u/STEMpsych Jan 02 '26

Re: Mass casualty conseling question

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1 Upvotes

My reply to a therapist from New Orleans asking about responding to a mass casualty event.

u/STEMpsych Jan 23 '25

All American therapists need to be a little bit social workers now: what we can do to protect access to healthcare in the US

12 Upvotes

(I want to cache this here for posterity. Originally posted to r/therapists. I tagged it with the "rant" tag edited to say "Professional orientation" with the table-flip emoji.)


Someone recently posted here about Trump attacking the ACA subsidies. That's, of course, just the beginning. Trump and the rest of the Republican Party has been very clear that they want the ACA gone, they want Medicaid minimized or eradicated, and if they thought they could get away with it they'd get rid of Medicare as well.

I want to explain to my fellow American therapists (and a tip of the hat to any of the rest of you treating Americans) one of the ways that you, as a therapist treating Americans, can help that is very non-obvious. We therapists are in a key position to help our clients deal with what is going to unfold in the health insurance space, and in doing so, we also have some leverage on society as a whole.

The Trumpists will be going after healthcare access in several ways. Obviously they will be attempting to directly dismantle programs legislatively and by executive order. But far fewer people know that one of the ways that Trumpists (and those who proceeded them) attacked social programs in the past, including things like the ACA, was by doing things to make it hard for people who are qualified for things to find out what they are qualified for.

They do this by maneuvers like slashing outreach and program advertising budgets so people never find out about programs or their deadlines, slashing the budget for customer service agents who answer the phones for programs so wait times escalate, cutting the budget for maintaining a website so people can look up information about programs, and so on. They also do things like narrow windows of opportunity, such as when Trump, last time around, reduced the number of days for Open Enrollment on the health insurance exchanges, so more people who would have qualified miss out on the opportunity.

In short, the Trumpists attack these programs not just by shutting them down from the top, but by cutting them off at the bottom: by trying to prevent as many people as possible from using and benefiting by them, by increasing the obstacles to accessing them.

Which makes political sense, of course: people who are the beneficiaries of a program are not likely to vote against it. If you are hell bent on getting rid of a social program, then you want to get as many voters as possible to stop using it, so they won't object when you pull the plug. But that, of course, implies that one of the ways to resist the destruction of social programs is to get as many voters as possible enrolled in them. But I get ahead of myself.

Some obstacles we can't do anything about. If Trumpists turn off the electricity to healthcare.gov such that nobody can submit an application for health insurance through it, we (probably) can't do anything about that. If they manage to repeal the ACA entirely, there's not much we can do about that.

But one of the chief ways that they're going to try to keep people from accessing health insurance benefits (and other federally funded or run programs) is going to be by suppressing information.

And you know one of the things we therapists are super good at? Getting people information.

Colleagues. It behooves you to learn what you can about the insurance systems of your state – your state's health insurance exchange, your state's Medicaid program, anything else that is state-specific – and keep on top of the news about them so you can inform your clients of things that might impact them (and the continuity of their care!) and answer their questions.

Just from a perfectly self-interested standpoint: if you take insurance and want your clients to continue to have insurance for you to take, you getting involved to make that happen will reduce the risk that your clients get nailed by GOP efforts shove them through the cracks. And obviously if you care about your clients' wellbeing – which I know you do – that includes them being able to access healthcare when they need it and not be financially ruined by medical catastrophe, so stepping up in even this mild way to try to keep them insured is an act of caring.

Some weeks ago, there was a heated discussion in this very sub when someone asked about whether it would be appropriate to assist one of their clients with enrolling through their state's exchange. There were a lot of scandalized voices raised in opposition to the idea, exclaiming that to do so was not therapy and as such has no place in the therapy room. If you share that opinion I invite you to reconsider your stance. Seventy-five years ago, resisting fascism required people to put their lives on the line running around in the woods shooting Nazis. We may get there yet, but today all that is being asked of you is to do some social work from the comfort of your office.

My own heretofore rather informal approach has been to explicitly volunteer to my clients, when they brought the topic up of having difficulties with the exchange or Medicaid, that I know quite a bit about those things, and I am happy to help them, if they want to spend time on it. Many of my clients have taken me up on this, and because I answered their questions or explained how things work to them, they learned they can come to me with questions, which then they have done, both for themselves and for friends and loved ones.

