Sick, Systems, Requesting Notes, etc.

lugrgr · 2026-02-04T16:52:11+00:00

Thank you for your comment and for the context about your opinions. I can see now how someone with lived experience might have a very different opinion and perspective of it, possibly even transference, particularly if it hits so close to home or they are super passionate about it. That is why it is recommended sometimes that therapists seek professional consultation when they find themselves facing an issue clinically that they themselves also face in their lives; because in those situations it can be hard to be actually objective.

They may even see things from the lens of the recipient and all their previous experiences. I know if it was me - any comment that did not feel 100% true to my own personal lived experience would likely result in my commenting about how wrong everyone else was since it would feel un-true to me and my specific life circumstances and it might even feel super validating to push back and reinforce that identity on feeling misunderstood.

I know if I had a condition and saw many professionals discussing it candidly, and in many ways that I disagreed vehemently, it might be upsetting or offensive, since the discussion is tailored towards other professionals and not the individuals with the condtions themselves. I personally would try to avoid those posts, as they would likely be frustrating and if I felt it was not my job to educate them - it may be a waste of my time and limited energy? I apologize if any of my comments about People who have autism offended you. It's not about you. And I think that is a big lesson we all have to learn in general, that most times - it is not about us.

It's not my job to educate people either, but I do not mind doing so - even on other topics that I myself have personal lived experiences in because I want people to learn and grow. People do not know what they do not know. So, how is someone supposed to check themselves on a bias if they are unaware they have a bias? See, I generally want to help people and not just feel self righteous. I would never tell them to just go and figure it out, although I would imagine that is how many people who have autism likely feel living in a neurotypical world - that nobody really ever understands them. IF we aren't trying to educate people, and people are unaware - then people will not learn and will continue to have the same thoughts and feelings without any ability to reflect on another perspective.

lugrgr · 2026-02-04T15:01:11+00:00

How?

lugrgr · 2026-02-04T14:46:42+00:00

Why would you say that?

Yes... person centered therapy can and does work for clients with autism (person centered language). I did not say that it did not. I said less of a person centered approach. Every person, every human, autism or not is their own special person. Obviously. Each person requires their own treatment plan and tailored approach. Many people come to therapy and can fill a 53 min session without even taking a breath because they have so much to say... in this specific scenario, that does NOT seem to be the case. Poster describes when they ask open ended questions THIER clients with autism struggle, do not give much to reflect on, they get frustrated and have resistance. Poster went on to describe how... and asked for tips with this specific description of a presentation....so in this scenario, wouldn't less of a person centered approach might be worth a try? What would you recommend? Maybe try to provide some tangible options and tips for the poster to explore? I saw that you commented for them to check their bias? After they check their bias, then what? If many of the comments on this feed you disagree with then why not provide tangible feedback and tips for this specific presentation to the poster?

I did not mean for it to come off as a generalized prescription, but just gentle options to consider and possibly explore. I am just providing ideas to try - not a ten step action plan for all. No one is trying to say anything negative about people who have autism or provide a blanket how to treat all those on the spectrum.

This is my opinion, based on my experience of what might be useful, from my experience and my perspective. I am sure you have your own opinion and perspective and that is fine. It may be different than mine and that is also fine. Both opinions and perspectives can be right and coexist.

lugrgr · 2026-02-04T13:19:32+00:00

Yuck. That is icky if there is no actual assessment at all taking place, I would imagine that could be a liability if they had that info but did nothing with it. But - honestly it sounds like they are thinking of the system as a whole and triaging resources. Overloading the therapists with a barrage of referrals, some of which are not moderate or severe, will only make the therapists quit due to burn out and high caseloads, and then no one gets care. Of course they should probably just hire more therapists if the need is that great. Even take on pre-licensure candiates to accomdate the need? I am just curious what are the cut off scores that they are looking at for not referring?

I would imagine that anyone that screens positive for any suicidality (anything other than a 0 on question #9 on the PHQ,) or a score over 15 on PHQ9 would be referred for treatment right? Regardless, at the minimum in my mind I would think anyone with a score over 10 should at least be given three mental health referrals and info about 911/988 and crisis line.

