Are there any therapists who don’t use checklists?

June 21, 2024 12:40 PM

I’ve been trying to get a veteran to treatment for a while. He came pretty close, but backed out when he got to the pre-therapy questionnaire. Are there any therapists or methods of therapy that commit to not using those? Details abound.

One of the problems with this, and other veterans I’ve dealt with, is that the usual questionnaires don’t really gauge their danger level well, they fear being red-flagged if they answer them honestly, and if they start off lying they think “well, what’s the point?”

For example, most combat veterans I know have homicidal ideation on a daily basis. I suspect that with a lot of new gun laws, therapists are worried about liability if one of their clients shoots someone and they didn’t know about it, but it might just be a time saving tool.

If it’s just a time saving tool, are there any schools that start out with just talking about what the person wants to talk about and going from there, sans questionnaire?

posted by corb to Health & Fitness (14 answers total)

Not a therapist here. But I know a lot of therapists and I think many of them would be willing to forgo the checklist if asked. I would look for someone specifically who talks about patient-lead or -directed therapy.

Therapists are often mandated reporters but those with lots of experience do tend to develop a nuanced understanding of what that means in terms of suicidal ideation.
posted by lunasol at 12:49 PM on June 21

You're likely to have better luck with the request if you're working with someone in private practice or a small-group practice (like, a handful of therapists sharing an office). And also if you're private pay, if that's an option. Large organizations, either providers or insurance companies, sometimes require quantifiable proof of need ("medical necessity" at the beginning) and then quantifiable ways to track progress.

Other therapists may just use them so that they have a sense of what's going on with the client, though. Generally, ethically, some sort of intake process is required, but that could be spending a few sessions just talking to the person about what's going on. Again, that'll be easier if the therapist doesn't have to prove to an insurance company or employer that the client meets criteria for therapy.
posted by lapis at 12:56 PM on June 21 [3 favorites]

(Also, though, clients lie on those forms pretty consistently, unknowingly or not. It's ridiculous to think that traumatized people even should trust a random stranger with some of that info, and good therapists know that. Could he either not fill it out completely, or just put down what he's comfortable with and not worry about it?)
posted by lapis at 12:59 PM on June 21 [2 favorites]

I would empower your friend to say, "I'd rather not fill out the questionnaire and just cover this in person, thanks." If pressed, "no, I won't be filling this out thanks, I'll cover it in person." Repeat x infinity. Firm.
posted by phunniemee at 1:06 PM on June 21 [3 favorites]

What about therapists who specialize in working with veterans? They may better understand the concerns, and being someone who specializes in veterans could instill some confidence (and probably more so if the therapist is a veteran as well). Psychology Today has "veteran" as a category in their therapist search (for example, this is the Missouri search).
posted by Meldanthral at 1:11 PM on June 21 [2 favorites]

Yeah, I think this probably goes beyond the checklist. I would concentrate on finding a therapist who is a veteran themselves. No point to getting past the checklist only to find the therapist doesn't have the context to understand your life.
posted by Tell Me No Lies at 1:17 PM on June 21 [2 favorites]

Two thoughts. One, I refuse to fill out those pre-visit forms whether it is a therapist or a internist or any doctor. I simply say "No thank you" and look them in the eye. If they push back, I tell them I am willing to answer any question they may have verbally that will help them help me. I have never been told to leave. Some doctors use it because their huge practice thinks it is a thing they need to do. T

wo, my friend the surgeon once said about those pre-visit forms, "I have to ask the questions. I do not have to believe the answers."

My ex was a social worker for the VA. I never asked, but I do not think they ever turned anyone away bc they did not answer the questionnaire. She did tell me that once, similar to Tell Me No Lies above, she was presented with a checklist from a Veteran asking if she was a Veteran (No), if she ever treated someone for PTSD, if she was available off hours for emergency phone calls, and similar questions about her qualifications to treat that specific Veteran.
posted by JohnnyGunn at 2:29 PM on June 21 [3 favorites]

You can just not fill it out and attend the appointment anyway, it's not usually a problem. Also, therapists are used to managing risk. If they have homicidal ideation, they should disclose it. If they want to know exactly what kind of disclosures will cause therapists to have to break confidentiality and make a mandated report, they should ask about this before discussing the matter. Therapists do not have to break confidentiality for every situation where a person has a thought about hurting themselves or others; a therapist can tell you what kinds of disclosures will cause action to be taken.
posted by shadygrove at 3:26 PM on June 21 [1 favorite]