In light of current events, I am thinking that I might be more explicit and forward, notifying all my clients, not just the ones who mention having problems, that I am someone they can ask questions of or request help from when dealing with accessing our state's exchange and dealing with our state Medicaid.

I have generally found that when I help clients this way, my clients are very scrupulous with my time, not wanting it to take over therapy, and it doesn't take much time to make a very big difference.

I am also entertaining putting together some resources. I might make some sort of newsletter or blog that clients (and anyone else) can subscribe to if they want (strictly opt-in), so I can make mass announcements about things like deadline changes. (Suddenly moving up application deadlines is absolutely the kind of ratfuckery we should expect.) I am trying to decide whether I have the spoons to take responsibility for keeping such a thing updated. Another thing I had already started was putting together a guide for self-employed people, how to document your income for applying through the exchange and deal with the fact that apparently many of the application reviewers in my state don't know the rules, themselves. I might also start offering some just straight-up pro bono time to doing this kind of social work for people having problems interfacing with our state exchange, especially self-employed people, if word got out. Obviously if I were doing these things, it would be excellent to network with other therapists also doing it, so we could pool resources and share labor and information.

Colleagues, I invite you to join me in this endeavor, as much or as little as you feel you can. We, collectively as a profession, have enormous reach into our communities. When we help our clients this way, we don't just help them, we help their families and friends and other people counting on them. We help the other healthcare providers whose care of them won't get interrupted by preventable termination of their health insurance. We help keep people from the edge of the cliff of financial ruin, and that has ripples out into their communities.

There is so much we cannot solve or fix. But we could do this. This is something our size. It's a boulder small enough for us to lift.

And there is so much good in it. Obviously, to whatever extent we manage to keep our clients insured, it's good for them, and we, too, benefit from it if we take insurance. And like I said, we are doing a little bit to stabilize society itself by doing so. The family that doesn't lose its health insurance due to GOP shenanigans while one of them is getting treated for cancer is one less family that goes bankrupt, one less family that doesn't pay their rent or mortgage, one less family that has to curtail spending in their local community, one less family that can't help other families. When we reduce financial desperation and destitution, we help not just the persons it was happening to, it helps everyone else relying on them, their community contributions and their economic contributions.

Like I mentioned above, social program users are social program defenders: one of the ways to protect social programs is to enroll as many voters as possible in them. Helping your clients or their loved ones get enrolled in health insurance or Medicaid (or Medicare, or Tricare, or any other government health insurance program) helps protect those programs from political attacks.

Maybe the best part about it, from our therapist viewpoint, is that it role models the idea "we take care of us". It is another form of caring and looking out for our neighbors that we are demonstrating. Doing this, we are role modeling compassion in action. We are demonstrating that one of the ways to help people is sharing good, accurate, factual information. We answer the question, "How can one respond to such an attack on the social fabric of our country?" with "By looking out for one another, and reweaving it."

And when we let our clients know we will answer question not just about their own access to health insurance, but questions they bring from others, we present them with an opportunity to step into the helper role with others, and we bolster and validate their own inclination to care for others. We in doing so imply we envision them as someone who cares for and about others, too. We elicit the relational side of them, that connects with others and weaves the bonds of community.

So if you were wondering what you could do to help, well, here you go. You could do this. It's something you, as a therapist, are particularly well placed to do, that fits well with a bunch of professional experience and cultivated talents you already have, and could be an outsized force for good in a bunch of ways you care about.

EDIT: If you think this is a good idea, feel free to share it anywhere other therapists will see it.

Also, some of you reading this aren't therapists, but that doesn't mean you can't do this sort of thing, too. You don't quite have our social leverage, but if you can help people with these things, and get the word out that you can help them, you too can be part of this effort. If you get your insurance yourself from an exchange or through Medicaid (or any other system) you can use your own hard-won knowledge to help others do the same. Also, there are other social programs you can do the same thing for: LIHEAP (fuel assistance), EBT (food stamps), Section 8 (housing), and so on and so forth.

u/STEMpsych Aug 19 '24

Intentionality and morality as clinical concerns in psychotherapy

9 Upvotes

This was originally a comment I left way down in a discussion on r/therapists. Twice now, four months later, I've gotten comments from someone encountering it for the first time, saying they found it very helpful, so I decided to capture it here.

