Dealing with Angry/Upset Patients

[neurotic_cow]

Hello!

I'm curious about how others handle patients who are upset with you/the results of an evaluation/service? How often does this happen to you? I've had a few disgruntled patients this week (to say the least) and my supervisor has been helpful in navigating it, but I'm worried about dealing with this when I'm out on my own in a few months.

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[WisNeuro]

Hello!

I'm curious about how others handle patients who are upset with you/the results of an evaluation/service? How often does this happen to you? I've had a few disgruntled patients this week (to say the least) and my supervisor has been helpful in navigating it, but I'm worried about dealing with this when I'm out on my own in a few months.

This was like every other mTBI evaluation in the VA. You just calmly explain the results of the evaluation. Inform them that they are always welcome to seek out a second opinion, and you can provide referrals of they choose to do so. Insurance will likely not pay for a second eval, though. If you are in a hospital system, you can direct them to the patient advocate. If they'd like to make a complaint, they are free to contact the state board, etc.

 

[Sanman]

Be clear about who your client really is and set realistic expectations ahead of time for what patients can expect. Beyond that it is more about accepting that people may become mad at what you have to say.

 

[AcronymAllergy]

Agreed with both of the above, and a lot can depend on the context (e.g., are you doing assessment or therapy, what are they getting mad about, etc.). For neuropsych, you can start setting the groundwork for feedback during your interview and evaluation. And as WisNeuro said, calmly explain the results, remain empathic but firm in your results and conclusions, provide additional information or possibly referrals as needed, etc.

 

[borne_before]

1. If you aren't pissing people off sometimes during an eval, you aren't being a good psychologist.
2. We deal with crazy people and their parents who are also crazy.
3. I usually switch into rogerian mode.
4. Bring out the elephant in the room. Name it. "You wanted your kid to have autism because they can get more services and is a real handful."

 

[cara susanna]

Validate, validate, validate. And recognize that they may still be pissed off at you no matter how beautifully you validate them or present the feedback. Just remind yourself, it isn't your job to tell people what they want to hear.

 

[smalltownpsych]

Usually the people that get pissed off at me are the same people I don’t really want to spend much time with anyway. I have learned that I can be very empathic and caring or I can be very cool calm and clinical. Nice people who will benefit get the former and the jerks get the latter. I will give extra time and energy to the nice ones and the jerks get the bare minimum. Having very clear professional boundaries and being able to communicate those helps too. We tend to be nice people that want to be helpful and setting boundaries doesn’t typically come easy for us. I also help the staff deal with these people too. I hate it when clinicians duck and run and make someone else deliver the hard news. It always makes it worse.

“No. I have already explained it there is nothing more to say.” ”My answer will not change, this conversation is unproductive.” Most important of all is don’t engage in debate. When I find myself trying to justify to someone who is just being challenging or confrontational, I know I’m sucked into a toxic interpersonal pattern and it’s time to set a boundary and disengage.

 

[clausewitz2]

Remind yourself, and do whatever you need to do to truly believe, that you can make people legitimately angry at you without having done a single thing incorrect, immoral, or ill-advised.

 

[ClinicalABA]

Depending on the situation (and particularly in the case of an evaluation), i might tell them that- despite my confidence in the results and my conclusion- I recognize that I'm not infallible, I may have seen them on a good/bad day, etc.. I then direct them to their insurance company to request information on how to get second opinion, kindly offering to share my results and communicate with anyone they would like to help them with the process.

This has only happened to me a few times during the past 7-8 years where I have been primarily doing assessments. Due to scarcity of providers im my area, I'm rarely referred a marginal case and during the 6-10 months they have waited since the initial referrall, symptoms have likely gotten worse (or not, and they don't show up). I've only really been yelled at once, and that was in Ukranian. Mother was very angry and in my face for what seemed like 30-60 seconds. Dad, who spoke English, simply said- "She wants to know if you could be wrong." I wasn't wrong (it was one of only a handful ASD Level 3 diagnoses I've ever given) but admitted that it was possible and went over the process for obtaining a second opinion, strongly encourageing them to pursue my recommended services in the meantime.

 

[deleted1100659]

Hello!

