VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Sanman]

I would really encourage the clinic to revisit this policy. We are required to offer them options, sure, but they don't have to be therapy if the patient has demonstrated they can't engage. It just takes up valuable appt slots and burns out therapists. We're a CBOC with just us, no specialty mental health clinics (unless you count my 50% PCT role), and we still manage to set boundaries.

The latest policy about rescheduling efforts helps with this, too.

I don't disagree with you but not really my problem in this case.

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[cara susanna]

I don't disagree with you. but not really my problem in this case.

Haha, touche.

For OPMH therapists in this thread, definitely find out how much control you have. Often, it's more than you think. It's not like one visit to the patient advocate is gonna get you fired (assuming your clinical rationale is sound).

 

[Fan_of_Meehl]

My patients wait 2-3 months, many have MCI/mild dementia and still show up to their appointments, and on time.

My patients (at VA) claim that their 'traumatic brain injury' (remote history of mild concussion) makes it impossible for them to remember how to distinguish left from right, up from down, or day from night. They also claim to be incapable or reading/writing well enough to complete measures while filling out (perfectly) a travel pay form printed in microscopic font.

 

[cara susanna]

They get soooo many reminders, too. I'm always suspicious when they say that they thought it was a different day/time.

 

[Fan_of_Meehl]

OK, I think I know the answer to this...

I work in a BHIP setting, general mental health clinic at a VA. How do we effectively manage chronic no showers that keep asking to get back on our panel? More or less I was told we have to deal with it. Is this something I can effectively use in my informed consents going forward or would it be largely non-enforceable because of larger VA policy that allows for Veterans to do this without any consequences?

In my experience, non-enforceable. I've had good results from simply keeping very good notes on patient responsivity (or not) to increasingly lower 'response effort' laden task demands (requests?) in the form of self-monitoring forms, worksheets, therapeutic structure, etc. Eventually, they passively drop out of your caseload after being gently confronted for the 15th time on non-completion of homework. You can't let up on making the therapy environment non-reinforcing for non-engagement type behavior.

I've enjoyed some of the most unintentionally hilarious discussions with therapy patients in the VA who try in vain to explain EXACTLY how behavioral and/or cognitive change is not only difficult but impossible for them to achieve (even the most miniscule changes) at which point I share with them the 'sad' news that therapy just ain't for them (since it's all about self-change).

 

[cara susanna]

I really don't get no shows, especially. You can cancel so easily via text without having to talk to anyone.

 

[WisNeuro]

My patients (at VA) claim that their 'traumatic brain injury' (remote history of mild concussion) makes it impossible for them to remember how to distinguish left from right, up from down, or day from night. They also claim to be incapable or reading/writing well enough to complete measures while filling out (perfectly) a travel pay form printed in microscopic font.

When I gave the feedback that, if taken at face value, a vet's performance on testing would be at the level of, if I left the room for more than 20 seconds, and came back in, he would not know who I was, or where he was. To which Fu ckles the Clown doubled down and suddenly started asking "where am I?!" Despite driving independently two hours to the appointment solo.

 

[Fan_of_Meehl]

When I gave the feedback that, if taken at face value, a vet's performance on testing would be at the level of, if I left the room for more than 20 seconds, and came back in, he would not know who I was, or where he was. To which Fu ckles the Clown doubled down and suddenly started asking "where am I?!" Despite driving independently two hours to the appointment solo.

I swear we need to publish a 'Veterans Affairs Casebook of Malingering, Shucking/Jiving, and Otherwise Non-Credible Clinical Presentations'

 

[aim-agm]

When I gave the feedback that, if taken at face value, a vet's performance on testing would be at the level of, if I left the room for more than 20 seconds, and came back in, he would not know who I was, or where he was. To which Fu ckles the Clown doubled down and suddenly started asking "where am I?!" Despite driving independently two hours to the appointment solo.

"Veteran demonstrates ability to integrate new information in furtherance of his malingering, supporting finding of intact cognitive function and deficient moral functioning."

 

[cara susanna]

Look, it's the VA

 

[Fan_of_Meehl]

Look, it's the VA

Mine would be, 'please do'

 

[Sanman]

Mine would be, 'please do'

To add to this, No shows are so much better when they are VVC and I am working from home.

 

[cara susanna]

I just got offered a side private practice gig (PTSD focused), with as few or as many hours as I want. What do people think about doing side gigs? I'm famously lazy so I usually try not to do extra work, but I also kinda see an appeal of being able to do effective therapy and have complete control.