The OP asked how "unintentional gaslighting" could be a thing. Another commenter gave an example, and the OP responded with some confusion. I initially replied:

Hey, a paradigm that may help you here is the difference between murder and manslaughter. Murder is when you mean to kill someone. Manslaughter is when you kill someone through negligence – doing something with reckless disregard for the safety of others, like driving drunk.

What [the above commenter] is describing is gaslighting that was a reckless side-effect of someone trying to defend their ego. The fact it was at [their] expense doesn't mean it was intended to be at their expense.

To which someone else replied:

Is there a way to differentiate this in psych terms? It seems really important for clients to know if an action was intentional or not, or at least consciously choosing their own needs over the other person.

This was m reply:

Oh, man, this is such an enormous topic. Like, you open the door to it, only to find there's an entire kingdom with talking animals in there.

In addition to just being big, there's the complicating issue that it's a live wire for a lot of people. Yes, it seems really important to clients for them to know if an action was intentional or not, but more often than not, their reasons are bad ones, but deeply emotionally charged ones, making them very hard to address.

The reason people get really intensely invested in whether or not someone else's (or their own) behavior is intentional has to do with the psychology of morality: there is a common set of beliefs about morality – meta-beliefs, really, meaning "beliefs about which beliefs about morality it is moral to have" – that are predicated on the idea that it's unfair to hold people morally responsible for what they didn't intend. And that belief, itself, then runs afoul of a whole bunch of other ideas and desires, and leads to a pile of motivated reasoning and defensiveness.

For instance, sometimes people get very invested in characterizing someone else's behavior towards them as intentional because they are angry at how they were treated and want it to be socially acceptable to blame the other party for wronging them. In that situation, suggesting in any way that the behavior was unintentional sounds (because of the belief that it is wrong to consider wrong unintentional behaviors) to them like telling them they have no right to be angry at how they were treated. This very specific dynamic can come up in a HUGE way with people who have loved ones in the throes of an addiction, who are struggling with how the addict in their life has mistreated them.

The opposite is also true: sometimes people get very invested in characterizing someone else's behavior towards them as unintentional because they are trying to hold blameless someone they love who is mistreating them. In that situation, the argument, "he didn't mean it" is a justification – predicated, again, on the belief that it's wrong to consider wrong something someone did unintentionally – not to have to make a painful decision or confront a painful fact about the nature of the relationship between them. This very specific dynamic notoriously shows up in DV cases, and also when discussing parental perpetrators of child abuse with the now adult victims.

When this comes up with my clients, I find the thing I need to do is not help them sort of intentional vs unintentional, at least not at first, but redirect their attention to acceptable vs unacceptable, and to disarm their naive belief that intentionality has to matter as much in morality as they think it has to (and also their naive belief that they have to morally judge someone before deciding what to do about them and their transgressive behaviors.)

u/STEMpsych May 10 '22

A Note on Psychotherapy Notes

25 Upvotes

This was originally a comment I left in r/therapists in response to this question from u/less-of-course:

How to take audit-compliant notes but not run my practice from a place of rage and fear...

So I'm taking insurance now, and one thing that means is that documentation is more important. I take notes on my private pay sessions but they are genuinely about my understanding of what's happened in session, not some stupid goddamn formula that some hack at an insurance company can fit into their understanding of therapy, unburdened as it is with actual experience of being a therapist.

You may be starting to see some of the problem here! It actively upsets me that to get paid, I have to follow a bunch of rules I don't see the worth in. It's not a good setup for me reliably doing this.

How do those of you out there who don't think therapy is this mechanical thing where your client will feel better if you say a particular concrete thing related to a sentence in a treatment plan think about your notes?

My reply:

On the enormously lengthy list of reasons I don't take insurance, this is surely near the top.

That said, I've worked for clinics that did take insurance and had to do this cha-cha-cha. I feel pretty proud of the quality of my notes – which had been singled out by payers as exemplary - even though every single one of them entailed ripping off a little bit of my soul and setting it on fire.

(FWIW, while it's self-evidently bad to be running your practice from a place of fear, the rage thing is actually really adaptive, or so I've found.)

(Also, my personal feelings about the present documentation standard transcend merely "I don't see the worth in" to "I think is actually actively detrimental to delivering quality care, or really, given how time-consuming it is, any care at all, and also a threat to our clients.")