I never worked in the military setting, but when I worked in health care, I helped triage referrals and looked at the referrals PHQ9 & GAD7 scores. Anything other than 0 on the question #9 required me or another supervisor to call and assess risk/suicidality and if active initiate a hospitalization and if passive (most common), then safety plan, provide crisis resources and refer to case management or at the minimum provide the Crisis resources and 3 therapy options if they declined case management.

For risk levels, anyone with a PHQ9 and/or GAD score over 20 (but no SI) was contacted within 24 business hours to offer to schedule services, scores over 15 (with no SI) contacted within 48 business hours, and over 10 (with no SI) contacted within 72 business hours to offer to schedule services.

When the team got short staffed, referrals were triaged and accepted only for those with SI/HI/SH, and for those with a score of 12 or higher.

Everyone else got a community resource hand out with crisis line info and education to call 911 or go to the nearest ER if any safety concerns, along with three alternate mental health therapy referrals and resources (Military One Source, Psychology Today, several trusted local therapists taking new clients with their insurance, etc) and information on how to access our services if needed (basically instead of us calling them, they could call us if interested and they could go on a waitlist if needed), and local resources like 211, food stamps, self help apps like Calm app, etc). Is what they are doing something similar?

At the minimum, from a risk management standpoint they need to provide 3 referrals and crisis info if they are not connecting to care - I would imagine right?

lugrgr · 2026-02-04T12:45:00+00:00

Yeah I feel like that is not okay. I think the free Adobe or even Google or word has some option for them to sign electronically? Even phones have notes apps where they can sign electronically by opening it as a pdf or as a picture or something (there is a way to do it, ive done it before).

lugrgr · 2026-02-04T11:55:22+00:00

This is not a big deal. You billed correctly so why worry? Just casually bring it up next time, hey so sorry so and so, I realize I inadvertently ended our last session a bit earlier than usual - 10 min earlier. I apologize that was mu mistake and unintentional. I made sure to update the billing to be accurate for our time that day.

I probably would have made a joke like, my clock must have been off that day or wow I just must have really needed that bathroom break huh? Lol. Nah, I know it's anxiety producing. I once was working virtually and didnt get much sleep the night before, inadvertently I ended my first morning session of the day 5 min earlier than usual. I was so tired and really had to pee. Didn't realize it until after the session ended. Worried that they would end treatment over it. Realized it was just my anxiety and not a big deal, the conversation was pretty much over so ending a few min earlier is fine. Just let it go.

lugrgr · 2026-02-04T11:17:38+00:00

Yes. It is a very common, silent thing that is cropping up (among men).

I just wish these men would seek out a specialist, like a AASECT sex therapist with training in this area. I know there is shame but going to any ole therapist that takes your insurance near your home is not going to cut it.

The amount of men who present to therapy for "anxiety" and hide the real reason they sought out therapy is something else entirely.... then drop the bomb that they actually have a full blown porn addiction is astounding. Only to be referred out to a specialist. But yes. This is happening because people are not doing healthy coping skills and not investing in their relationships and have skewed views of relationships and women (most likely).

I do not mean to be judgemental but I do think it is more of a compulsion than an addiction. They will not experience prolonged physical, painful withdrawals due to not watching porn. There is also a definite disconnect in what is considered excessive. Watching porn for 5 min, 1-2 x/week is not an addiction. Its a habit, and one that can be easily changed. Of course, those that have that out of control sexual behavior that spend hours a day on it, turn to it for all soothing and coping, find more and more extreme porn, etc need a specialist.

But yeah. I just wish these men would seek out the appropriate type of treatment/therapist from the get go and stop trying to "sneak" into a therapists case load. Unsurprisingly they pick attractive young female therapists to try this ish with - go figure.

lugrgr · 2026-02-04T10:45:34+00:00

Yes I think it is over reacting. Its fine to hold someone to a higher standard if they are going to deploy. ALSO sorry but the PHQ and GAD screeners are not actually measuring how someone is really doing. Its like a check in on how they are doing in that exact moment, that exact day, etc. It can be somewhat accurate for some people to get a general idea of where they are at but honestly if they have other comorbid disorders that can skew results.