I'm curious about how others handle patients who are upset with you/the results of an evaluation/service? How often does this happen to you? I've had a few disgruntled patients this week (to say the least) and my supervisor has been helpful in navigating it, but I'm worried about dealing with this when I'm out on my own in a few months.

Set expectations. Respectfully, but firmly I often tell patients who come here seeking benzos/stimulants/inappropriate things "Look, what you want is xyz. I am not going to give you xyz. You are more than welcome to see someone else who may or may not give you xyz, but there is no point in arguing about it with me, because these are my recommendations and they will not change. I do not feel there is more to add at this time, and wish you the best of luck in your journey. Have a great day."

You are entitled to to respect and at a minimum being treated like a human being. If someone raises their voice and becomes verbally aggressive, I would refuse to take that and you should not either. We are not emotional punching bags.

Be concise and succinct and give verbal cues that the session is over, there is nothing further to discuss. I never resort to insults/name calling/etc but I will definitely be firm and say "Hey, it is what it is. What we want is not compatible. Good luck with your journey".

 

[neurotic_cow]

Thanks for all the thoughtful responses!! I've recently had a string of patients who have been very upset with me when their evals came back as being normal and proceeded to send multiple nasty messages through the patient portal to me and about me to other providers, as well as yelling at me, hurling insults at me, all the while I'm trying to be empathetic, validate, etc, to no avail. I stand by my findings, as does my supervisor. I'm not sure if it's the fact that I'm a trainee that makes them think maybe they can treat me like that/push me around and get their way or if perhaps I am just still new at this, but it makes me apprehensive about working on my own. I know it's bound to happen, it's just anxiety provoking and frustrating.

 

[WisNeuro]

Thanks for all the thoughtful responses!! I've recently had a string of patients who have been very upset with me when their evals came back as being normal and proceeded to send multiple nasty messages through the patient portal to me and about me to other providers, as well as yelling at me, hurling insults at me, all the while I'm trying to be empathetic, validate, etc, to no avail. I stand by my findings, as does my supervisor. When my supervisor has stepped in, they completely changed their tune and apologized to them, but never said a word to me. I'm not sure if it's the fact that I'm a trainee that makes them think maybe they can treat me like that/push me around and get their way or if perhaps I am just still new at this, but it makes me apprehensive about working on my own. I know it's bound to happen, it's just anxiety provoking and frustrating.

Just remember, as in any business, including healthcare, the customer/patients is not always right. This has gotten a little worse with the whole client/customer mindset in that patients now feel like they are purchasing a diagnosis, rather than an objective assessment. Just do good clinical work, and you'll be fine in the long run.

 

[PsyDr]

1) Validation only reinforces the behavior.
2) Document the presence or absence of the 5 psychiatric diagnoses with aggression in the diagnostic criteria. If present, document the idea that this behavior is due to the psychiatric diagnosis. If absent, document the idea that this behavior is not due to any psychiatric diagnosis.
3) Document behaviors in the context of contested abilities.
4) APA ethics has some stuff about being threatened.

 

[smalltownpsych]

Thanks for all the thoughtful responses!! I've recently had a string of patients who have been very upset with me when their evals came back as being normal and proceeded to send multiple nasty messages through the patient portal to me and about me to other providers, as well as yelling at me, hurling insults at me, all the while I'm trying to be empathetic, validate, etc, to no avail. I stand by my findings, as does my supervisor. When my supervisor has stepped in, they completely changed their tune and apologized to them, but never said a word to me. I'm not sure if it's the fact that I'm a trainee that makes them think maybe they can treat me like that/push me around and get their way or if perhaps I am just still new at this, but it makes me apprehensive about working on my own. I know it's bound to happen, it's just anxiety provoking and frustrating.

You’ll get better at it. Our first instinct is to try and be nice. That is not always the best strategy. Sometimes being firm and directive is necessary. How to do that within your own interpersonal style is something for you to discover. It’s like when my little sister was struggling with classroom management as a new teacher and said she wanted to be like the guy across the hall. Except he was over six feet tall, ex-marine with a booming voice. I told her that she had to use a different strategy. She did and ended up probably being more effective than him in a lot of ways. Also, I don’t like certain types of clients and cases and I try to steer clear of them. If denying people who are motivated by secondary gain is not your thing, I am sure that there are other areas you could steer toward. I know I wouldn’t want to do it. That being said, it is still a great training opportunity because dealing with difficult people effectively is a great skill for us to have regardless.