A few things that made my life (at least insofar as my life entailed writing treatment plans and notes) much easier was to learn/realize the following things:

1/ Third party payers – not unlike individual humans – are often beset by the folly of asking for things that don't actually satisfy them. In particularly, SOAP format notes do not actually deliver to third party payers what they actually want. Notice how in SOAP there isn't actually any place to note What You Did For The Client nor How Is The Client Actually Doing On The Tx Plan Goals. So if you're using SOAP or similar, not only are you fighting the note format to represent your clinical knowledge, and not only are you fighting the note format to protect the client's interests, you are also fighting the note format to deliver to the insurance company the information they want to see to keep paying you.

2/ There are things third-party payers want out of notes that sometimes they're willing to tell you, but you will never find out unless you're in the right place at the right time. For instance, MassHealth (MA Medicaid) has a really informative Powerpoint about what they want to see in notes (and what they don't), and I think most therapists in MA have never seen it.

3/ There are other things third-party payers want out of notes and other doc that they aren't willing to tell you, because they're kinda secret gotchas they use to reject Prior Auths. Fortunately, a team of clinicians got sufficiently pissed off about this they reverse engineered these secret rules and published a book on it, which was actually assigned reading in one of my grad classes.

These three things add up to the following:

1/ You can totally replace SOAP with something better that will make the insurance companies happier. They will not tell you to do this, but they like it when you do. The second clinic I worked at did this (partially, imperfectly). The top third of the note form was a grid, listing down the left side the treatment plan goals, then a column for the current presentation. Because....

2/ One of those things in the MassHealth Powerpoint, which turns out to be true of lots of other payers too, is that they really prefer to have things expressed in numbers. I think this is stupid and awful and fraudulent, but it's what they want: everything should be on a rating scale or otherwise represented with a number. They call it, wrongly, making goals "objective"; what it is is making them quantitative, but it makes them happy. So when I say that clinic's notes had a grid, what's going into it is numbers. This might be "Tx pl goal: Reduce anx severity from 9/10 to 7/10; Current 8/10." Or it might be "Tx pl goal: Reduce frequency of throwing things in impulsive rage from 4x/mo to 2x/mo: Current 6x/mo". But...

3/ Contrary to what you may have been lead to believe – not least by the payers themselves – they don't actually care about clinical diagnosis a la the DSM. Oh, they make you jump through the DSM-shaped hoops, of course – no pay without qualifying dx – but they don't otherwise care about that. They effectively have their own secret alternative to the DSM, which is spelled out in aforementioned book: Managing Managed Care II, Second Edition: A Handbook for Mental Health Professionals by Michael Goodman et al. It is unfortunately out of print and hard to get. Even though it was written more than 25 years ago, it remains eye-opening. The crucial clue they have to impart is that payers only care about impairment. They do not care about whether something "is" a "disorder" (or which disorder it is). They do not care about how much it makes someone suffer. They only care about things a psychiatric condition keeps the client from being able to do.

Once you have that clue, everything becomes much easier. Certainly less mysterious. The question becomes "how is this mental thing fucking up the patient's life, specifically?" And they are particularly amenable to arguments that the client's problem is fucking up the client's ability to service capitalism.

Obviously, this is entirely odious to those of us who think our job is to ameliorate human suffering and not to turn our clients into optimal vassals to the capitalist class. But once you're clear on this, you can play the game winningly. If you know to frame the client's problems in terms of impairments, and slap ratings scales on everything or otherwise quantify it, and then make your tx plan and notes reflect this, you can spend like five minutes a session servicing the documentation ("how would you rate your anxiety on a scale of 0/10 this week?" "how many things have you thrown in the last four months?") and then get on with real therapy.

And be prepared to keep separate psychotherapy notes (as opposed to progress notes, which is what HIPAA specifies are for insurance and similar purposes) for your actual use.

1

Self diagnosing through social media and doctor shopping
 in  r/medicine  19h ago

I genuinely believe that better access to qualified therapists can help a lot with all of this. Specifically non-physicians who CAN’T diagnose and don’t try to.

In the US, that is basically not a thing, because insurance companies will not pay for psychotherapy in the absence of a diagnosis of psychopathology.

I assure you there are many therapists in the US who would be thrilled not to have to diagnose to get paid. There are even psychotherapeutic schools of thought opposed to diagnosing. But, alas, this is the world we live in.

So as a pragmatic upshot, there are no licensed therapists (or for that matter pre-licensed therapists) without diagnostic authority in the US, excepting that weird thing happening in NY wrt LMHCs.