 

[Sanman]

I just got offered a side private practice gig (PTSD focused), with as few or as many hours as I want. What do people think about doing side gigs? I'm famously lazy so I usually try not to do extra work, but I also kinda see an appeal of being able to do effective therapy and have complete control.

Depends on the side gig, how much you need the money, and what your plans are. IMO, given the current climate of politics and the VA, it never hurts to have a back up option for practice in your pocket if you want to transition out.

Do you already keep malpractice insurance? I do, but I know many VA only folks that do not.

 

[summerbabe]

I just got offered a side private practice gig (PTSD focused), with as few or as many hours as I want. What do people think about doing side gigs? I'm famously lazy so I usually try not to do extra work, but I also kinda see an appeal of being able to do effective therapy and have complete control.

I think about this every once in a while and have always gone against this, even when I was working acute inpt and missing doing actual therapy (plus sometimes have days where I was bored out of my mind & not tapping into the achievement part of my brain).

Ultimately, I currently value my free time more, my finances are fine enough & I'm also not excited by big purchases or fancy vacations

To Sanman's point about having backup options in case one wants/needs to leave the VA, I think about that a lot. And I figured if I needed to do that, I can probably throw something together pretty quickly and at least keep myself afloat for a while.

 

[AcronymAllergy]

I agree that it ultimately comes down to how much you'd make, how much it might cost you (e.g., for your own malpractice insurance if you don't already have it, any materials you might need), and how much time you're willing to set aside for it. I did side work while at VA, but it was assessment-oriented and paid relatively well, which made it a bit easier to work in and just do as desired on weekends. For therapy, there's a bit more of a longer-term tie in, which can be a pro and a con.

 

[WisNeuro]

I just got offered a side private practice gig (PTSD focused), with as few or as many hours as I want. What do people think about doing side gigs? I'm famously lazy so I usually try not to do extra work, but I also kinda see an appeal of being able to do effective therapy and have complete control.

Might as well do a side gig for some PTSD IME evals and take away some of my travel work

 

[ThatPsyGuy]

Why doesn't anyone use their goddamn CPAP machine

 

[WisNeuro]

Why doesn't anyone use their goddamn CPAP machine

"I lost like 3 pounds, so my BMI is only 35.7 now, so I'm pretty sure that cured my OSA, so I haven't been using it."

 

[thebalmofhurtminds]

But then also are here for a sleep evaluation and want a fix from me.

 

[Sanman]

Why doesn't anyone use their goddamn CPAP machine

Your choices are that they always use it or never use it. Never use it wins by a 4:1 margin. Always use it is usually co-morbid with an anxiety disorder.

Reasons? It was uncomfortable the one time I tried it.

 

[psycho1391]

Why doesn't anyone use their goddamn CPAP machine

Right. Just completed a round of CBT-I with someone who improved their sleep efficiency tremendously, but they are still exhausted/fatigued during the day. Guess what? No CPAP adherence.

 

[aim-agm]

I've been fairly successful with building motivation for CPAP adherence with psychoeducation - "Being repeatedly suffocated in your sleep is bad for you." I also of course normalize that it is uncomfortable, and recommend wearing the mask for a while while awake to get used to sensation. It also helps that I can prescribe something to help ease getting to sleep despite the discomfort.

 

[cara susanna]

PCP: Patient is reporting memory and attention problems, can you do neuropsych testing? Chart: Patient is not CPAP compliant

Nothing is more satisfying than denying a testing consult because the patient isn't CPAP compliant, lol.

There is even evidence that untreated OSA interferes with PTSD treatment.

 

[Fan_of_Meehl]

PCP: Patient is reporting memory and attention problems, can you do neuropsych testing? Chart: Patient is not CPAP compliant

Nothing is more satisfying than denying a testing consult because the patient isn't CPAP compliant, lol.

There is even evidence that untreated OSA interferes with PTSD treatment.

Definitely doesn't help nightmares. You're choking to death every night all night long (if the OSA is severe) and your brainstem is screaming at your CNS that you are about to expire. It's akin to being waterboarded all night, every night.