 

[deleted1100659]

1) Validation only reinforces the behavior.
2) Document the presence or absence of the 5 psychiatric diagnoses with aggression in the diagnostic criteria. If present, document the idea that this behavior is due to the psychiatric diagnosis. If absent, document the idea that this behavior is not due to any psychiatric diagnosis.
3) Document behaviors in the context of contested abilities.
4) APA ethics has some stuff about being threatened.

100% agree with number one. Notice OP, my response is not to validate their feelings/behavior, in my opinion it enables them to further abuse you. When you're at the phase where insults are being hurled at you or torn down, theres nothing to validate there. Too often healthcare workers are abused and little often gets done about it. You dont have to take it, and I dont think you should take it. If any job tried to force me to take abuse then I would ditch them in a heartbeat.

Shut down their behavior. They have an issue with your eval? That's fine. You gave them your expertise. They dont agree. They can go get a second opinion from someone else. They want to call you names to others? It only makes them look petty. Other providers will often see through that quickly. They can go on their twitter and post in all caps how much they hate you and get their anger out that way instead of using you as a verbal punching bag.

 

[summerbabe]

I generally try to validate the valid, set limits against the inappropriate, and brush off the rest/give patients other options to pursue complaints/dissatisfaction.

This approach often includes reflection and hypotheses about what is driving the dissatisfaction from the patient’s perspective.

Is it secondary gain? Do they want an overly simplistic answer/solution to a complex issue? Is it poor education about what we offer and/or unrealistic expectations (e.g., bad referrals)?

 

[cara susanna]

1) Validation only reinforces the behavior.

Not if you only validate the valid.. You can validate without tolerating or reinforcing unwanted behavior (I mean, DBT therapists do it all of the time).

 

[Therapist4Chnge]

Agreed with both of the above, and a lot can depend on the context (e.g., are you doing assessment or therapy, what are they getting mad about, etc.). For neuropsych, you can start setting the groundwork for feedback during your interview and evaluation. And as WisNeuro said, calmly explain the results, remain empathic but firm in your results and conclusions, provide additional information or possibly referrals as needed, etc.

This is my approach too. Probably 75% of my cases are mTBI and at least 30-50% of those cases are people who are angry that they tested so well. Education throughout the intake and feedback session can provide the best opportunity for them to hear the results. Unfortunately, many don't want to hear that they don't have brain damage and that there are psych and behavior related factors that are driving their struggles.

There are also some decent to good books about giving effective feedback. Of course, I can't remember which ones are best because I've read 2-3 of them over the past few years. Soooo...they exist, hopefully others can recommend which books are best.

 

[deleted1100659]

I

Is it secondary gain? Do they want an overly simplistic answer/solution to a complex issue? Is it poor education about what we offer and/or unrealistic expectations (e.g., bad referrals)?

all of the above usually

And I think it depends validation in the right context can be good, im more saying once it gets to to the insult/raised voices phase im usually just ending the interview though. In my setting verbal aggression can turn into physical aggression real quick. I work with a lot of patients with significant history of violence and a lot of probation evals and that fun stuff.

 

[AcronymAllergy]

all of the above usually

And I think it depends validation in the right context can be good, im more saying once it gets to to the insult/raised voices phase im usually just ending the interview though. In my setting verbal aggression can turn into physical aggression real quick. I work with a lot of patients with significant history of violence and a lot of probation evals and that fun stuff.

Context can definitely be important. I'm probably more willing to tolerate and work around verbal aggression or insults from a frail 85-year-old patient with dementia than I am a generally healthy, fit, young patient with a history of aggressive behavior who's upset my evaluation doesn't support presence of ADHD or won't help them in challenging the criminal charges they didn't tell me about.

 

[erg923]

Early in my training I had an old man become very objectionable during the neuropsych testing assessment. I mean, I tried to do what I thought would be appropriate to de-escalate him. But after a while, he clearly did not want to do it. Then....then he got really, really nasty (which I don't think was dementia or anything... he was just being a dick). After an expletive filled rant abut "the colored's" and " the Jews", he told me to "keep the money!" I then went all Pete Venkman on him and said..."Well Thanks, I will, mister! Then my supervisor wanted to know why he left and didn't want to do the 5 hours worth of "tests" she had in store for him. I was like.... are you kidding me? I'm not putting up with that nonsense! **** that guy! That was probably the start of my "No, I will not just "therapeutically navigate" all patients. How can I get out of this?