It could be that they'd fear being red flagged for refusing to do the questionnaire, too, but they can just say "I don't want to focus on the wrong thing" or "that triggers my anxiety" or "I'm here to focus on my fear of avocados, and I think the questionnaire would be a distraction from that."
posted by amtho at 4:19 PM on June 21 [2 favorites]

If they want to know exactly what kind of disclosures will cause therapists to have to break confidentiality and make a mandated report, they should ask about this before discussing the matter.

This is really important. When I started working with my current therapist, we had a very extensive initial conversation about what kinds of situations could trigger their reporting/breaking confidentiality requirements. Any good therapist should be comfortable answering those questions and giving examples of situations that would and wouldn't trigger those requirements before commencing treatment.
posted by terretu at 4:28 PM on June 21 [4 favorites]

I work for a large, American health care provider and specifically worked on a project involving those self-same questionnaires. Any place not a solo practitioner will send them out or expect them to be completed but as people mention above, it's not a requirement for care. Barring a filled out questionnaire, the provider will most likely ask the same questions as part of intake.

If it's the questions themselves, they will be asked, in some fashion. If it's the format, it's optional. I know there's a type of MSW or psych that does not like these questionnaires at all but the point of them is that "normal people" are getting lost in the depression and addiction cracks and these things help them get what they need. It's not usually intended for cPTSD patients or people with more complex care needs.

Hammer, nail, etc.
posted by fiercekitten at 5:21 PM on June 21

Therapists are trained to understand the difference between just ideation vs ideation, plan, and intent. Suicidal ideation is very common and homicidal ideation is fairly common too. It's not reportable without plan, intent, and means (2 out of 3)

As far as a "checklist"; no, it's not required for all therapists, especially those in private practice, as mentioned above. And I work at a public angency- we do a depression and ptsd screen but if someone refuses, we skip it. However, if homicidal or suicidal ideation is brought up the therapist checks for plan, intent, and means.
posted by bearette at 7:23 PM on June 21 [2 favorites]

One way to think about intake questionnaires -- the forms are designed to help the therapist be somewhat prepared for the first session. Many clients prefer to fill out the forms and provide them in advance rather than pay for a therapist to ask all those questions in the first session. If the client doesn't mind paying for the time, most therapists would probably be willing to fill out the forms interactively in session.

That's about the "checklist" part of your question. You are also asking about your friend's fear of being "red-flagged." I can understand why they feel sensitive about that. By the same token, veterans are also entitled to interview potential therapists and make sure the therapist is equipped to listen to and help them with their experiences. Any therapist who would "red-flag" a veteran in the way you describe is probably not the right therapist. Unfortunate, but true.

I wonder if you could help your friend get their sense of agency back by inviting them to interview therapists to find someone they feel comfortable with. Many therapists offer a free introductory call -- often pretty brief, so your friend would have to come prepared with questions and know what kind of answers they are looking for.
posted by gigimakka at 7:37 PM on June 21 [1 favorite]

I think the questionnaires are a part of seeing VA therapists; unsure if they're also required when using the insurance for therapists outside the VA? Measurement-based mental health care at the VA:

Measurement-based care (MBC) is the use of patient-reported information to inform clinical care and shared decision-making among clinicians and patients and to individualize ongoing treatment plans. The information is collected as part of routine care. VA’s Measurement Based Care in Mental Health Initiative, which began in 2016, focuses on outcomes reported by Veterans themselves in response to regular questionnaires related to their mental health. Providers and Veterans work together to use the information from outcome measures to tailor mental health treatments to their individual needs.

If the person in your question is not comfortable with this clinical model, can they consider these questionnaires as part of the paperwork for insurance purposes, or as the therapist taking a 'mind' temperature reading (similar to body temperature recording in a medical exam office, before the doctor enters the room for the actual visit)? (I also think conversations with prospective therapists about this known stumbling block is worthwhile; if the questionnaires are a VA or insurance requirement, "regular" reporting may still have some flexibility. Thank you for helping out, corb.)
posted by Iris Gambol at 4:39 PM on June 22 [1 favorite]