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Taylor Harbin
04-06-2016, 04:37 PM
My new story has a psychologist questioning a patient who has been referred to him by another doctor. The patient is convinced he has something wrong with him. I would like to know what line/direction the questioning would go and how long it might take before a professional would feel comfortable with making a diagnosis. They have been seeing each other for less than a month, so maybe three appointments?

The patient is plagued by nightmares of him doing terrible things, and he thinks they are not just dreams. The story touches upon the concept of multiple timelines and alternate universes.

cornflake
04-06-2016, 07:21 PM
Questioning about what? What goes on in an appt. depends on the point of the appt., theories the psychologist subscribes to, the people involved... You're talking about ongoing appts., not even an intake.

veinglory
04-06-2016, 07:36 PM
At this point the "patient" is the psychologist's private fee-paying client, I assume? In that case they will start by asking why they are there, what their problem is etc.

Taylor Harbin
04-06-2016, 07:40 PM
Questioning about what? What goes on in an appt. depends on the point of the appt., theories the psychologist subscribes to, the people involved... You're talking about ongoing appts., not even an intake.

Let me clarify. If the client comes in and says "Doc, I think I'm crazy" I want to know how the psychologist would direct his questions to determine if this is true. Does he ask more about family history or the symptoms/complaints?

cornflake
04-06-2016, 07:44 PM
Let me clarify. If the client comes in and says "Doc, I think I'm crazy" I want to know how the psychologist would direct his questions to determine if this is true. Does he ask more about family history or the symptoms/complaints?

This is likely intake, not an appt. in an ongoing series. Generally, it'd likely be 'why do you think that? Tell me what's going on.' Both those things would likely be discussed. A lot depends on the answers the psych is getting. If someone says, 'because I have nightmares,' is different than 'because I hear voices no one else does,' or 'because I can't stop counting letters in words - that sentence had 38, etc. Answers beget questions.

You can likely find an intake form from a hospital or someplace, but that'd sort of differ from a private appt. intake.

bombergirl69
04-06-2016, 07:53 PM
Totally agree with Cornflake here!! it depends.

Is the person there for treatment or for an assessment? If for treatment, sadly, in many cases, we get ONE session to sort out a diagnosis. That's if there's an insurance company involved. Depending on the practice, the client may have already filled out a bunch of paperwork and submitted it before their first appointment, which the doc may have reviewed. That can help. For some cases, we can make a provisional diagnosis, what we're thinking to be confirmed by more data, but lots of times, you get that one appointment, at least to generate rule outs.
We hope to get collateral info as well, but that's not always possible.
With the new DSM V, there is testing as well some doc's have clients complete, which can also help with the diagnostic process, but not all docs do that.

Is there a clinical team? In that case, a doc will present their basic findings and review with the team before confirming a diagnosis, but again, that depends on the practice and the agency

If a client is referred for an assessment, well, that can take a lot longer. Multiple interviews, lots of collateral sources, testing (depending on the referral issue) It can be quite complex and can take months (depending on the issue.)

Different providers have their own intake process - paperwork, questions to help focus a client, how to get a good history efficiently. Generally one wants to avoid close ended questions (where the client can answer yes or no) in favor of open ended "tell me about..." kinds of questions.
What you don't want is
Do you drink alcohol
Yes
Do you drink more than three drinks a day?
uh...sometimes
Do you drink more than 14 a week?
I don't think so. maybe sometimes.
have you ever tried to stop?
no. not really.

This can go on forever and not give someone any really useful information!

bombergirl69
04-06-2016, 07:58 PM
And of course, just to add that you would want to rule out risky items - is the client currently suicidal? (definitely want to get a handle on that) or homicidal? One goes over all reporting obligations - child/elder person at risk, intent to self harm and so on. That will certainly be on paperwork, but a provider is most definitely going to ask.

veinglory
04-06-2016, 10:37 PM
Also, getting a diagnosis is not the main thing that is happening here. The diagnosis is a step towards the goal of helping the person, but not instantaneous or even necessarily helpful in its own right. A client can be in treatment for some time before there is any real certainty of what the underlying conditions are. Just as with a physical/disease/disorder diagnosis it can be simple or complex or elusive. One conversation is probably not going to do it.

cornflake
04-06-2016, 11:35 PM
That depends though, on where the person is and what's going on. As bg notes, in some settings, you need a diagnosis.

A private client seeing a psychologist on his or her own dime doesn't need an immediate diagnosis, though most docs will try to figure out what's going on.