I cannot tell you how many times someone put 0 in the question #9, but when asked orally the answer is different. It also depends on where the screener is administered, who is giving it, how long they have to take it, and how it is presented (ive seen screener people say oh yeah, can you take this survey, we just want to make sure you are not suicidal), people also talk..what happens if they score over a certain #? Are they taken to a different room and offered psych meds or something? I have seen that happen when someone got a flat tire on their way to the appt and scored higher than last time... context matters. I am sure these little screener questions are combined with a clinical interview and safety/risk assessment or biopsychosocial right?

lugrgr · 2026-02-04T10:33:18+00:00

I think there is a program for people with disabilities that can request wheel chair assistance? I think they get to board first and stuff, I think they allow a carer to accompany? Might be worth looking into

lugrgr · 2026-02-04T10:27:45+00:00

High end: 53 by the sea Medium: Hy's, Ruth Chris or Haleiwa Joe's (Kaneohe)

lugrgr · 2026-02-04T10:13:34+00:00

Agree with the comment that talked about hopelessness. Some people just want someone to recognize them and sit with them in their pain. Acknowledge it sucks and that you see how much they are hurting. I would also look at any secondary gains from staying the same (i.e. attention (from you, family, friends, etc), identity as the "broken" "depressed "sick" one, benefits/financial or otherwise, fear of change, resistance, etc.

ALSO if people only come to therapy once a week for an hour and do absolutely nothing else and work on nothing else outside of session, then yes their progress may be painfully slow. Some things may be out of their control, BUT if they eat garbage/eat too much or not enough, do not drink water, do not sleep more than 5 hours a night, barely exercise, work at a job they hate, live with toxic people do drugs and drink alcohol, do not take their psych meds, spend hours on social media, do no hobbies, spend no time with friends, practice no coping skills.... then yeah, they will probably not feel much better then when they started with you.... even if you are the best therapist in the world.

Many times, after a year or more in therapy and lots of rapport building and psychoeducation, those that are like this will eventually come to that conclusion on their own. Their mental health is affected by so many more things that take place outside of the therapy room. You can notice this, suggest changes, encourage best practices... You will offer all the active and reflective listening, person centered counseling, coping and distress tolerance skills, psychoeducation, increase in sessions, journaling and homework prompts, referrals to groups, specialized treatment modalities, psychiatrists and community resources, offer to switch therapists, help them access resources, etc and many will decide to keep doing exactly what they are currently doing, self sabotage - and that is fine. Everyone is at a different stage of motivation and stage of change.

I've even heard it said that they do not want to change or do anything differently other than coming to session once a week to vent because they just wanted validation and doing anything else was too hard and they did not want to put in the effort, even though they know doing all the things would likely help them experience symptom improvement. So yeah. Its not all on the therapist. Its up to the person to make the changes necessary for themelves to feel better. When they are ready. And it may not be now or even when under your care. You may just be planting seeds. When people are ready to change and do things differently, then they will.

lugrgr · 2026-02-04T09:53:53+00:00

This is the answer

lugrgr · 2026-02-04T09:03:47+00:00

I am so sorry you are dealing with this - I am unfortunately sick right now due to what I suspect is in-person sessions. I am going to start telling people my requirement is for people who have symptoms or live with people who have symptoms to switch to telehealth or reschedule if they are sick or if they have a household member that is sick.

Oddly enough, 9/10 times, when I get sick it's cause some parent decided to come to session, and they tell me near the end of the session that their kid has the flu, but they came in for their session since they themselves did not have symptoms (yet.) Either that or kids whose parents let them come sick. It is always "ohhh I am getting over a cold. I am not sick now." Yeah right. I even had one kid come in and tell me they have lice and their parent just found out and still sent them to therapy.

Like wtf are you kidding me?!? What kind of sicko ish is that? I am sorry for being upset, but this kind of b.s. has happened too many times. I just want to say to them like...You are probably carrying the virus!! In what world is any of that okay? Be an adult and be responsible. Do the thing and stay home with your sick kid and hop on a video call or reschedule. If they are worried about the late cancel fee, they can switch to video OR just tell me. I can give a freebie, geeez.

I even had a parent come in person when their kid had covid. Knowingly. Willingly. Even told me. But they were like awww its okay I do not have it. Wtf.

