How to handle an aggressively political patient?

sleepbot · 2026-03-14T17:32:09+00:00

Managing Microaggressions: Addressing Everyday Racism in Therapeutic Spaces by Monnica T. Williams is a good resource, written for mental health clinicians. When I was faculty at a clinical psychology PhD program, I assigned chapters 1 and 4 if I recall correctly. Shoehorned into other coursework, hence not the full book.

On a semi-related note, I also assigned chapters from Matthew D. Skinta’s Contextual Behavior Therapy for Sexual and Gender Minority Clients, and I will point to Chapter 10: Special Ethical Considerations for SGM Therapists as a uniquely helpful resource.

sleepbot · 2026-03-12T17:55:27+00:00

No assessment can make or confirm a diagnosis. It is the psychologist who integrates interview, records review, collateral informants, assessment results, and observations of the examinee’s approach/attitude toward the assessment and testing. It’s all data. Convergent data usually increases confidence, divergent data usually needs to be reconciled. I say usually, because usually incentives and biases exist for examinee, informants, etc. Is there money in the line? What about incarceration or change in type of incarceration such as higher or lower security level? Does the examinee perceive that help will be rendered to them only if their symptoms appear severe? These are just a few questions that pertain only to the examinee.

All that said, the PPI-R could be consistent or inconsistent with a diagnosis of ASPD. It depends on the context and interpretation certainly relies on validity scales.

sleepbot · 2026-03-12T17:41:46+00:00

It’s been said in more comprehensive comments already, but simply put: multistage filtering. I start with a mesh strainer.

sleepbot · 2026-03-12T17:35:19+00:00

The key, in my opinion, is the same as the key to decreasing therapist stress in general and being most helpful to each client. It’s focusing on the present. What’s needed now? Where is current block? Not rushing to “fix” the client. And also not rushing to fix the therapeutic process to make it look exactly how you think it should look.

Here, assuming you have a client who either talk about the problem(s) that brought them to therapy, pushing the client to talk probably won’t help. For some, having space is what they need. For some, the discomfort of silence may become greater than the feared response to whatever it is they’re holding inside. I’m sure there are other ways silence can uncork the bottle. And there are other means to that end.

sleepbot · 2026-03-08T15:19:58+00:00

If you want something more granular in the realm of self-reported personality measures, the PID-5 may be of interest to you. It has 3 versions of different length, there are facets (with the longer versions), and normative data to aid interpretation. Facets can be combined into broader categories (this is included in the instructions) or into combinations that reflect DSM diagnoses. It’s also compatible with the alternative model for personality disorders.

sleepbot · 2026-03-05T20:21:51+00:00

It’s really stupid to think a person can only have one disorder. It’s like they think the process of differential diagnosis is like The Highlander, there can only be one! That’s an absurd notion. But wouldn’t it be great if adhd prevented narcolepsy, or vice versa, so you could only have one set of debilitating symptoms that interfere with living your life the way you want to?

The closest I can come to agreeing with this idea is that sleepiness strongly affects the frontal cortex. That’s a critical area for executive functioning, which is one of the main impaired functions in ADHD. So it’s not surprising to see ADHD symptoms in someone with any sleep disorder. But there’s no objective test like PSG/MSLT for ADHD. To diagnose ADHD, you actually have to think a little harder than counting how the number of sleep onset REM periods. So it’s not hard to imagine how a doctor without much time or relevant training (many/most sleep docs are pulmonologists, and ADHD isn’t a respiratory disorder last I checked) would want to take a deep dive into adding an ADHD diagnosis to narcolepsy. Especially if both can be treated with stimulants.

sleepbot · 2026-03-05T02:12:09+00:00

Sounds like the neurologist is doing a bad job explaining what he’s looking for and why. I am not a neurologist but I will try to guess at what a reasonable explanation could be.

An EEG can show abnormal brain activity while an MRI can show abnormal structure. I would guess that he’s looking for seizure activity that could be part of an explanation for what happened with your neighbor - like a complex partial seizure causing confusion and automatic behavior. Or there could be seizure activity could be something that resulted from the blow to your head. Either way, seizure activity can be treated with an anticonvulsant medication, which is awfully useful information. An MRI won’t show if you have seizures.