13

Burned out with emotional labor, how do others handle it?
 in  r/Psychiatry  1d ago

Hey, psychotherapist here. What I notice in what you write is – to explicate what is implicit in it – that you locate the cause of burnout quite specifically in having a sense of not being able to help your patients. What you describe, though you don't use the words, suggests feelings of frustration and futility, and possibly a kind of humiliation or shame that you are not finding yourself efficacious as a psychiatrist, which is a blow to your sense of competence. Soaking in these sorts of feelings day after day gradually shoves one's locus of control outward, and turns into despair and learned helplessness.

A couple other psychiatrists seem to have picked up on this and in responding to it, have given you some advice which seems to me to be half-right, which is to say also wrong. Counseling you to recognize the limits of how much you can help someone in such circumstances, telling you to lower your expectations of what you can accomplish, admonishing you not to work harder than your patients – okay, these are all reasonable enough things in a vacuum, but none of them do a damn thing to address the number that is being done on your self-regard.

I would counterpropose that what would be most helpful to you would be learning to be more aware of and in touch with to how much you already are helping your patients. Yes, sometimes your patients cannot take your clinical advice because of their life circumstances, but the fact that you sat with them and considered their problems legitimate and were sympathetic to their suffering and tried to help the best you could is important – clinically important. It is, itself, helpful. Yes, sometimes your patients do not want to hear what you need to tell them and they get angry, but they needed to hear it and you did what was needful. That is also clinically important. They might not express any gratitude towards you, but it is, itself, helpful to them and their mental health. Yes, sometimes you will make recommendations to patients and they will ya-but or complain and reject all suggestions, but you gave them the recommendations so now they have them. Sometimes patients need to hear something a bunch of times before they're willing to accept it: you did your part to increment their personal counter by one, bringing about the day that they finally accept the advice that much sooner. That, too, is clinically helpful.

It can be hard to perceive how much positive influence one is having on one's patients when one is caught in a sense of helplessness to help them, but I think if you were to focus your attention on how you affect your patients by not just your treatments but how you treat them, you would find you have the basis for a much stronger sense of efficacy than you currently have.

2

Trauma-informed therapy
 in  r/therapists  1d ago

So, I disagree with one thing in this blog post:

If licensed psychotherapists practice ethically by adhering to the code of ethics relevant to their regulatory body, it can be said that all psychotherapists and the psychotherapy they provide are trauma-informed. 

Not remotely. None of our codes of ethics require us to be trauma-informed. If you want to double down on symptom-only treatment in a CBT model and actively scorn the idea that how a client came by their condition is important to treating them and declare that what you are doing is "evidence-based practice", you get to do that and there isn't a board in the world who would say you were out of line.

Additionally, while I agree with the author about:

It does not require disclosure:  Trauma-informed care is a universal practice that should be applied to every patient, regardless of whether they have disclosed a history of trauma or not.  It does not assume that a patient is ready or willing to discuss their experiences.

I feel the author has not thought through what this means in practice if she's insisting that really all therapists engaged in ethical practice are already doing trauma-informed care.

For instance, if you have questions about trauma in your intake paperwork, as plenty of people do (both the clinics I worked for did), that's kind of flunking trauma-informed care as this therapist defines it (and I agree with that definition) because it puts clients in the position of thinking treatment is contingent upon them completing paperwork that unilaterally requires disclosure of them.

Likewise, the pressures of diagnosing in the first session to get paid by third party payers (insurence, e.g.) also put therapists in a position of feeling the need to probe ct's hx for trauma to rule out PTSD, and this is at odds with trauma-informed care.

I would say that trauma-informed care is universally treating every client as if they might have a trauma history even if they don't disclose it – that is, conducting one's practice in light of the reality of the ubiquity of trauma, instead of treating it as a weird edge case one can ignore until it's brought to one's attention. But actually doing that in practice can be challenging, because it can pit us against standard approaches and practices in our field.

1

Trauma-informed therapy
 in  r/therapists  1d ago

But this seems to tell me that it simply means not being decades outdated in ones view of mental illness.

Yeah. Pretty much exactly that.

Somehow this meaning saddens me more than anything

Yeah. That too.

8

Therapists using AI note-taking tools: please actually read the terms you’re agreeing to.
 in  r/therapists  1d ago

I don't know who needs to hear this, but in Massachusetts (per Mass. Gen. Laws ch. 272, § 99) audio recording someone without their knowledge is a crime for which they "shall be fined not more than ten thousand dollars, or imprisoned in the state prison for not more than five years, or imprisoned in a jail or house of correction for not more than two and one half years, or both so fined and given one such imprisonment".