A hospital admit, or someone coming in with insurance likely needs a codable diagnosis as soon as possible (which may involve, again as bg notes, consulting with others in the practice, or with supervising people in some settings). There may be comorbid stuff going on, or stuff that's hard to separate out, and sure, like anything there can be delays, but insurance being what it is in the U.S...

veinglory
04-07-2016, 12:10 AM
Indeed. I'm assuming this is a private context. But indeed, if someone is coming in on insurance etc. But even then it is sometimes a diagnosis of best guess/convenience that is more a description of symptoms than an identification of cause. Not something I would take as absolute truth if it comes from one of those 15 minute appointed psychiatrist sessions where the person is already in some kind of crisis situation.

bombergirl69
04-07-2016, 01:28 AM
Yep, Cornflake is totally right about hospital admits--you need a codable diagnosis. But diagnoses are quite helpful. They definitely guide treatment. It's big difference between treating a trauma victim vs someone personality disordered. And actually, after one's been doing it for awhile, you do get pretty good at doing it quickly--at least getting a solid working diagnosis. Certainly one can be wrong (and modify it.) I' ve worked with some outstanding psychiatrists would really, would have someone diagnosed very quickly, just because they've heard a lot of stuff before. My supervisor in grad school nailed my MMPI code!

But the client is relevant here too in the process. I've worked with a lot of mandated clients, and you can see a lot of pretty but totally irrelevant country before you get close to what might be the main destination (one might have to work harder.) And that's diagnostic. OTOH, you can have clients who present with, "So I've had recurring depression for years but over the past two weeks it's gotten a lot worse. I've gained weight, I sleep all the time and I've starting wondering if the world is better off with out me. I used to take a tricyclic antidepressant, but it didn't work that well, so I was wondering about maybe trying an SSRI" ie, clients who have a lot of insight and make the job a lot easier - oh Im a recovering alcoholic struggling with my dad's drinking/I was abused as a kid and thought I was doing pretty well, but now that my daughter is at the same age, I m really struggling/I need to talk about whether or not to leave my wife, etc

And after you've been doing it awhile, you can also pick up on less than truthful reports (which are also diagnostic-why would someone minimize or exaggerate symptoms?)

for the purposes of the story though, I agree with getting a copy of an intake form, which will show the types of info generally sought. And yes, if a client came in asking, "So do you think I'm crazy?" a provider is likely to ask them what makes them wonder about that, ie what brings them in, what's the issue. One hopes that what follows will clarify that - I sometimes mistake my wife for pigeon, the morning DJ talks directly to me, I want to marry outside my religion, I have fish in my underwear, I want a divorce - whatever.

And a doc will want a history (how long?) why the person has tried, any medications (this can be a big clue, if the person presents a list of antipsychotics, or an ADHD med, or an anxiolytic or something, that would be a tip off about what someone else thought anyway)

one is also listening for how a client tells their story ("fucking cunt PO sent me here because she's too stupid to see I've already done craptons of treatment," vs "well, I got another DUI and my PO thought I better get some help. I agree. I need to stop drinking!" ') because as was pointed out, one is not only just listing a code, but also impressions (thought, language, insight, judgment and so forth)

Again, for your story, it would not be unrealistic for a client to make an appointment with a private practitioner, come in and ask if s/he thought he was crazy, and then be asked "why would you think you are?" And he would just tell the shrink his symptoms (the nightmares.) You don't need him to have some crazy ass complex diagnosis, right? IF it's not involving insurance, he doesn't need a specific diagnosis (although IRL one still has to have a case conceptualization about what's up with a client, but in your story, you probably don't need that- he could just talk about his nightmares) The shrink would certainly be interested (is there a history of trauma? Is the person on medication/have a drinking/drug problem? Family history of psychosis? And so on) Your story is on the guy with the nightmares, right? Not the shrink.

good luck! ;)

Taylor Harbin
04-07-2016, 02:26 AM
Thanks for the comments. Very helpful. Maybe I'll post a draft in SYW when it's done and let you weigh in.

cornflake
04-07-2016, 02:26 AM
"Doc, I think I might be crazy."

"Oh, what makes you think that?"

"Well, when I kill people nowadays, I'm just not getting that same ol' rush. Also, my pop tart this morning told me to vote for Trump."

"And how do you feel about that?"

"I feel like I might vote for Trump."

"Yeah, you seem pretty crazy."

