confrontational in the future.

Anyways, vent. Thanks.

 

[DrGero]

I've also had psychiatrists tell me to "educate" patients who have moderate to severe cognitive impairment to behave themselves. The social worker and I looked at each other. Often times, the most effective way to tackle this was to "educate" the team why it was not going to help.

I guess I would be shocked to hear a psychiatrist doing that because they, like any reasonably trained, competent social worker, should also know better. Hopefully they were open to the education you offered. And, at least, you had a social worker who seemed savvy......

 

[O Gurl]

So after multiple discussions a special "behavioral IDCP" was called to, as I framed it, make more explicit our process of deciding on behavioral plans as a group, for this patient (the dementia patient with the foul language issue). In other words, as I put it, when there are two or more practitioners doing independent interventions with a patient at best, this confuses staff, patient and/or family, and at worst, the interventions cancel each other out. This was my polite, nonconfrontational way of saying it.

I recommended we move the patient to another unit (I framed my reasons for this, again, nonconfrontatively but my reasons were that I had serious doubts that this social worker and a close colleague of hers, the ward clerk, were able to work with this veteran appropriately). I also voiced my deep concern that the approach the social worker was taking with this colleague was at best a waste of time, but more than likely at worst was counterproductive in that it encourages an inaccurate and inappropriate understanding of this patient (e.g., that his behavior is somehow volitional), which only encourages his behavior problems. I elaborated (again) what the neuropsych. testing showed for this patient. I cited the fact that if this social worker's notes were submitted to medicare for reimbursement, they would likely be flagged as potentially fraudulent due to the patient's established dementia. I elaborated on the evidence basis for my approach.

Kudos to you for a valiant effort and sound reasoning. 👍

I know this had to be frustrating for you, but I am glad that you are not letting it silence you or push you into practicing in a manner that contradicts your training.

 

[SingingCow]

I guess I would be shocked to hear a psychiatrist doing that because they, like any reasonably trained, competent social worker, should also know better. Hopefully they were open to the education you offered. And, at least, you had a social worker who seemed savvy......

Well, they are "open" in the sense that they never tell me to shut up, but they sometimes will follow that with "But it's still worth trying... talk to him/her (patient) and tell him/her not to do that (behavior) anymore." I do not believe it has to do with the profession you are in. It can be a psychiatrist, a social worker, a nurse, and even a fellow psychologist.

In the case you presented, I think trying to "reason" with the veteran and explaining to him why what he does is inappropriate will not be the best use of time. He clearly has disinhibition issues. I wonder if there is a way to adjust the behavioral contingencies related to his behavior -- or is he too impaired at this point for any work to be done? Just curious.

 

[Ollie123]

In the case you presented, I think trying to "reason" with the veteran and explaining to him why what he does is inappropriate will not be the best use of time. He clearly has disinhibition issues. I wonder if there is a way to adjust the behavioral contingencies related to his behavior -- or is he too impaired at this point for any work to be done? Just curious.

I was wondering this as well. I have seen behavior modification work with people that are in pretty rough shape, very low functioning, and with all kinds of cognitive deficits but I suspect this would depend on the exact nature of the damage. I'm not anywhere near familiar enough with dementia to make that call, but if any sort of psychosocial treatment could be implemented effectively in this scenario, that would likely be it. Weekly "Bad boy" meetings admonishing the patient (which is what it sounds like this "treatment" is really going to consist of) certainly isn't going to achieve squat. Then again, I'm teaching behavior mod right now, so I am biased😀

Either way, sorry to hear about the difficulties. This doesn't surprise me though...it fits well with what I have witnessed firsthand and heard about going on in many practice settings around here. Its unfortunate, but sometimes there is only so much you can do and some systems are harder to change than others...I expect anything VA-related is pretty high up on that list.

My (admittedly minimal) experiences also point towards VAs being reluctant to let go of employees who, frankly, have no business being employed. I suspect the paperwork to fire someone is astronomical, and is discouraged due to concerns about opening the government up to lawsuits. There certainly appears to be no level of incompetence too great for someone to work in HR. Maybe this woman should transition there. Heck, the patient would probably be an improvement over many of their staff.

 

[DrGero]

I was wondering this as well. I have seen behavior modification work with people that are in pretty rough shape, very low functioning, and with all kinds of cognitive deficits but I suspect this would depend on the exact nature of the damage. I'm not anywhere near familiar enough with dementia to make that call, but if any sort of psychosocial treatment could be implemented effectively in this scenario, that would likely be it. Weekly "Bad boy" meetings admonishing the patient (which is what it sounds like this "treatment" is really going to consist of) certainly isn't going to achieve squat.

Yeah, it ain't gonna achieve squat, and worse, it's a bit condescending in this case as well - an issue which sticks in my head (the so-called "bad boy" sessions, with a 91 year old man with a 20 year stint under his belt as a regional manager at a Fortune 500 company).

So, yes, behavior mod is the only way to go with patients with dementia - the guideline used in Medicare review tends to be a MMSE score of 18 or less (which is somewhat arbitrary), but the idea is that actual psychotherapy with at least some sort of insight-orientation or educative component built in is simply inappropriate with patients with documented dementia.

Behavior mod can be very successful with generally most kinds of neurodegenerative disorders up to the most severe levels of impairment - however, it requires an extremely high level of consistency and follow-through by the caregiver / team to make it work, and of course the whole problem with dementia is that things always change - you solve one problem and another behavioral issue pops up.

Take for example a successful case I worked on with a particularly talented practicum student I had last year - the patient has mild dementia s/t MS, and has been engaging in repeated, unassisted transfers and has been falling all over the place. My student utilized a "star chart" with the patient (essentially a way of providing visual feedback as to his reinforcement schedule) and reinforced safe-transfer behavior by having him earn stars which went towards receiving individual painting classes (which he loves).

He went from being the top faller in our facility (falling 3x per month on average) to having no falls at all. The problem is that as soon as he stopped falling, he started pooping in his bed (!!!!). Although this is obviously a problem, the nursing staff all agreed it was a much better problem to have as 1) it helped reduce their fall numbers for the hospital and 2) poop is much less dangerous for the patient than a fall.