President Trump Jeopardizes Mental Health Internationally

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President Trump will damage the international efforts to research and react to illness and disease all over the world. Specifically he will damage mental health concerns in a time when more, and not less, mental health is needed. In a tweet on April 14th President Trump notified the world that he will halt funding for WHO. WHO provides mental health resources to the international community. They provide direction and guidance to governments to create and maintain their mental health programs. They even provide quarterly news letters that bring mental health current events from all over the world to the attention of it’s readers. In a time when the world is in a crisis and more mental health concerns are expected, to eliminate funding into it’s research and exploration needs to be reconsidered.

President Trump believes that the World Health Organization (WHO) failed to appropriately react to the COVID19 crisis. He has decided that the WHO, seen by him as China-centric and too politically correct according to Fox News, would have funding cut completely. This decision, a possible attempt to shift blame from his administrations own reaction to the COVID19 crisis (see Time article), seems reactionary and does not take into account the volume of work that the WHO does. It does not measure the impact it will have on mental health.

The mental health impact of COVID19 cannot be understated. It has already been explored by Reuters in their article form April 3rd, Researchers warn the COVID-19 lockdown will take its own toll on health. Not only do they discuss “Soaring Suicide” and increases in Domestic Violence, they explore the impact on vulnerable populations such as students and those who have lost their jobs. In the United States we do have the National Institute of Health (NIH) providing mental health guidance as well as the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers. While the United States has these resources other nations may rely on WHO for their mental health information. The United States needs to continue to act as a leader in the world by ensuring organizations like the WHO have the funding they need to serve other nations mental health needs.

Timothy D Vermillion, DSW, LCSW, BCD

Traumatized by your Patient Record

Reading your own patient records can rekindle that lack of trust and those feelings of vulnerability that brought you to therapy. The discrepancies, falsehoods, and what sometimes seem to be personal attacks can be shocking and add to the trauma that you work through. Honest considerations of certain personality disorders and mental health diagnoses, if not framed appropriately, can end or greatly limit careers prospects. Patients and clinicians should make an effort to review records periodically. If not reviewed, records can have decades of inconsistencies that will interfere with disability claims, that can change how providers treat patients and can lead to further injury, traumatization, and possibly end careers.

Cherry Picking Moments of Joy in a Troubled Life

Working in the military, in private practice and for a large medical system I have had the opportunity to work with patients claiming disability and workman’s compensation for their physical and mental health concerns. In all of these settings I have witnessed the devastation that notes in patient records can have on lives. During disability evaluations the disability evaluators comb through records to determine appropriate compensation. Many times it seems that their goal is to cherry-pick the words and phrases that will help them deny or limit compensation. Providers’ notations that celebrate successes or healthy behavior, if not framed correctly, can be found in disability decisions as evidence of functioning and to decrease or deny a claim.

Success and healthy behavior should always be framed in terms of a patients diagnosis or illness. There have been patients worried that insurance investigators were spying on them trying to catch them doing something that their disability should limit. Similarly, disability evaluators find nuggets of healthy behavior in health and mental health records to use as ammunition against a claim. Clinicians want to record successes in therapy but should also consider how their records may be used in the future.

The health record should entrench successes and positive, healthy behavior within the greater experience of the Veteran’s diagnosis. When being evaluated for disability the patient has to frame their positive experiences to ensure their disability is fully appreciated. The health record and individual patient records/notes need to be written the same way. It’s further traumatizing and can even cause a rift in therapeutic relationships when a note about the patient “sailing again” or some other positive/healthy activity, is used to show that the patient is functioning well enough to deny or limit compensation.

When a Veteran goes to a compensation and pension exam they are often coached to present their worst day. A patient may feel good on evaluation day and want to present as healthy. People often hide their symptoms from others and especially in front of strangers and strange doctors. In a compensation and pension exam you don’t want to be an optimist or wear rose colored glasses. You want to entrench your life in your diagnosis. This isn’t an exaggeration of your symptoms it is an attempt to give a down-and-dirty window into how they affect you.

Yes, you are taking care of your kids and your mom is helping. That sounds great. Make sure you say you can’t keep a job and that your at your moms because your on a break with your wife. Add that your mom “helps” because both your mom and your wife don’t trust you with the children because your memory is bad or because you can’t control your angry outbursts.

Yes, you are going on a skiing trip… You were just doing a dolphin encounter last week… You just started sailing and are looking forward to go on a SCUBA adventure next month… Make sure you say that the ski trip is for disabled Veterans and you will have escorts helping you down the mountain at all times. That the SCUBA encounter is for disabled Veterans and accommodations are made depending on the disability. Tell the evaluator that the dolphin encounter is part of your “recreation therapy” prescribed by your therapist to help with your social isolation and your loss of ability to find enjoyment in things.

Patient records should similarly include the context that healthy behavior and treatment success occurs. It’s important to celebrate progress. It is also important to show that progress does not mean “cured” or without impairment.