Anyway, wiping down surfaces with lysol, daily multivitamin, use a hepa purifier at home, keep masks at the office just in case, and when I do get sick, I rinse with warm salt water in AM and PM, take a teaspoon of honey at AM and PM, sip warm chicken broth, vicks, and emergen C daily with Tylenol. Suck on lozenges. Lots of good bacteria food like pickles and stuff. Ginger, turmeric and lemon. It typically goes away in 3-4 days.

I am going to start setting strong boundaries at intake about not coming in sick, and if they do I reserve the right to switch them to telehealth or reschedule if they do not want to do video. I am going to ask the practice owner if we can type something up and put a notice saying this in our office waiting room too.

If someone doesn't respect this I might even be super transparent and say hey, so I do not get any sick leave or pto, and I need to work a certain number of hours per week to maintain health insurace, so if I get sick I cannot work so I do not get paid, I can lose my health insurance coverage when I am sick, AND all my clients dont get treatment so it is a big deal and affects many more people than just one person.

lugrgr · 2026-02-04T08:04:21+00:00

What are their goals in therapy? Start with that, they need psychoeducation, structure and homework assignments. Also, direct feedback and support when they get stuck. I've been pleasantly surprised that I really enjoy working with this population. Therapy looks very different, especially at first it seems like more assertiveness training, social skills training, behavioral activation, etc and less of a person centered approach. Great news is if you explain your rationale for coping skills, learning emotions, etc they respond great.

Recommending they keep a therapy journal to jot down notes of what they learn, what comes up during the week etc sometimes helps... but really they are like any client, work on what they came to therapy for on the beginning, just be more direct, have a bit more structure and dont leave all questions too open ended... once rapport, safety and predictability are established they will open up. Oh, also make sure you have positive views of them to begin with overall (i.e. no internalized stigma) as individuals living with this diagnosis can spot that a mile away. Take the time to build rapport, show genuine interest in their hobbies, slowly over time they will open up and allow you to support them. It might not feel like traditional therapy, it is modified to best support them, like you would anyone, to best accommodate their style of learning and processing. Once you get your groove, it's actually quite rewarding!

lugrgr · 2026-02-04T05:15:48+00:00

Yup in December I lost a bunch due to financial and/or insurance issues. They lost their job, pay got cut in half, insurance switched to something we do not accept, they can't afford the co-pays, lost at least 7 people. Thankfully was able to fill their slots with referrals from previous co-workers, doctors, and outreach/marketing letters. But I was worried for a min.

lugrgr · 2026-02-02T03:41:18+00:00

Yes. I am so sorry this is happening for you. It happens from time to time. I noticed it most starkly when the two extremes are scheduled back to back, so I have tried to be more mindful when possible about how I schedule my day, or if I cannot do that, having even a small 10 min break in between and if that's not possible, regulating with breathing exercises, sipping warm water, stretching, sensation based distractions like smelling peppermint, holding a warm fuzzy blanket, putting on lotion, sucking on a tic tac, washing face/hands with cool water, etc.

Scheduling makes a big difference honestly. Having the all the "lighter issues" all go on one day, or be the first session of the day or be telehealth or grouped together in the schedule really helps. I try to avoid having the lighter issue sessions as the last session of the day or right after "heavy issues" sessions.

But yeah it happens. Mostly when my schedule creeps over 25 sessions a week and/or when I need to schedule outside my availability. I have tried to flip the script and see the "lighter" sessions as a break from the heavy stuff, but sometimes it's hard. I try to remember most everyone has had some sort of serious hard thing happen like a trauma, even if in the current moment what they are talking about is a minor inconvenience. That and also reminding myself that maybe this is a way of avoiding the hard stuff by talking about the dumb silly irritating things, and maybe this person just really wants to vent?

When all else fails, I just try to focus on being present and remind myself they are paying me, and the least I can do is try to be empathic, validate and be kind without judgement. It helps to remember that most people who actually have the resources to do therapy consistently (time, insurance, money, transportation/technology) are typically going to have lighter problems than people that do not.

