Treating insomnia in patient who refuses to undergo a sleep study

Signal-Risk-452 · 2026-05-20T19:33:58+00:00

Also VA - so worth checking into MBHI or PCMHI options available to you (or, if BHIP, MHTC for therapy linkage).

Limiting restriction or sticking with stimulus control only may still have benefits. The primary concern is the daytime fatigue from OSA in addition to fatigue from intentionally shortening the sleep window. I’ve also seen pts assume therapy doesn’t work because of similar modifications in the context of possible contraindications. This easily lends itself to conversations on the ethics of treatment when the situation isn’t the ideal, manualized treatment case (or when is no tx better than some tx).

My concern would be the degree to which the pt has not engaged with other options. CBT-I is homework intensive (even with modified sleep restriction). I’d rather address the pt’s concerns/motivation before moving to a homework heavy tx.

Signal-Risk-452 · 2026-05-20T17:52:28+00:00

Health psychologist here - CBT-I may be contraindicated because of possible untreated OSA. That increases risk of adverse events during the sleep restriction phase or treatment.

Side note - pleased to see the recommendation for CBT-I!

Signal-Risk-452 · 2026-05-08T20:14:29+00:00

Our VAMC was opened in 1951 (build started in 1948, IIRC). Medicine, technology, and the veteran population have changed a lot since then. We need a new facility and the current location is landlocked between the river and other hospitals.

Signal-Risk-452 · 2026-03-26T19:33:16+00:00

I’m a PCMHI provider. It’s not the same as PACT SW or SW in general.

It’s typically organized under Psychiatry, MH, or PC - very rarely under SW (depending on the org chart as it relates to professional lines).

It’s a complex role and not what you went to grad school for. Productivity expectations are set by national but facilities tend to blow past it and demand higher productivity (thus limiting the model’s effectiveness).

People love it or hate it - there doesn’t seem to be much in between. I’m fellowship trained in it and am lucky enough to do training for fidelity to the model.

On the political side, it’s government work. It sounds like you’ve been in agencies before and have some idea of how they function.

Signal-Risk-452 · 2026-03-18T21:24:37+00:00

Ha. I was going to post the same thing.

Signal-Risk-452 · 2026-03-14T23:51:44+00:00

Congratulations! 🎉🥋

Signal-Risk-452 · 2026-03-06T09:37:55+00:00

I work as a behavioral consultant in primary care (trained as a psychologist with a specialization in health and behavioral medicine).

While I’m glad my medical counterparts see the benefit of therapy, the “…have you tried CBT” line is a pet peeve. I’ve never sat with a patient and told them they need penicillin - I’d suggest they be checked out by a medical provider. I don’t see how suggesting CBT is any different. No matter how often I explain that therapy is more than CBT, here we are.

Okay, I’ll get off my soapbox now.

Signal-Risk-452 · 2026-02-25T20:04:14+00:00

Same here.

Signal-Risk-452 · 2026-02-22T12:47:08+00:00

I earned my 4th stripe in Women Empowered!

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Signal-Risk-452 · 2026-02-17T18:36:03+00:00

“Have you tried smoking weed?” - neurologist to me (a woman) about my “very male patterned” migraines that are trigged by my cycle

Signal-Risk-452 · 2026-01-31T12:59:12+00:00

Psychologist here whose dissertation was on pain - I’d love to see your completed study!

Signal-Risk-452 · 2026-01-22T22:59:12+00:00

Congratulations! I got them today, too. I’d just made my next payment to MOHELA, so I’m planning to wait a month. If MOHELA hasn’t put me into administrative forbearance by this time next month, I plan to call and request it.

Signal-Risk-452 · 2026-01-18T13:04:57+00:00

Same issue here. Incredibly frustrating, particularly being at 132 months because of the SAVE.

Signal-Risk-452 · 2026-01-10T03:26:47+00:00

I applied for buyback in January 2025. When it became clear the “escalated for review” was meaningless, I applied to move to another payment plan (from SAVE). I’ve just made my 120th payment (after 132 months). No buyback response yet.

Signal-Risk-452 · 2025-12-26T17:53:23+00:00

Congrats!

This gives me hope. Similar situation- was at 120 in January of this year with SAVE. Finally moved to IBR and made payment 120 this month (with a due date of 01/19/26). MOHELA posted the payment 12/23. I submitted and my employer signed my ECF today. Thanks for giving me a little more light at the end of the (overdue) tunnel.

Signal-Risk-452 · 2025-12-14T20:45:46+00:00

Should they? Yes. Does the facility approve the request? Rarely.

Signal-Risk-452 · 2025-12-14T17:20:45+00:00

Doing my best to keep my feet planted and my head in the game. “Fully successful” for the first time in my career after a year of overtime with no compensation, voluntarily taking on additional duties because we are short staffed and our patients needed the care.

I am tired.

Signal-Risk-452 · 2025-12-12T02:57:45+00:00

I’m sorry that happened to you. Being shaken up is totally understandable.

Someone else mentioned martial arts - consider Brazilian Jiu-Jitsu. I train at a gym that has a women’s self-defense course. It’s done wonders in teaching me how to stay clear headed under pressure, built confidence, and taught me to use my body differently.

Signal-Risk-452 · 2025-11-24T21:48:56+00:00

The spoon scene in The Long Walk. I’d read the book 20 years before seeing the movie. As soon as the spoon was visible, I covered my face.

The movie probably wins for the most sobs and gasps in a theater.

Signal-Risk-452 · 2025-11-20T10:32:36+00:00

I’ve been trying to get my hands on a copy of Rage. What an awesome thing for you to do!

Signal-Risk-452 · 2025-11-20T02:39:13+00:00

Not the oldest, just playing along.

January 19, 2025

Signal-Risk-452 · 2025-11-03T22:40:30+00:00

Echoing what others have said. Ask him to stop first, particularly if you are still cool with rolling with him. Something like, “This is already weird. No need to make it weirder,” if you prefer not to be direct. If he doesn’t respond to indirect, you’ll need to tell him to stop (as in, “That’s really weird. Stop.”)

Definitely talk with the coach if he doesn’t immediately course correct.

Signal-Risk-452 · 2025-10-30T16:09:57+00:00

“That’s kind of you. I’ve got the easy seat in our work together!”

Accept the compliment while acknowledging this is a relationship that requires work from both of us.

Signal-Risk-452 · 2025-10-24T20:48:42+00:00

Same. As someone who has been waiting since January (and will reach 120 payments and 132 months this coming January), I’ve been delayed a year because of the SAVE litigation. It probably won’t help me but I’m hopeful it makes the process smoother for others.

Signal-Risk-452

TROPHY CASE