The Specters of Possible Career Ending Diagnoses

Diagnoses in patient records can limit or end careers, they can change how healthcare providers receive and interact with patients, and once a diagnosis is in the record it is almost impossible to remove the specter of having been labeled by it. Providers often consider diagnoses and note them in the record to rule out. These rule-out diagnoses sometimes don’t get appropriately assessed afterword and diagnoses such as “bipolar” or “borderline personality disorder” linger for years in patient records. Often a provider will carry the diagnoses from previous clinicians records without further assessment or consideration. These habits and concerns change how patients are treated and can have devastating effects on their lives and careers.

Consider the military reservist who is having symptoms of Post-Traumatic Stress (PTS). Without experience and specialized training many seasoned therapists and psychiatrists may see their symptoms as possible bipolar illness or even schizophrenic processes. The diagnoses are seen by a military evaluator during a periodic health assessment and a red flag is raised. These are possible career-ending diagnoses for service members. The patient now has to try and get second opinions or find ways to have their providers change their diagnoses.

A new clinician/provider may be unwilling to take the risk of reversing a diagnosis made by another provider. If the diagnosis is changed and the patient’s symptoms lead to adverse circumstances, such as suicide or homicide, the new clinician may be on the hook. The tragedy is that even if a provider does take the risk and changes the diagnosis, the patient will always have the diagnosis in their history. “A history of bipolar…” can be just as bad as the diagnosis itself. In the military and with law enforcement agencies changing a diagnosis can mean approving the use of fire arms and being around explosives. Who is willing to take that risk?

“How do you treat a borderline? Refer them out.” The diagnosis of borderline personality disorder (BPD) has a stigma among almost all professionals. With the advent of shared medical records diagnoses are often on a “problems list” and can be seen by all healthcare providers serving a patient. If you have a diagnosis of BPD in your record professionals often treat you different. PTSD, bipolar and other mental health diagnoses can also draw similar treatment differences. Monitoring patient records and ensuring rule-out diagnoses are actually ruled out in the record could avoid much of this trouble. Reviewing your own patient records and ensuring you are confronting diagnoses that can have such an impact could also help you avoid trouble. With the advent of shared records diagnoses can have a huge impact on regular treatment and we need to make sure records are as accurate and current as possible.

A diagnosis can end careers and change how a health team treats a patient. Frequent review of the record and the diagnoses can help avoid trouble with a patients career. It can also help patient avoid being treated based on a stigmatized diagnosis. It is hard to change a diagnosis and almost impossible to remove it from a record completely. Once written into the patient record there will always be a history of the diagnosis, a specter of the diagnosis, that can continue to affect the patient’s life and career.

When Providers Attack

One of the most devastating and long-lasting corruptions of a patient record is the attack. Patients and providers do not always get along. Patients are not that pleasant sometimes. Certain mental health diagnoses are known to not be pleasant. In exploring a patients record you can sometimes read the discomfort, anger, frustration and genuine dislike of a patient written in descriptions of behavior or assessments of their personality. This can happen within a regular patient/provider relationship but it is also seen during insurance and disability evaluations where no other treatment relationship is maintained. Attacks are important to catch and confront by both providers and patients as they can lead to negative consequences.

Providers are human and subject to the same irrational behavior as any other human. They too can suffer their emotions and have bad days. They can have their biases and although we hope they do not affect care, their prejudices. Sometimes providers start out with these issues and sometimes they become cynical and judge mental over their practice. In any case, their issues, biases and beliefs affect the patient record. Clinicians are often advised to have their own therapy so that their issues and transference do not affect treatment.

When a patient is already disliked, periods of tardiness or cancellations can be framed negatively by the provider. A patient who is distraught in traffic and drives slow may be framed as “frequently late” without explanation or exploration. Cancellations can also be framed in a way to make it seem the patient does not want care or is not sufficiently treatment compliant. A more liked patient may be understood for how their symptoms interplay with their ability to participate in treatment. In these cases the providers own issues preclude a thoughtful exploration. This can lead disability claims being denied, court ordered treatment being extended, patients being returned to jail for non-compliance, or administrative action by clinics and hospitals to remove the patient form active status.

Confronting providers when records demonstrate these attacks can also be an issue. It is best to get the support of another provider or a patient advocate in the clinic/hospital system. There is a good chance that you will need to change providers if possible. In rare circumstances everything may be a misunderstanding and this will be an opportunity to repair a rift in the therapeutic relationship and may even improve treatment. Most of the time it may be the end of the therapeutic relationship and an opportunity to create a new one.

But I did have Cancer

Mistakes in records need to be corrected and fast. Copying and pasting is a common provider mistake. It makes life easier for a provider to copy and paste things that usually don’t change from one note to the next but it could lead to missing something and making or perpetuating grave errors. If for none of the previous reasons, you should frequently monitor patient records for incorrect or outright false information.