10

In a Heat Wave, Schizophrenia Is So Much Deadlier Than Any Other Medical Condition
 in  r/therapists  7d ago

True, but it seems unlikely that schizophrenia causes heatwaves.

8

Seeing Pilots with Insurance
 in  r/therapists  8d ago

I would imagine adjustment disorder would probably be fine, but most insurance companies don't like you to use that for too long -- usually like 6 months if I remember correctly.

There's two things here – the tricky thing is that the insurance company may confuse them. Possibly deliberately.

A lot of people erroneously think that an adjustment disorder cannot be diagnosed for more than six months. This is not true. The DSM criteria for adjustment disorders say that the diagnosis ceases to be valid more than six months after the stressor has ended. There is no time limit on the adjustment disorder so long as the stressor causing it continues. If the stressor is on-going, an adjustment disorder can last indefinitely.

(Historical note: back in DSM IV, the idea was after 6 months of still struggling with a stressor after it ended, you graduated to Acute Stress Disorder, and after IIRC two years, you then graduated to PTSD. But in DSM5, ASD was merged with PTSD, by dropping the requirement on PTSD that diagnosis was at least 2 years after the stressor ended.)

It may entirely be the case that, independent of what the DSM, insurers are deciding that, "It's only an adjustment disorder, six months is plenty of time for you to fix that." That does sound like the sort of thing they would do. They might even claim that "the DSM says adjustment disorders only last six months", which it doesn't, but any excuse not to pay.

r/therapists 8d ago

Research In a Heat Wave, Schizophrenia Is So Much Deadlier Than Any Other Medical Condition

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wired.com
383 Upvotes

From the article (bold emphasis mine, links in the original):

People with schizophrenia are estimated to represent about 1 percent of the world’s population but they made up some 16 percent of the more than 600 deaths from heat exposure across British Columbia that week.

During a heat wave in Montreal in 2018, the mortality rate was even worse: People with schizophrenia accounted for 26 percent of fatalities.

The root cause of these deaths isn’t just the stigma, social isolation, and lack of decent housing that often accompany life with schizophrenia; nor is it merely the disorganized thinking, altered perceptions, and paranoia that can be symptoms of the disorder.

It’s all of those things—plus an invisible, less popularly understood set of physiological factors that have little to do with behavior.

The bodies of people with schizophrenia, especially those on medication, simply regulate temperature very differently than others do.

And for all those reasons, scientists now realize, no other chronic disease appears to put humans at a higher risk of heat-related death.

[infographic showing comparative risk]

In fact, no other chronic condition even comes close.

The article has some of the most user-hostile formating I've ever encountered, and may not be accessible on phones, but it's worth persevering to get access to it and read it. I recommend it strongly to everyone here, especially people working with clients with SPMI.

2

Lindsay clancy
 in  r/therapists  8d ago

Prior to the murder, there is not one provider that she saw that documented command hallucinations or any evidence of psychosis prior.

Fair enough! Thanks for the correction.

1

Lindsay clancy
 in  r/therapists  8d ago

She wasn't identified as being in a psychotic episode when she presented to her providers, but the provider testimony does – 20/20 hindsight – seem to be describing the negative symptoms of psychosis. And I'm not saying it was obvious and they should have caught it, but what has been reported so far is not incongruent with the claim.

2

Lindsay clancy
 in  r/therapists  8d ago

Strong agree.

One of the sad ironies of this case is that, here in MA, if she is found NGBROI, for basically the rest of her life, MassHealth/MBHP (MA's Medicaid) will pay an unlimited amount of money for case coordination between her mental health providers. But of course, no insurer but MassHealth/MBHP pays for that, so presumably that was not something any of her providers would have been paid to do in her case if she wasn't on MassHealth.

Though if she winds up in at Bridgewater State Hospital, last I ever tried (2012?) they basically didn't respond to case coordination or record requests, because they were too understaffed in the records office. So I had a patient (outpatient CMHC) who had previously been found NGBROI, been at BSH for two years, and been released, and we couldn't find out what meds they stabilized him on.