'I wake up gasping, sweating and swinging...like I'm fighting someone.'
Don't remember any clear dream content (and certainly nothing thematically-related to the presumed traumatic events [that occurred 50+ years ago]).
'Nightmares' had their onset about five years ago.
Patient is 71 years old.
The G.E.D.umb and Q.E.D.umber chorus (social worker/LPN/neurologist) all agree that this is a 'classic case' (TM) of PTSD because...wait for it...(a) he is a 'veteran' and (b) he has 'nightmares' (Q.E.D. (in lieu of D...S...M...))
Snores 'like a freight train' and stops breathing in his sleep according to wife.
Wakes up with cotton mouth and headache. Feels like **** every morning after 10 hours of 'sleep'
Sleep study conducted. Severe OSA is diagnosed, AHI is something godawful
'Do you use your CPAP?'
'Hell no! I can't keep that {MIKE FOXTROT!} on. I get better sleep without it.'

And...

It's about to get a LOT worse, folks.

They just proposed changed/updated rules for the standard service-connection percentage assigned to folks with OSA.

Up til now, it's been a real 'anchor' contributing to massive bumps in 'total' service connection percentage since it has automatically been assigned a 50% rating (by itself), regardless of whether it was 'well controlled' (or even perfectly controlled) with CPAP therapy.

As I understand it, the updated rules are that it will be assigned a 0% rating if successfully treated/controlled by CPAP therapy. If the CPAP therapy isn't effective (or isn't used?), you'll get a percentage (maybe 50%?)

You gotta love the first hits you get on a Google search of the issue these days...

Veterans with Sleep Apnea – Why NOW is the Time to File Your Claim for Disability Benefits | Bross & Frankel, P.A.

Proposed changes to the VA ratings for veterans with sleep apnea mean NOW is the time to file for your veteran's disability benefits for sleep apnea.

brossfrankel.com

Sleep Apnea VA Rating Changes Are Coming. Learn How You Can Protect Your Benefits. - Rep for Vets

Changes to the sleep apnea VA rating schedule could impact tens of thousands of veterans. Here's what you need to know to protect your benefits.

www.repforvets.com

 

[aim-agm]

Definitely doesn't help nightmares. You're choking to death every night all night long (if the OSA is severe) and your brainstem is screaming at your CNS that you are about to expire. It's akin to being waterboarded all night, every night.

'I wake up gasping, sweating and swinging...like I'm fighting someone.'
Don't remember any clear dream content (and certainly nothing thematically-related to the presumed traumatic events [that occurred 50+ years ago]).
'Nightmares' had their onset about five years ago.
Patient is 71 years old.
The G.E.D.umb and Q.E.D.umber chorus (social worker/LPN/neurologist) all agree that this is a 'classic case' (TM) of PTSD because...wait for it...(a) he is a 'veteran' and (b) he has 'nightmares' (Q.E.D. (in lieu of D...S...M...))
Snores 'like a freight train' and stops breathing in his sleep according to wife.
Wakes up with cotton mouth and headache. Feels like **** every morning after 10 hours of 'sleep'
Sleep study conducted. Severe OSA is diagnosed, AHI is something godawful
'Do you use your CPAP?'
'Hell no! I can't keep that {MIKE FOXTROT!} on. I get better sleep without it.'

And...

It's about to get a LOT worse, folks.

They just proposed changed/updated rules for the standard service-connection percentage assigned to folks with OSA.

Up til now, it's been a real 'anchor' contributing to massive bumps in 'total' service connection percentage since it has automatically been assigned a 50% rating (by itself), regardless of whether it was 'well controlled' (or even perfectly controlled) with CPAP therapy.

As I understand it, the updated rules are that it will be assigned a 0% rating if successfully treated/controlled by CPAP therapy. If the CPAP therapy isn't effective (or isn't used?), you'll get a percentage (maybe 50%?)

You gotta love the first hits you get on a Google search of the issue these days...

Veterans with Sleep Apnea – Why NOW is the Time to File Your Claim for Disability Benefits | Bross & Frankel, P.A.

Proposed changes to the VA ratings for veterans with sleep apnea mean NOW is the time to file for your veteran's disability benefits for sleep apnea.

brossfrankel.com

Sleep Apnea VA Rating Changes Are Coming. Learn How You Can Protect Your Benefits. - Rep for Vets

Changes to the sleep apnea VA rating schedule could impact tens of thousands of veterans. Here's what you need to know to protect your benefits.

www.repforvets.com

Paying people to not be adherent to psychiatric treatment is one thing, paying them to not be adherent to medical treatment is much worse.