M.S. Wiggins
04-07-2016, 02:39 AM
Hoping I can elbow in on this thread with a question of my own and a, 'pretty please?' (It's regarding a ms I've just finished with similar subject matter.)


one is also listening for how a client tells their story ("fucking cunt PO sent me here because she's too stupid to see I've already done craptons of treatment," vs "well, I got another DUI and my PO thought I better get some help. I agree. I need to stop drinking!" ') because as was pointed out, one is not only just listing a code, but also impressions (thought, language, insight, judgment and so forth)

Would this also be true of a group therapy session of approximately eight patients? Would the physician allow them to discuss the assigned discussion topic/s among themselves as they would normally discuss these things in any other given situation? In other words: without interference, even if the conversations become 'colorful', in the hopes of learning more about them?

*If 'elbowing' is unacceptable, tell me to scram. I'll understand and scoot out quietly.*

cornflake
04-07-2016, 02:44 AM
Hoping I can elbow in on this thread with a question of my own and a, 'pretty please?' (It's regarding a ms I've just finished with similar subject matter.)



Would this also be true of a group therapy session of approximately eight patients? Would the physician allow them to discuss the assigned discussion topic/s among themselves as they would normally discuss these things in any other given situation? In other words: without interference, even if the conversations become 'colorful', in the hopes of learning more about them?

*If 'elbowing' is unacceptable, tell me to scram. I'll understand and scoot out quietly.*

Generally, a psychologist would be leading group therapy, not a physician (psychiatrist), though some certainly do have their patients in group and might lead them... just in general.

Mostly, the psychologist knows who's in a group, and has placed them in the group for a purpose. Which doesn't mean you wouldn't learn things about people, but again, in general.

Aside from that, this entirely depends on the makeup and point of the group. Generally there's not an assigned topic of discussion, though there may be suggested areas, or things the psych would like to get into. Moderation and leading is key. There's a huge difference though, between a prison-based group therapy session, an addiction-based one, one of people who are having trouble overcoming general anxiety, etc., etc., etc. Also depends where the members are at, etc., etc...

bombergirl69
04-07-2016, 03:35 AM
yep, and again totally agreeing with Cornflake, particularly with the "it depends." ;)

so, there are different kind of groups, as CF said. Not only in terms of theme (addiction, parenting, depression, DBT-a particular skills group for those dx'd with Borderline Personality Disorder, etc) and location (as CF said - prison, hospital, outpatient), but also type of group. This means whether or not the group is process oriented - i.e., people process various emotional issues, which may or may not be on topics offered by the facilitator (usually their own stuff,) or a psycho-educational one (specific topic-boundaries/assertiveness/communication skills, etc) where people do not process emotional issues but participation focuses on the specific topic (like a class.)

Lots of treatment includes both process oriented and lifeskills/psychoeducation groups. So in the process oriented groups, it depends (again!) on the facilitator in terms of let 'em roll with comments (in many cases, after discussion about group rules-no interrupting, no telling people what to do, whatever, language is not usually a group rule, not with me anyway) or whether they go around the room offering thoughts and observations or how they do it. And yes, the facilitator could have them do some kind of exercise (in both process and psychoed groups) that involves them discussing something among themselves (exercises are more psycho ed than process groups but not always.)

I could go on and on and on and on about how to run good groups (I love groups) and how to run very poor ones but I won't!!!!


ANYWAY - long tangent! apparently lots to say about that!! Good luck!

bombergirl69
04-07-2016, 03:52 AM
I realized I was rambling but really, yes, there could be exercises that have group members sharing. Typically though, stuff is processed in full group. And processing (discussion) can indeed be without facilitator intervention (depending...) or with(more structured) Usually I let language go. People talk like they talk-no one's grabbing their pearls and we talk about group norms (how to give feedback, for example)

But what Cornflake said about lots of variation. If one has NOT set group norms, just letting clients chat about stuff and not offer any meaningful feedback is NOT helpful, nor is it productive group work (a lot of lazy facilitators do that, IMO.) A facilitator (in a process group) will probably do more initially, setting the tone and norms, in the beginning, then fade out a bit more as the members do more of the work.

Probably much more than you needed!

M.S. Wiggins
04-07-2016, 04:21 AM
You guys are awesome. Thank you so much.

Taylor Harbin
04-07-2016, 06:13 AM
"Doc, I think I might be crazy."

"Oh, what makes you think that?"

"Well, when I kill people nowadays, I'm just not getting that same ol' rush. Also, my pop tart this morning told me to vote for Trump."

"And how do you feel about that?"

"I feel like I might vote for Trump."

"Yeah, you seem pretty crazy."

I'm stealing this...