There was also this mantra at the State Hospital I worked at before grad school that said if this one, absolutely nuts schizophrenic patient (we will call him "Pete") punches you....he is "not at fault." And don't hit back...and certainly don't press any charges! Again, I was like what the **** is that matter with all you people??? If someone one attacks me unprovoked, they will be certainly be getting clocked to protect myself and/or anyone around me. I am not "Saint ERG"...in case anyone here was mistaken here?

 

[msc545]

You have to be careful about this stuff. What will not get you kicked out of a training program will most certainly get you fired from many jobs.

Patients will not generally attack your report or your diagnoses directly since most of them know they don't have the expertise to do so, but instead, they will complain and lie about you and your behavior to your boss, supervisor, or whoever they think can hurt you. I have been accused of being a sexist, a racist, and an anti-semite (I'm Jewish) over the years by people who didn't like my conclusions. Not a word was ever said to my face.

The worst have been parents with kids who they needed to get an autism diagnosis for. Also, child custody cases are the kamikaze airplanes of Psychologists.

 

[AcronymAllergy]

You have to be careful about this stuff. What will not get you kicked out of a training program will most certainly get you fired from many jobs.

Patients will not generally attack your report or your diagnoses directly since most of them know they don't have the expertise to do so, but instead, they will complain and lie about you and your behavior to your boss, supervisor, or whoever they think can hurt you. I have been accused of being a sexist, a racist, and an anti-semite (I'm Jewish) over the years by people who didn't like my conclusions. Not a word was ever said to my face.

The worst have been parents with kids who they needed to get an autism diagnosis for. Also, child custody cases are the kamikaze airplanes of Psychologists.

I very much respect the folks who do that work (well), but have never even considered getting involved myself. Oof.

 

[msc545]

I very much respect the folks who do that work (well), but have never even considered getting involved myself. Oof.

You should never do this work. People who do it have very short careers as they are constantly sued or get board complaints or both from disgruntled parents who don't get the custody that they want, which is usually all of it.

The amount of custody a parent gets is equivalent to money (via child support) for women. For men, not really, since at least where I live child support orders are almost never enforced against women but are always vigorously enforced against men. Both parents will come after you albeit for different kinds of findings, not that it matters.

 

[BuckeyeLove]

Also, child custody cases are the kamikaze airplanes of Psychologists.

What always amazes me are the amount of psychologists I meet (approximately 10-15 over the years) who do these on the regular, not up to AFCC standards, not even in a forensic manner (i.e., interviewing only one parent), and who for some reason still get called to do them, even after their credibility has been called into question. And the stories they tell about being held up at gunpoint or stalked by an angry dad, yet they still do them. There's been a shortage in my city of ABPP legit forensic child custody evaluators since the last 2 who did them for years retired. Since then it has been the straight up wild west.

 

[neurotic_cow]

The worst have been parents with kids who they needed to get an autism diagnosis for. Also, child custody cases are the kamikaze airplanes of Psychologists.

When I started pursuing my PsyD, my initial plan was to focus on Peds and ASD... but after my first case in our internal clinic in grad school which was a nightmare due to custody issues, childline report, etc, I quickly dropped that and ran in the opposite direction. I'm now primarily geriatric-focused. I can appreciate people who can do forensic type stuff, especially pediatric/custody stuff, I am not at all cut out for it.

 

[Fan_of_Meehl]

Validate, validate, validate. And recognize that they may still be pissed off at you no matter how beautifully you validate them or present the feedback. Just remind yourself, it isn't your job to tell people what they want to hear.

Agreed. I'd even say that it's the OPPOSITE of our job to tell people what they want to hear. People telling them what they want to hear is what got them into our offices, lol.

 

[Fan_of_Meehl]

100% agree with number one. Notice OP, my response is not to validate their feelings/behavior, in my opinion it enables them to further abuse you. When you're at the phase where insults are being hurled at you or torn down, theres nothing to validate there. Too often healthcare workers are abused and little often gets done about it. You dont have to take it, and I dont think you should take it. If any job tried to force me to take abuse then I would ditch them in a heartbeat.