In addition to CBTi there should be CpapBT to get people to be compliant with the damn thing. There are brief codes for substance use counseling (e.g. 3 minutes of tobacco counseling is 1/3 of an RVU), they should also make some for OSA tx adherence counseling. Although maybe this will all become irrelevant when there are enough GLP-1s to go around.

To be fair, I have seen many cases of nonrestorative sleep w/o nightmares, sometimes with a parasomnia, that I'm reasonably confident were best described as PTSD related sleep disturbances and which remitted with sympatholytics. Of course, OSA (or nonadherent OSA) was ruled out first.

 

[Shiori]

My clients have accepted that working with me means I will be gently, but firmly nudging them toward adherence. I inform them that their medical notes will tattle on them.

I have seen an increase in patients wanting Inspire now. Has anyone heard about reviews? It seems...intense.

 

[WisNeuro]

My clients have accepted that working with me means I will be gently, but firmly nudging them toward adherence. I inform them that their medical notes will tattle on them.

I have seen an increase in patients wanting Inspire now. Has anyone heard about reviews? It seems...intense.

Only had a handful of patients with it, they generally liked it. As far as the research, I've only seen some scattered trials data and some 3-5 year follow-ups. Those data look good. I haven't seen a meta-analysis yet, but also haven't done a deep dive. Outcome and adherence data looks solid in the individual stuff, with relatively low adverse outcomes. CPAP-BiPAP still the first line tx, but for those unwilling/unable to go that route, probably a good second option.

 

[clausewitz2]

I sometimes share the anecdote with my OSA patients that I have worked with one single solitary person who found CPAP comfortable. He had been a fighter pilot in Viet Nam and the mask reminded him of the glory days.

Perhaps worth noting I didn't see him at the VA.

 

[Fan_of_Meehl]

Paying people to not be adherent to psychiatric treatment is one thing, paying them to not be adherent to medical treatment is much worse.

In addition to CBTi there should be CpapBT to get people to be compliant with the damn thing. There are brief codes for substance use counseling (e.g. 3 minutes of tobacco counseling is 1/3 of an RVU), they should also make some for OSA tx adherence counseling. Although maybe this will all become irrelevant when there are enough GLP-1s to go around.

To be fair, I have seen many cases of nonrestorative sleep w/o nightmares, sometimes with a parasomnia, that I'm reasonably confident were best described as PTSD related sleep disturbances and which remitted with sympatholytics. Of course, OSA (or nonadherent OSA) was ruled out first.

I've been sent some guidelines for behavioral 'treatment' of nonadherence to CPAP therapy (and I've operationalized it at various levels of intensity/structure...all the way from general principles of attempted habituation by wearing it several minutes at a time while awake to trying to implement some of the more structured stuff that I was sent by colleagues).

Here's the practical problem I have run into the vast majority of the time. The vast majority of the time the folks who are (passive?) aggressively non-compliant (in that they have rejected to advice/help of their medical providers/helpers who have seen them in CPAP clinics and tried to work with them on different masks, suggestions to try to habituate, etc.) is that they are still basically in pre-contemplation and aren't willing/able to accept suggestions.

That being said, it is definitely an area that we need to increase focus, research, and intervention around because it causes massive problems (medically and psychologically) and, if the CPAP therapy can ultimately be tolerated/implemented, it is very effective. There is almost certainly a reality that some folks with PTSD are going to have a MUCH harder time tolerating the mask/pressure/claustrophobia elements and this should be approached with empathy by the counselor and medical professionals attempting to help them adjust to the CPAP therapy. However, there are also dispositional variables emanating from the patient side that--if present--basically means you're peeing into the wind (until these dispositional variables change, if ever). No amount of behavioral technology/nuance is going to be 'effective' with a patient who is basically fighting against you as a matter of principle (due to Axis II factors) and/or to establish a medical record that 'my CPAP therapy is ineffective' in order to increase service-connection percentages and monthly disability payments. If you see patients full-time in VA settings, you probably know what I mean.

Also, I agree that there is an understudied reality of sleep-disordered behavior/parasomnias that appear related to PTSD and that aren't nightmares (no clear dream content), per se. There's some research indicating that certain parasomnias are more common in folks with PTSD and with an apparent onset after their traumatic events. There's also a lot of malingering going on in this area, as well (in my opinion), which makes it an incredibly difficult area to do solid research on outside of, say, a setting where response bias is formally assessed and actual sleep studies are done on the participants.