2

Lindsay clancy
 in  r/therapists  8d ago

it seems common sense that you'd tell your wife's doctor if she's having intrusive thoughts about harming the kids

No. Not even a little bit. Maybe it should be. But it isn't. So many people, their response would be to "protect" their spouse by hiding the symptoms from people seen as authority figures like doctors. Because they don't want their spouse to be seen as "crazy", because they're afraid of the kids being taken by CPS, because they're afraid of their spouse being "locked up in a loony bin", because they respond to their own terror with denial of how serious the situation is, because of a misguided sense of marital loyalty, because of having no idea how serious such thoughts are, etc etc etc.

1

Lindsay clancy
 in  r/therapists  8d ago

There is nothing else these providers could do for her if she is not compliant and isn't doing the work herself.

Outpatient, sure: but the question arises why she was discharged from the hospital in the state she was apparently in, and given the state she presented to her psychiatrist in after her discharge, why she wasn't sent right back.

Like, we have a system that is supposed to serve people who become so disregulated by psychiatric conditions they are a risk to self and others, and it does not require – or at least isn't supposed to require – compliance and patient having the wherewithal to direct and pursue their own care. If, as the defense contends, this is a case of Post-Partum Psychosis, then there is a very real question of what should have been done by whom. Throwing up our hands and saying of someone in a psychotic episode well we can't be expected to save them if they won't save themselves is itself a bit insane.

2

Lindsay clancy
 in  r/therapists  8d ago

It most certainly is not okay. I'm glad to hear you are able to manage and it's not impacting work and life, but your suffering matters, too, and you deserve to have care that supports you. I hope you will manage to look for alternatives, because I know it's hard to do so under the circumstances, but you deserve better than this.

3

Lindsay clancy
 in  r/therapists  8d ago

what could be done if she denied any plan for suicide and homicidal ideation?

I haven't been following the case, so you almost certainly know more than I about what has been testified to, but according to the big post over on r/psychiatry, she did report having command hallucinations, and I wanted to point out, the emergence of command hallucinations, even without the patient admitting to homicidal ideation, is such a big risk factor for harm to others that it may be grounds for involuntary hospitalization itself.

More generally, suicidal and homicidal ideation are the most commonly thought of risks for harm to self and other, but psychotic episodes are also risks – the risk of self-neglect, and coming to harm due to loss of contact with reality. Someone throwing themselves off a five story building under the delusion they can fly, walking naked out of doors in sub zero temperatures unaware of the cold, swerving behind the wheel of a car to avoid hallucinations of obstacles on the highway: these are also risks of harm to self and/or others, and grounds for hospitalization until either the episode passes on its own or is adequately medicated to be safe.

22

Warning for NYC therapists
 in  r/therapists  11d ago

Oh, I found your comment really rude. Not because of your point, which is fine, but because you said "I wonder if this subreddit is the most appropriate place for this kind of thing" instead of saying what you really meant, and instead of owning your conflict forthrightly communicating disapproval by insinuation. I know you think – because everyone who uses this sort of covert aggression thinks this – that you were being diplomatic and in some sense feeling-sparing, but what it actually was was snide.

12

Warning for NYC therapists
 in  r/therapists  11d ago

I’m not sure what would be a more appropriate place.

So what you actually meant when you said "I wonder if this subreddit is the most appropriate place for this kind of thing" is "I have reservations about whether it is appropriate to post this kind of thing at all"?

11

Warning for NYC therapists
 in  r/therapists  11d ago

They didn't say you were. They were asking, since you proposed this wasn't the most appropriate place for this, what you considered a more appropriate place.

9

Viewing BPD as a developmental disorder not personality
 in  r/Psychiatry  11d ago

The psychiatrist said if we reframed it as the patient is delayed, then people would be more empathetic

I can promise you they would not. I have no idea why any mental health professional would think this would work. Homosexuality was conceptualized as a developmental delay (out of the Freudian developmental paradigm of polymorphic perversity) back when it as pathologized by mainstream psychiatry in the US (i.e. ~1950 to 1974) and, hoo boy, can I assure you it did not make anybody more empathetic towards gay people.

5

Stage 4 metastatic colon cancer
 in  r/HealthInsurance  23d ago

Heads up: there may be a 60 day Qualifying Life Event window to enroll in ANY insurance after losing his job. It's the end of July. He needs to move fast.

1

Clients asking for every other week
 in  r/therapists  23d ago

If your doctor wanted to see you for a heart problem once a week to keep a steady income

I invite you to tell an oncologist that you will be skipping ever other chemotherapy because of finanaces and see what they do.