Shut down their behavior. They have an issue with your eval? That's fine. You gave them your expertise. They dont agree. They can go get a second opinion from someone else. They want to call you names to others? It only makes them look petty. Other providers will often see through that quickly. They can go on their twitter and post in all caps how much they hate you and get their anger out that way instead of using you as a verbal punching bag.

I could be wrong, but I think the 'validate' that was mentioned earlier might have more referred to a 'reflection' back to them of their obvious emotional state (in the context of managing the situation and attempt to at least somewhat defuse/disarm them and try to take some 'air' out of their anger balloon) rather than to 'validate' their position, their thinking, or their actions. And I would certainly keep it brief and to the point and immediately pivot into what others have suggested. Of course, depending on the patient/context, it may be preferable to skip the 'validate' step altogether...it would think it really depends on the context, the history with the patient, one's own ability to defend one's self in the situation. For example, if you're a physically small person being angrily confronted with a prior Delta Force veteran who seems incredibly unhinged in the moment and has a history of potentially lethal violent behavior, then at least a bit of 'empathic' labeling/validating of his emotional state in context just might be wise. I think it's a judgment call in a particular situation.

 

[borne_before]

You have to be careful about this stuff. What will not get you kicked out of a training program will most certainly get you fired from many jobs.

Patients will not generally attack your report or your diagnoses directly since most of them know they don't have the expertise to do so, but instead, they will complain and lie about you and your behavior to your boss, supervisor, or whoever they think can hurt you. I have been accused of being a sexist, a racist, and an anti-semite (I'm Jewish) over the years by people who didn't like my conclusions. Not a word was ever said to my face.

The worst have been parents with kids who they needed to get an autism diagnosis for. Also, child custody cases are the kamikaze airplanes of Psychologists.

You're giving me PTSD. I got a good referral for a kiddo with speech delays, trouble at school, etc., I saw that the parents were divorced and mom wanted a call back. Foreshadowing: she's the problem and is def borderline and dumb.

So I called her and was like "FYI - I do not do custody stuff and explained that a lot of psychologists get sued, their are proper practices, and psychs who specialize in that. Rather, I could hopefully shed some light on possible neurodevelopmental disorders that are present." So they come in and both parents are okay. Everything is going good and we start planning the eval. However, mom wanted to sit in and videotape the eval. I set a professional boundary and mom, as is her right, did not want to pursue an eval. Fine. Less drama for me - parents have every right to screw up their kids.

Well... three months later, I get a call from dad and mom is telling him that "Dr. Borne is being sued for malpractice." (to my knowledge, i'm not). So I set the record straight and call mom and inform her that i'm not being sued. But, basically, mom is already trying her best to draw me into custody bs.

Basically, parents suck. Even when we're doing our best for the kiddo.

 

[cara susanna]

I know someone who was the only psychologist in their state who did custody evals. I couldn't even imagine how stressful that is.

 

[WisNeuro]

Yeah, I simply cannot fatho, doing child custody evals. There is so much high paying work out there that is far less stressful and will lead to far fewer board complaints/legal hassles. You either have a passion for the work, or a masochistic streak to do these.

 

[allantois]

This is very insightful. On a psychiatry side of things, I can just waive my hands and say go see a psychologist for testing..

Most of the times what these kids need is training for their parents

 

[borne_before]

This is very insightful. On a psychiatry side of things, I can just waive my hands and say go see a psychologist for testing..

Most of the times what these kids need is training for their parents

I do a ton of parent management training. You'd also be surprised how many poor boundaries there are. Parents who just give up and say "let's just let my 15 or 16 year old run the show."

 

[allantois]

To be more specific, there is a lot of mostly young females who present wanting to be diagnosed with Autism. I know there are quite a few psychologists who would be more than happy to give out the diagnosis for a 2-3k assessment fee

 

[borne_before]

To be more specific, there is a lot of mostly young females who present wanting to be diagnosed with Autism. I know there are quite a few psychologists who would be more than happy to give out the diagnosis for a 2-3k assessment fee

This is the bain of my existence. It really bothers me. I think we are in an age of complete autism madness.

However, I think it has to do with a couple of things. Many of those seeking an autism diagnosis that verbally yearn for a more severe disorder label because things are legitimately hard for them. Often they have pretty bad anxiety, but tend discount their own experiences as if they are saying "it has to be more than just anxiety, my life is really hard."