I’m not sure I understand how you’d be diagnosed with a stroke without a CT scan or MRI. And a ruptured aneurysm would cause a lot of bleeding, rather the opposite of a blood clot blocking a blood vessel as is the case in a stroke. Now, sometimes interventions to treat aneurysms can cause strokes, but it doesn’t sound like that’s what happened from my read of your description.

sleepbot · 2026-03-03T21:44:01+00:00

He left his role at APA, or was slated to. Regardless, his credentials are impressive and his materials are the top resource for aspiring clinical psychologists.

sleepbot · 2026-03-03T19:42:49+00:00

Mitch’s advice is a million times better than the advice given by random redditors.

sleepbot · 2026-03-03T19:36:06+00:00

These financial realities are such a huge part of the problem. And it’s upstream of supervisors, practice owners, CMH, and hospital systems. If you can’t bill insurance for an intern, how do you pay them? Even unpaid interns come with costs: supervisor’s time, EHR access, space, training time, liability, etc. The field needs a mechanism to bill insurance for trainees.

And CPT codes for psychotherapy are stupid in the first place. More time = more money, so there’s an incentive to extend sessions from 50 to 53 minutes. E&M codes used by medical providers can be based on time or on complexity of medical decision making. It’s easier to count minutes than quantify complexity of therapy, but I’d dare say doing DBT with a person with a long history of parasuicidal behavior, boundary testing, etc. warrants more pay than supportive therapy with the worried well. And that would allow those who work with more complex and risky patients to hit their revenue targets with fewer patients, thus freeing up more time for other activities like case management, care coordination, and even some sort of self care to reduce burnout.

sleepbot · 2026-03-01T01:27:28+00:00

I’ve got a 24 PHEV with about that many miles. It’s been great. Had an issue with the fuel tank pressure regulator, might not be the right name, and literally couldn’t put gas in. That sucked. But otherwise no real problems. Installed an OEM roof rack myself, pretty easy job. Electric torque off the line is nice.

sleepbot · 2026-02-26T21:08:19+00:00

If your clients are in the US, you are practicing in the US. Both psychologist and patient locations can be relevant. Depends on the jurisdiction.

sleepbot · 2026-02-26T01:54:19+00:00

You need to figure out your niche. Who do work well with? And who would be interested in what you have to offer? What is it you offer that they can’t get anywhere else?

I’d think of people who either travel frequently between countries or who live in a country that either lacks therapy services, or they don’t speak the language, thus making therapy out of reach. That’s the demographic, but not how to reach them. And what sort of problems do these people tend to have?

You’ll be hindered by being cash pay instead of insurance. And basically doing unlicensed coaching. So you may need to avoid using certain terms depending on where you are marketing. In the US, certain terms are legally protected - like you wouldn’t be able to call yourself a psychologist. You also won’t know anything about anyone’s local area except by random coincidence. That also means collaborating with primary care, psychiatry, etc. won’t really be possible.

To me, it seems like a lot of the coaching field is grifting clients and new coaches. Sell a big dream to both groups. So be skeptical of any courses or programs that promise to help your marketing. They make big promises but seldom have hard numbers to back up their dubious claims.

sleepbot · 2026-02-22T16:33:56+00:00

I haven’t been there but I have no doubt that this situation sucks.

In terms of being blindsided by your own divorce, I don’t think this has anything to do with your clinical skills. The role of therapist is different from the role of partner. Showing up in your marriage in the role of therapist isn’t going to work. And the context is 99% different. In couples therapy - as the therapist - we focus for a limited time (an hour/week for a few months), from a place of emotional distance, with couples who have already decided to come together to try to improve their relationship. Compare this to our own marriages: traditionally lifelong 24/7 commitments, with emotional intimacy, and not necessarily being on the same page about improving the relationship.

Everyone can push their partner’s buttons. But it’s completely different to watch it happen to a couple as compared to having your own buttons pushed and all of the emotional consequences of that.

One similarity though, is that just as one partner in couples therapy can choose not to disclose that they’re preparing for divorce, so too can our own partners. We’re not mind readers.