 

[aim-agm]

Also, I agree that there is an understudied reality of sleep-disordered behavior/parasomnias that appear related to PTSD and that aren't nightmares (no clear dream content), per se. There's some research indicating that certain parasomnias are more common in folks with PTSD and with an apparent onset after their traumatic events. There's also a lot of malingering going on in this area, as well (in my opinion), which makes it an incredibly difficult area to do solid research on outside of, say, a setting where response bias is formally assessed and actual sleep studies are done on the participants.

My suspicion is that, given how vulnerable one is while asleep the body is trying to "sleep with one eye open" which can lead to parasomnias or parasomnia-like presentations.
The most common PTSD-related sleep disturbance I see is abnormally high levels of motor activity during sleep, e.g. swinging or thrashing limbs (I don't believe I have seen overtly acting out dreams) even in absence of nightmares. Often associated with complaint of non-restorative (or less restorative); can also cause problems in relationships. Likely often not detected because it is not asked about, and relies on collateral for detection. Typically resolves with prazosin or clonidine.
Other presentations have included night sweats, night terrors, and one case of sleepwalking (although there was question of comorbid narcolepsy).

 

[cara susanna]

I've read that PTSD nightmares are more direct replays of traumatic incidents

 

[cara susanna]

I saw in a chart from someone who was just discharged from hospitalization (non-VA) and the hospital refused to schedule f/u appts with us for the pt because they said they're "more than capable of making decisions and scheduling on their own."

Shots fired at the VA? lol

 

[WisNeuro]

I saw in a chart from someone who was just discharged from hospitalization (non-VA) and the hospital refused to schedule f/u appts with us for the pt because they said they're "more than capable of making decisions and scheduling on their own."

Shots fired at the VA? lol

Yeah, we ain't buying into the entitlement and infantilization here in the outside world.

 

[Fan_of_Meehl]

I saw in a chart from someone who was just discharged from hospitalization (non-VA) and the hospital refused to schedule f/u appts with us for the pt because they said they're "more than capable of making decisions and scheduling on their own."

Shots fired at the VA? lol

I'm not even lying when I tell you that in our recent "PTSD Awareness Month" meeting I asked (out loud), "what makes us believe that people are currently insufficiently 'aware' of PTSD?" Of course, I got back shocked uncomfortable silence followed by the official party line but...really. The disconnect with reality and common sense is just too much at times.

 

[Fan_of_Meehl]

I saw in a chart from someone who was just discharged from hospitalization (non-VA) and the hospital refused to schedule f/u appts with us for the pt because they said they're "more than capable of making decisions and scheduling on their own."

Shots fired at the VA? lol

VA 'policies/procedures/commandments' written by non-practicing excellentologists typically are FAR in excess of standards of care/practice in the field and are, therefore, iatrogenic (to patients) and burnout-inducing (to providers) in the extreme. And rates of mental health problems and suicides continue to climb.

 

[cara susanna]

Yeah, we ain't buying into the entitlement and infantilization here in the outside world.

The hilarious thing is SPC reached out (I know, it's their job, no shade to them) and they were scheduled for f/u appts with us

 

[Shiori]

Hank heard us chatting. Behavioral health doesn't get any love though. He focused on the medical side.

 

[WisNeuro]

Yeah, nothing surprising here, really. Controlling for adherence and other health factors still pretty key. I'd still say that the high adherence data in clean-ish samples still looks good for the variable I'm interested in. But, as can be expected, even high CPAP adherence is not going to fix high BP/cholesterol/poorly controlled diabetes due to diet and next to zero exercise in many of our patients. One of the issues we need to address in a more holistic way, there are usually many things contributing to health outcomes, and solely focusing on one will only go so far, if at all. Mild attention/EF issues affecting memory as well? Treating OSA is one key, but if Stubborn 75-year old Ed still refuses to wear his hearing aids, auditory stimuli still ain't getting in there in the first place.

 

[cara susanna]

We're supposed to make 4 contact attempts for cancelled appointments. How the heck are we supposed to do this when we don't even know who cancelled the majority of the time?

 

[Fan_of_Meehl]

We're supposed to make 4 contact attempts for cancelled appointments. How the heck are we supposed to do this when we don't even know who cancelled the majority of the time?

Wow...this is a new one.