 

[cara susanna]

This is the bain of my existence. It really bothers me. I think we are in an age of complete autism madness.

However, I think it has to do with a couple of things. Many of those seeking an autism diagnosis that verbally yearn for a more severe disorder label because things are legitimately hard for them. Often they have pretty bad anxiety, but tend discount their own experiences as if they are saying "it has to be more than just anxiety, my life is really hard."

There's also a built-in support community online.

 

[smalltownpsych]

I haven't really run into people wanting an autism diagnosis. I have had patients ask about it fairly frequently and I explain to them that not every socially awkward kid is autistic and they tend to accept that. I also tell them that autism isn't a real thing anyway and explain how we don't know what causes it and that even if we did know a cause it is not a unitary construct and will often go over the criteria with them. If they are a little nerdy, which they usually are if they are thinking they might be autistic, they really enjoy the discussion.

I tend to have a similar conversation even when they do meet diagnostic criteria for autism. I had enough empathy and social awareness to connect well and assist spectrum kids and socially awkward going all the way back to high school so in my mind the label is pretty irrelevant to the treatment. As mentioned above, the challenges of being neurodiverse in world that is designed for the neurotypical can lead to symptoms and so I treat the symptoms and then improve their ability to navigate the world. Kind of similar to what I do with all of my patients.

To be honest, I don't usually need a DSM for that. Not to say that I don't have most of the criteria and categories readily available to memory or reference it frequently when diagnostic questions arise. It can be a very useful tool when one knows its limitations and uses. I also use it to try to get people to stop calling every obnoxius patient Borderline. Sometimes it might work better for that purpose if I just hit then over the head with it.

 

[smalltownpsych]

To be more specific, there is a lot of mostly young females who present wanting to be diagnosed with Autism. I know there are quite a few psychologists who would be more than happy to give out the diagnosis for a 2-3k assessment fee

I'm curious as to which part got the hmm. I do throw out a lot of controversial types of statements at times and I put a couple out there that have led to dialogue and arguments with others. The one about autism not being real gets quite a few clinicians raising eyebrows. Usually when I explain further they get what I mean by it. Obviously, there are patterns of related symptoms that are tied to observable functional neurological issues, we just can't measure it very well and without really being able to discriminate between potential etiologies, then it makes it hard to say it is a thing when it could be multiple things that look alike. I think of the concepts of errors of accommodation and assimilation where a kid learns that a large animal with four legs and horns is called a cow so when he sees a moose, he calls it a cow. Just fun with semantics.

 

[allantois]

I'm curious as to which part got the hmm. I do throw out a lot of controversial types of statements at times and I put a couple out there that have led to dialogue and arguments with others. The one about autism not being real gets quite a few clinicians raising eyebrows. Usually when I explain further they get what I mean by it. Obviously, there are patterns of related symptoms that are tied to observable functional neurological issues, we just can't measure it very well and without really being able to discriminate between potential etiologies, then it makes it hard to say it is a thing when it could be multiple things that look alike. I think of the concepts of errors of accommodation and assimilation where a kid learns that a large animal with four legs and horns is called a cow so when he sees a moose, he calls it a cow. Just fun with semantics.

The part that autism isn't a real thing.. I mean you can say that mental disorders are not a real thing because they are based mostly on expert consensus.. Of course we don't understand autism, but we can all agree that kids with autism are different from kids without autism. I don't necessarily think that putting it in terms of "it's not a thing" is necessarily helpful, but I am all for deemphasizing diagnostic categories in general. These patients come up probably at least weekly, and I mostly avoid it by referring them to seek out a psychological evaluation (of course most of them will not). I have never really considered the part where they actually do get to the psychologist's office and then you have to deal with the issue. I do know of psychologists who give out these questionable diagnoses that have very little to no clinical utility, so I am not at all sure why these patients seek out these diagnoses in the first place. It has become fashionable to be diagnosed with a mental disorder, which, I suppose is better than having terrible stigma and having to hide one's mental issues. However, these patients use these diagnoses in a way to justify why they behave in certain ways and to avoid trying to change their behaviors..

In fact this has gotten so bad that our monthly provider meetings have all been about autism for the past few months..