Diabetes I is a different animal than diabetes II. The dangers can be different and the treatment is different. It is an easy mistake to leave off that “I” but can have devastating effects. I have seen this mistake personally so I know it can happen. With patients that have to constantly monitor their health a mistake like this can affect the trust the patient has in their providers. These mistakes can cause anxiety and develop feelings of hopelessness. Patients need to trust their providers to get their conditions correct, incorrect treatment can mean certain death.

Not having a history of cancer is different than having a history of cancer. This is true especially when it led to major surgery and had significant effects on self perception, self confidence and how one lives their life. A male that had their prostate removed and is having incontinence and erectile issues has different health and mental health needs than one that didn’t. Similarly a female that has spent her entire life judged by her appearance, who has cried as her hair fell out, her nails became brittle and break, and her breasts removed has different health and mental health needs than one that has not. These simple omissions or careless false declarations of “no history of cancer” can cause further stress and lead to a lack of distrust in providers and their healthcare.

Mistakes happen. Monitoring patient records needs to be a common practice by providers and patients to ensure patients aren’t further traumatized or victimized by what is written or omitted. The discrepancies, falsehoods, and personal attacks need to be confronted and remediated regularly. Helping patients with this can increase trust within the therapeutic relationship and also ensure appropriate health and mental health care is provided the patient. A patient’s record can impact their health, careers and disability evaluations. Patient’s do not need to be further traumatized by their record.

Timothy Vermillion, DSW, LCSW

Verbal Judo – Getting Unstuck in Therapy

Sometimes we keep running into a wall – or a fist. When doing therapy sometimes clients stop moving forward. It is frustrating to both the therapist and the client when this occurs. They spend their time and money coming to therapists to relieve their suffering and here they are stuck. We run into a wall – meaning we just come to a point where the client stops moving forward. They loop back to common themes- they are plagued by their “feeder memories’, or maybe they have blocking beliefs. Sometimes it’s like a fist – not just blocked or stalled from progressing but they counter you. They challenge you and your work with them. If we can’t find our way through this impasse, we run the risk of losing our client. Learning skills to help move a client through these impasses will teach the client that they can overcome their own stalled processing and, doing it right, may keep them working with you until their issue is resolved.

Looping can be the death knell of a therapeutic relationship. Clients experience looping when they seem to be progressing and then, suddenly, they come back to where they start. This may happen during one session or over multiple sessions. Both you and your client may become frustrated but it’s your client who had trusted you with their time and money and you are seemingly getting nowhere. You both begin to wonder where your adventure together will lead. For example, a client may say they are worthless, they hate themselves, they are defective. Through some difficult work they start to have better perceptions of themselves. They see themselves as successful and as survivors. Moments, a session, or a few sessions later they loop back to self-hate and worthlessness. This occurs repeatedly making the work that you do together seem tentative and developing mistrust of the clinician and the whole therapeutic process. Blocking beliefs and feeder memories may be the reason for looping. Managing these can help stop looping and move the client on to more successful therapeutic experiences.

Blocking beliefs seem to stop therapy in its tracks. Blocking beliefs often pop up quickly and seem to be commonsense to to the client:

“Men don’t cry”

“Feelings are for the weak”

“I should be over her death”

These thoughts are taken for granted by the client. The source of these thoughts are unquestioned and represent an imperative for the client- this is just the way it is. Often blocking beliefs are easily distilled and sometimes the client will volunteer the belief without any clinician involvement. Other times a clinician may need to do some digging to find out why therapy has stalled and what blocking belief is getting in the way. You may have seen this with a client who seems to get close to feeling and then shift quickly to intellectualizing. The assumption could be that they are avoiding the material but in reality it may be that they have a blocking belief about having feelings or showing them. Asking a client about a certain belief may result in the client becoming confused. The belief is often a “just because” belief as it has not been questioned. Some are strongly held beliefs that may take some time to explore. Despite this, blocking beliefs are often more easily overcome than feeder memories.

Insidious. An infection. Feeder memories are those past difficulties that leave remnants and scars that carry into your current life experience. They are akin to an infected splinter, apparently healed on the outside while releasing toxins into your body. No matter how much antibiotic you take, unless you cut open that wound and remove the splinter the infection will keep returning. While you are able to challenge beliefs and desensitize feelings in the now, the past re-infects the client. Feeder memories affect how you view the world and how you will encounter new incidents. The idea, “I’m defective” after being chastised as a child may recur when you are being reprimanded at work. Although we can challenge that belief and the client can learn that he is not defective because of a work difficulty, past experiences may challenge that and remind your client how defective she has been. Feeder memories may be at the core of blocking beliefs and looping.

For the month of May I will be exploring looping, blocking beliefs and feeder memories. The posts will be split up so that you can explore the topics that most interest you. If you have any ideas, questions or thoughts that you might want me to explore in my writing, please feel free to contact me.