Agreed...a patient cancels and they just disappear from your schedule (the provider isn't even notified). Patients canceling their last scheduled appointment is one way of them exiting my caseload without being hassled (at least here). For God's sake, it is one of the ONLY ways you can stop seeing/rescheduling veterans who chronically (verbally) demand access to psychotherapy but who, behaviorally, are clearly and firmly stuck in precontemplation and who--therefore--never actually do work in therapy but who--due to worrying about service-connection--also will never admit to not wanting/needing psychotherapy (though their disengaged behavior is clearly saying it). The only way these patients ever leave your caseload is by either (a) canceling their last/only scheduled session or (b) no showing and not responding to 3 phone calls.

For no-shows we have to document 3 phone calls on separate days but, here at least, I don't think we have any obligations necessarily to attempt to track down those who simply cancelled.

 

[cara susanna]

Wow...this is a new one.

Agreed...a patient cancels and they just disappear from your schedule (the provider isn't even notified). Patients cancelling their last scheduled appointment is one way of them exiting my caseload without being hassled (at least here).

For no-shows we have to document 3 phone calls on separate days but, here at least, I don't think we have any obligations necessarily to attempt to track down those who simply cancelled.

This is a new change to minimum rescheduling efforts SOP, apparently. Not sure if it's local or national.

No one that I've talked to is doing it, some because they refuse and some because they had the same question as me.

 

[Fan_of_Meehl]

This is a new change to minimum rescheduling efforts SOP, apparently. Not sure if it's local or national.

No one that I've talked to is doing it, some because they refuse and some because they had the same question as me.

This is one of the most demoralizing things for conscientious providers working at VA. There are tons of 'rules' that everyone just passively ignores but there's no guidance on which 'rules' you're supposed to follow vs ignore. Dealing with this right now in context of the 'peer review' process.

"Rules" often seem to be randomly or arbitrarily enforced on an ad hoc basis depending on how politically/socially connected the rulebreaker is or isn't or based on knee-jerk admin reactions from time to time.

 

[summerbabe]

This is a new change to minimum rescheduling efforts SOP, apparently. Not sure if it's local or national.

No one that I've talked to is doing it, some because they refuse and some because they had the same question as me.

Been hearing about this as well recently so I think this is national and different sites are getting pulled into compliance at different rates.

 

[Shiori]

We've been lucky that our MSAs do this for us. I rarely see my cancellations and I don't have the strength of character to look ahead more than a day.

 

[Fan_of_Meehl]

Been hearing about this as well recently so I think this is national and different sites are getting pulled into compliance at different rates.

Wow. Requiring that we hassle vets who try to cancel their way out of our caseloads is madness and is going to greatly amplify access issues and caseloads that only grow (but never shrink). This would also be expected to MASSIVELY increase the %age of appointments that aren't ultimately attended due to veterans attempting to just 'save face' once you track them down and 'reschedule' with little intention of attending that appointment.

At what point can we start having adult conversations about the reality of psychotherapy practice at VA and how to responsibly address behaviorally demonstrated lack of engagement in that process by veterans?

 

[WisNeuro]

Nearly every day y'all remind me that I made the right career move

 

[Fan_of_Meehl]

This is a new change to minimum rescheduling efforts SOP, apparently. Not sure if it's local or national.

No one that I've talked to is doing it, some because they refuse and some because they had the same question as me.

So, basically there will now be only four possible ways for a patient to 'exit' your psychotherapy caseload:

1) be 'cured' or treated to remission of PTSD symptoms (it does happen...rarely)

2) go on record to the therapist that they are declining to reschedule (e.g., are 'too busy,' don't think they need/want therapy (again, rarely happens)

3) 'ghost' you such that they fail to respond to 3-4 phone calls, letters, and/or bench warrants

4) they die

 

[aim-agm]

This approach also hinders dealing with the real issue that PTSD can lead to avoiding treatment for PTSD. Besides making it more difficult to discern if a patient desires treatment but is avoiding it (vs. not actually desiring it and avoiding it), you have a harder time confronting the behavior or setting a limit.

 

[cara susanna]

So, basically there will now be only four possible ways for a patient to 'exit' your psychotherapy caseload:

1) be 'cured' or treated to remission of PTSD symptoms (it does happen...rarely)

2) go on record to the therapist that they are declining to reschedule (e.g., are 'too busy,' don't think they need/want therapy (again, rarely happens)

3) 'ghost' you such that they fail to respond to 3-4 phone calls, letters, and/or bench warrants

4) they die

Well, the new SOP also says you don't have to make rescheduling efforts with 2 consecutive cx/ns or 3 during an episode of care, so there's that.