Stand up a bit

I’ve been writing about not diagnosing yourself, not generalizing, not analyzing yourself.  These are what you hire me for and your own efforts along those lines will usually lead you astray.  The topic comes up first in the main website, especially here, and in this blog.  You can read about it in the many entries to the right of this text that have “The Basics” in the title, and you can find more just below those entries if you look through the “archives” starting from April of this year.

The topic came up again in an exchange between several of us on the state psychological associations list-serve (do people still use that term?).   A colleague wrote in for advice about the pressure she was receiving from a very angry patient, his attorney, the courts, and she was unsure how to proceed; she was being roped into providing services and reassurances to the court that she can’t possibly provide, and doing much extra work for which she wasn’t being paid.  I wrote a response to the list which fits in well with what we’ve been talking about on this blog.  You may also find it applies to you when in your own work or private life you’re pressured to do the impossible.  Here is the letter (names have been changed):


Donna:  Big yes to Jen’s points about making your role, liability (or lack of), and area of control very explicit to all parties and to the court – I would do it in writing.  Everyone should hear you say, and see it written, the limits Jen mentioned, e.g. that you can’t know if you’ve reviewed everything your patient wrote, that you can’t know to whom he sent it, that you can’t know the context in which he wrote it or in which it’ll be received – i.e. what was said/written to him except from what he tells you – and so on.  As for billing, there is no CPT code for all this  extra work [CPT codes are how we psychologist and physicians bill insurance companies], so why not bill the patient for some of this extra time?  I’m sure it qualifies as out of network services; there’s no restriction I know of on a network provider billing for addition, non-covered services.

Also, Emily, you raise a very important issue about “random parties can just make up principles of psychotherapy if they care to”.  Seems to me this has been going on ever since managed care started 25 odd years ago.  Some of us are old enough to remember those OTR’s and telephone reviews with random people who never gave their names or credentials but told us what kind of therapy we should be doing, for how long, with what emphases…    It’s also, I think, a product of a certain consumer-courting that many fields have fallen into, e.g. colleges pleading for your business instead of expecting students to rise to their standards.  The public reads about therapy or medication on line and tells us what they want.  How many calls have i had from potential patients over the years who announce they have this or that disorder and want this or that treatment.  Once we meet it becomes clear they don’t have that disorder and the treatment they’re asking for wouldn’t work.  While the heyday  of psychoanalysis may have had its share of domineering analysts taking refuge behind their authority, labeling any disagreement or question “resistance”, I think the pendulum has swung too far the other way.  When we go to a physician with a new pain, we tend to trust his suggestion of this test or that, and conclusion that the pain is coming from such and such is valid, even if we then go for  a confirming second opinion.  We psychologists can ask for some of that consideration.
Driven as we all are to make some money, I fear we fall into the trap ourselves, and allow people – patients, the courts, and especially attorneys with an agenda – to tell us what we are and what we should be doing.  In addition to my private practice I do forensic work and have testified about 60 times over the years.  When the attorneys like what I’ve said, I’m “Dr. Pologe, the expert”.  When they don’t, they find 100 subtle and non-subtle ways to announce to me in front of the judge that I don’t know what I’m doing. They comment – with such theatric disdain – on how much time we should spend with various parties in an evaluation, what tests we should do, how to write a report, etc.  I had a great time in court a few months ago interrupting to thank one such attorney for telling me, the doctor with 9 years of higher education and 25 years experience in the field, what proper evaluation procedure was.  The judge laughed.
It’s important for us to remember who the expert is in dealing with the public and the courts. It’s easy to be thrown by the pressure people like Donna’s patient and all the ancillary parties bring to bear, and by our financial anxieties.  We have to pull back, breathe, and set the structure and limits, as all the other commenters on this thread are pointing out.  As my mother used to advise me, “Illegitimi non carborundum”.
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