 

[borne_before]

I'm curious as to which part got the hmm. I do throw out a lot of controversial types of statements at times and I put a couple out there that have led to dialogue and arguments with others. The one about autism not being real gets quite a few clinicians raising eyebrows. Usually when I explain further they get what I mean by it. Obviously, there are patterns of related symptoms that are tied to observable functional neurological issues, we just can't measure it very well and without really being able to discriminate between potential etiologies, then it makes it hard to say it is a thing when it could be multiple things that look alike. I think of the concepts of errors of accommodation and assimilation where a kid learns that a large animal with four legs and horns is called a cow so when he sees a moose, he calls it a cow. Just fun with semantics.

I interpreted the “autism” not being real thing as:

-a collection of symptoms without a distinct etiology like fibromyalgia

Versus

-the autism purist view. That it is a distinct condition with a distinct etiology like PKU or 22q

 

[smalltownpsych]

The part that autism isn't a real thing.. I mean you can say that mental disorders are not a real thing because they are based mostly on expert consensus.. Of course we don't understand autism, but we can all agree that kids with autism are different from kids without autism. I don't necessarily think that putting it in terms of "it's not a thing" is necessarily helpful, but I am all for deemphasizing diagnostic categories in general. These patients come up probably at least weekly, and I mostly avoid it by referring them to seek out a psychological evaluation (of course most of them will not). I have never really considered the part where they actually do get to the psychologist's office and then you have to deal with the issue. I do know of psychologists who give out these questionable diagnoses that have very little to no clinical utility, so I am not at all sure why these patients seek out these diagnoses in the first place. It has become fashionable to be diagnosed with a mental disorder, which, I suppose is better than having terrible stigma and having to hide one's mental issues. However, these patients use these diagnoses in a way to justify why they behave in certain ways and to avoid trying to change their behaviors..

In fact this has gotten so bad that our monthly provider meetings have all been about autism for the past few months..

The use of a mental health diagnosis as an excuse for bad behavior or lack of effort is rampant. I tend to smack that down pretty quick with my patients. The truth is that most people want to succeed and have themselves and others proud of them so if I can tap into that underlying motivation that has been buried under the excuses and the corrosive effects of low expectation, great progress can be made. “I can’t do this because of my diagnosis.” A good reframe is, it might be more difficult for you than others, but if you really wanted to and worked hard you could probably do it. I do a lot of challenging of negative self-defeating beliefs..

 

[smalltownpsych]

The part that autism isn't a real thing.. I mean you can say that mental disorders are not a real thing because they are based mostly on expert consensus.. Of course we don't understand autism, but we can all agree that kids with autism are different from kids without autism. I don't necessarily think that putting it in terms of "it's not a thing" is necessarily helpful, but I am all for deemphasizing diagnostic categories in general. These patients come up probably at least weekly, and I mostly avoid it by referring them to seek out a psychological evaluation (of course most of them will not). I have never really considered the part where they actually do get to the psychologist's office and then you have to deal with the issue. I do know of psychologists who give out these questionable diagnoses that have very little to no clinical utility, so I am not at all sure why these patients seek out these diagnoses in the first place. It has become fashionable to be diagnosed with a mental disorder, which, I suppose is better than having terrible stigma and having to hide one's mental issues. However, these patients use these diagnoses in a way to justify why they behave in certain ways and to avoid trying to change their behaviors..

In fact this has gotten so bad that our monthly provider meetings have all been about autism for the past few months..

When you make the statement that kids with autism are different than kids without autism, that just strikes me intuitively as being inaccurate. Some of the reasons and rationale that I am able to give are part of that, but I wouldn’t challenge this perspective if I didn’t feel that it is actually more problematic than just being incorrect. I just haven’t been able to fully think this one through yet. Trust me, when I am working with individuals who meet the diagnostic criteria, I use similar thinking and language myself because that is all we have.

I have a similar, yet less problematic issue probably because the treatment is fairly similar and also we get a few extra terms to use, with Bipolar with Psychotic feature verses schizoaffective verses schizophernia. Are they on a spectrum of severity or a progression of illness or are they different manifestations of they same underlying vulnerability or is it sometimes the same and sometimes not? Sometimes the patients fit a category neatly and it seems to make sense to use the label, but more often than not I’m thinking the label is limiting all of our thinking.