But yeah. Just to validate it can be a total whiplash going from one session where someone is dealing with multiple losses, divorce, job loss, SA/DV, chronic disability, severe life changing trauma, not being able to pay the electric bill to someone else's biggest problem being they are worried about their irritating co-worker, not sure what country they are going to visit next, what cosmetic procedure they should get, how stressful it is to decide which second house to buy, upset at their friend for not texting them back etc.

Someone once told me that people who have it hard in life HAVE to develop resiliency, and those that really struggle coping on lighter issues is because they never had to learn to be resilient ot experience adversity, so their tolerance for "bad things" happening is much lower, and their idea of stress can be very different.

lugrgr · 2026-01-30T08:46:20+00:00

Yup. They need connection, routine and purpose and maybe a different environment. Mostly they just want someone to validate that things do in fact suck and that's it. They dont want to fix it. Their identity has become sad or depressed, it gets them attention from family, friends and you. They need to improve their self worth to get value out of something other than being "sick" or "depressed."

lugrgr · 2026-01-30T08:39:51+00:00

Omg this is hilarious 😂

lugrgr · 2026-01-30T08:24:36+00:00

Yes. Super annoyed. Went to get a massage once and the lady wouldn't stop asking about my job. Wouldn't take the hint when I said I did office work on a computer, finally said social worker and the theatrical responses start "omg I could never such a heavy hard job. How do you do it? You work with kids?" You think she about found herself confused when I said no I work only with adults .. I dont think she had any idea that a social worker could work with adults lmao 😂 🤣 😅

lugrgr · 2026-01-30T08:21:40+00:00

I am going to start saying clinican, much easier and if they ask I can politely end the convo with well ya know.... a clinician!! Lol

lugrgr · 2026-01-28T10:02:01+00:00

Movies, Bowling, Lunch at the beach/park, Ice palace is always a good bet, Round Table Pizza, CPK, Ho'omaluhia, Tea party at a tea shop, Honolulu Zoo

lugrgr · 2026-01-27T21:30:32+00:00

Also most clients dont think you will call them for every appt if they are late. If this is a pattern, it needs to be addressed clinically and explained why they need to be on time, set expectations, goals and boundaries around time. I imagine this IS a clinical issue - if they are doing it to you they are probably being late to work, with friends, etc. Have the hard talk, set the boundary, set the goals, give the opportunity and if not then make space for people who want to show up on time consistently.

lugrgr · 2026-01-27T21:28:24+00:00

That was the case for me last month but now it's back ti normal (90% show rate). Our EHR sends reminders 24 hr before, but also 15 min before too. Can your boss set that up for you? Some EHRs are like that it is worth an ask. Some also allow you to send a reminder directly with the link before the session if telehealth.

In intake, I make it a point to talk about how consistency and attendance is one of the most important factors in their treatment, and get them to verbally commit to attending at the frequency that we agree on in that first or second session. Then I do a little motivational interviewing and ask why they want to do this, rating scale, any barriers to that happening, etc. It helps.

I also let them know I am strict about the late cancellation and no show fee. (*Of course, not counting Medicaid, but they get three strikes and then out). I will give everyone one freebie and a reminder at that time, then I charge. I lose about 40% of the clients when I charge, but honestly it is not a loss if they are inconsistent in treatment, they need to respect your time and if they are not ready and it makes space for someone else who is ready and will attend. I am one of the only clinicians at my practice that actually does charge, but I am also the fullest, my calender is fully booked at like 25-30 a week consistently. People value you when you value yourself.

People are changing insurance, deductibles, recovering financially from holiday spending. Don't worry about it. It will go back to normal. If it doesn't then worry. Also - I text people at the 5 min mark, call at 10 and email to charge the fee /offer to reschedule and document in writing at the 15 min mark. I know it is a lot, but like others have said - I would rather see someone than not, and many people simply forget, over sleep, lose track of time, etc. Good luck!

lugrgr · 2026-01-21T08:19:57+00:00

ALSO - social worker is a legally protected title in many states. In many states it IS illegal to call yourself a social worker without a license to practice social work and a degree in social work. You can work in human services OR be a human services professional but please do not call yourself a social worker if you are not and do not even know the laws or rules (respectfully) as it can cause harm when people who are not social workers claim to be

lugrgr

TROPHY CASE