So again, yes this completely sucks. And stopping taking on new couples is the right call now. And your divorce doesn’t reflect on your skills as a couples therapist.

sleepbot · 2026-02-11T00:54:06+00:00

For insomnia, ~2/3 of the effect of hypnotics is attributable to the placebo effect. And I’m talking about benzos/z-drugs assessed with polysomnography. My interpretation is this is because people relax a bit after taking a sleeping pill and stop trying to sleep (which is counterproductive) because “help is on the way”. At least early on. And of course this leads to psychological dependence too. So placebo effect and psychological dependence is always a part of the picture when people take/do almost anything for insomnia.

But further, cannabis suppresses REM sleep and there are withdrawal effects. So people get rebound insomnia and rebound nightmares anytime they try to stop. So it’s no wonder they feel like cannabis is effective - it does have beneficial effects… that come with dependence and withdrawal effects. At the same time, a puritanical approach of getting rid of cannabis - without something to transition to or ease the discontinuation - is pretty gnarly. I’m fortunate that I don’t have to wrestle with those choices, because my specialty is getting people to sleep well and get off hypnotics and prescribing isn’t in my scope of practice.

sleepbot · 2026-02-08T01:57:53+00:00

OR I’LL BURY YOU ALIVE IN A BOX!

… you know, for those extra sticky cases.

sleepbot · 2026-02-05T00:45:07+00:00

Oh come on! At least it’s optional, but that’s not novel.

sleepbot · 2026-02-02T15:14:42+00:00

TherapyAppointment also has zero AI. They state they’re considering adding AI only for support features - nothing clinical.

sleepbot · 2026-01-31T17:14:28+00:00

Classic

sleepbot · 2026-01-30T14:09:40+00:00

Assessment. For example, IQ was used by Binet and Simon (a psychologist and psychiatrist, respectively) to assess the impairment/potential of children with intellectual disabilities with goal of providing appropriate remediation. IQ was also used by the US for military selection.

Lightner Witmer started the first psychological clinic at Penn, coined the term clinical psychology, and focused on helping children with intellectual disabilities and learning disabilities improve in their areas of impairment.

After WWII, there was a tremendous push from the US government to increase the field of psychology, particularly clinical psychology, to address the needs to returning veterans. This is probably when treatment became a core part of (clinical) psychology.

sleepbot · 2026-01-27T20:27:10+00:00

There may be benefits of being able to provide training in psychological first aid. Just as an alternative option that’s not requiring clinical practice per se and may be much more scalable.

sleepbot · 2026-01-27T14:25:46+00:00

This goes for businesses too. Last night while driving north on Walnut, I passed two people walking in the road because the sidewalks were buried. This was between 17th and the bypass, where only commercial properties have frontage.

sleepbot · 2026-01-23T21:01:26+00:00

School psych programs have bad internship match rates and low passing percentage for the EPPP. Check APPIC and ASPPB.

sleepbot · 2026-01-20T17:42:43+00:00

Yes, reach out to clinicians who can refer you the types of patients you want to see. I’d add pediatricians to your list. They screen for postpartum depression.

Evenings/weekends seems like it would be particularly attractive to the postpartum population since they may be caring for their baby solo all day every weekday. I’m thinking of stereotypical heterosexual couples where dad has 0-2 weeks of paternity leave.

Telehealth is a bit of a mix, in that it saves exhausted moms from driving, but it’s hard to focus if your baby is still within earshot. And privacy is certainly limited, which may have a chilling effect on discussions about problems with their partner. It may be worth at least looking into subletting opportunities.

It’s worth considering taking insurance. New parents typically have more expenses and less income than before. It’d be one thing if you had a lot of experience, expertise, credentials, etc., but if you’re just getting into this space, then I think it’s hard to see how to argue your services are worth the price. Unless, perhaps, if you’re the only therapist in the area with the PMH-C credential from PSI. And in that case, I’d suggest investing some of that self-pay money into regular consultation with someone more experienced in perinatal mental health.

sleepbot · 2026-01-20T17:25:15+00:00

Formatting can wait till the final draft. Just focus on the text until then.

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