 

[msc545]

You're giving me PTSD. I got a good referral for a kiddo with speech delays, trouble at school, etc., I saw that the parents were divorced and mom wanted a call back. Foreshadowing: she's the problem and is def borderline and dumb.

So I called her and was like "FYI - I do not do custody stuff and explained that a lot of psychologists get sued, their are proper practices, and psychs who specialize in that. Rather, I could hopefully shed some light on possible neurodevelopmental disorders that are present." So they come in and both parents are okay. Everything is going good and we start planning the eval. However, mom wanted to sit in and videotape the eval. I set a professional boundary and mom, as is her right, did not want to pursue an eval. Fine. Less drama for me - parents have every right to screw up their kids.

Well... three months later, I get a call from dad and mom is telling him that "Dr. Borne is being sued for malpractice." (to my knowledge, i'm not). So I set the record straight and call mom and inform her that i'm not being sued. But, basically, mom is already trying her best to draw me into custody bs.

Basically, parents suck. Even when we're doing our best for the kiddo.

Sorry if what I wrote worried you, but better to be worried and still keep the license. Divorced moms are very bad news as they are usually upset and also hungry for the money they think they deserve. If the divorced mom is also a borderline, you essentially have an unstable bomb on your hands. Don't. just don't. In fact don't even refer, since if mom then dislikes the referral doc or the referral doc's results, you can be sued for negligent referral AND have a license problem. Seriously.

 

[msc545]

What always amazes me are the amount of psychologists I meet (approximately 10-15 over the years) who do these on the regular, not up to AFCC standards, not even in a forensic manner (i.e., interviewing only one parent), and who for some reason still get called to do them, even after their credibility has been called into question. And the stories they tell about being held up at gunpoint or stalked by an angry dad, yet they still do them. There's been a shortage in my city of ABPP legit forensic child custody evaluators since the last 2 who did them for years retired. Since then it has been the straight up wild west.

The only good news is these things pay very well. They should, considering the risks. Some malpractice carriers won't cover you if you do any child custody cases. They are not stupid.

 

[WisNeuro]

The only good news is these things pay very well. They should, considering the risks. Some malpractice carriers won't cover if you do any child custody cases. They are not stupid.

Do these pay considerably better than general IME/forensic work?

 

[AcronymAllergy]

Do these pay considerably better than general IME/forensic work?

I only have one example in which I think the total for an eval worked out to about $25k. But the only reason I know is because it apparently resulted in a board complaint due to the provider not being transparent enough about anticipated fees and billing as it occurred.

No clue how that total compares to the typical eval.

 

[WisNeuro]

I only have one example in which I think the total for an eval worked out to about $25k. But the only reason I know is because it apparently resulted in a board complaint due to the provider not being transparent enough about anticipated fees and billing as it occurred.

No clue how that total compares to the typical eval.

I'm curious as to the hourly breakdown. Personally, I don't think I'd even consider a custody eval for anything less than 3X my current IME rates. Simply not worth the added hassle.

 

[AcronymAllergy]

I'm curious as to the hourly breakdown. Personally, I don't think I'd even consider a custody eval for anything less than 3X my current IME rates. Simply not worth the added hassle.

Agreed, and even then I wouldn't go near it. I could re-read the complaint at some point to see if it discusses how many hours were involved. I just don't think there's any sum of money that would convince me to do these.

 

[msc545]

Do these pay considerably better than general IME/forensic work?

Yes, usually. Not always. The work is a lot more condensed relative to time. It is also a lot more dangerous. No matter what you do there will always be at least one person you piss off because they didn't get what they wanted in court. Not to sound sexist, but in my experience, it is usually Moms, since women in these cases generally feel entitled to more money and custody time than Dads do, and when they get angry when they don't get it they come after you. Also, keep in mind that women get more sympathy and forbearance from lawyers (including your lawyer) and Judges.

The excess money you get in fees will be spent trying to defend yourself and keeping your license.

 

[msc545]

I'm curious as to the hourly breakdown. Personally, I don't think I'd even consider a custody eval for anything less than 3X my current IME rates. Simply not worth the added hassle.

In SoCal, about $500 -$750 per hour for the eval and prep, $750 - $1200 an hour for court time with or without testimony.