Government certainly tends to be more lax about these things than the private sector. Part of the reason that you are hearing so much about RVUs at the VA is that they are trying (in a tone deaf manner) to get serious about such things after decades of being vary lax. If you know older employees at the VA, stories of two hour lunches and low productivity abound. In geriatrics at my facility, they only got serious about RVUs a couple of years ago.
I think this analysis is spot on.
I also think that the pendulum has swung way too far in the opposite direction.
It also creates perverse incentives that actually end up punishing ACTUAL productivity (i.e., doing active therapy with clients and getting them in and out of time-limited psychotherapy).
Those who work really hard (even outside of EBP protocol/manualized courses of therapy) to continually assess and provide feedback to clients regarding readiness to change, goal-setting, skills-building, between-session assignments, self-monitoring, workbooks, etc. and, therefore, tend to create therapy environments where clients have to either 'defecate' or cease occupying the toilet get screwed in most systems.
This is how it works. The vast majority of VA outpatient providers have two modes of doing therapy. Either a patient is in the midst of doing an EBP protocol treatment (CPT, PE, CBT-i, whatever) or they are in amorphous 'supportive therapy' land. Over time, most providers settle into rescheduling all of their 'supportive therapy' clients basically every 2 to 4 weeks for them to come back and audition for higher service connection benefits or otherwise externalize/complain about everything other than their own patterns of thinking and behaving in terms of contributing to their problems. Most providers are too worn out (due to their now overwhelming backed-up caseloads occupying nearly every moment of their shift) that they just give up and zone out and don't have the energy to 'fight' to re-establish with these clients a proper form of psychotherapy (it's REAL work to do so). They just end up using these sessions as 'breaks' in between the other 'evidence-based' (EBP) protocol sessions/clients that pepper their schedule. It's unsustainable because all the veterans build up into a quasi-permanent never-ending-expanding caseload (with no 'panel' size limits). The extra documentation/paperwork doesn't help here either.
I just spent a year keeping my caseload (or trying to) at an equilibrium point (seeing as many or more new patients per week as everyone else in the clinic, also taking multiple 'extra' cases from everyone else's caseload to 'build up' my caseload more) by aggressively trying to do actual therapy whether or not I was doing an EBP manualized protocol or not. It worked (for a good while). I worked my butt off and patients generally either (a) got with the program, actively participated in active CBT and got better and left/ terminated successfully or (far more commonly) (b) realized that my office wasn't going to be a permanent hobby for them to come in and complain about everything once monthly for the rest of their lives (that I was actually going to hold them/me accountable for providing actual psychotherapy) and they simply passively 'dropped out' of therapy with me. But it was a LOT of extra work (prepping for sessions, photocopying workbook chapters/worksheets, doing actual case formulations, following up on assignments, etc.).
And here's the bitter pill kicker...
Everyone in the clinic saw my 'availability' in my schedule (that I'd fought hard to have) as somehow indication that I wasn't working hard enough. Even though I was taking as many (or more) regularly scheduled intakes into my clinic (as everyone else) AND routinely having them give me patients from their caseloads (generally, the 'tough' patients they didn't want to have to deal with anymore...most of which eventually passively dropped out with me because I held them accountable in therapy). But at this point, I've finally gotten to the point of being overwhelmed/swamped (you can only take so many new referrals per week into your caseload even if you're trying hard to keep things cleared out).
I kept it up for about a year but in the clinic at weekly meetings they have the MSA's read off people's 'next available' appointments in the meeting (it feels like a shaming ritual to me because I have typically had a next available that wasn't too far out) as continued (I suppose) justification for the other providers always sending me extra cases from their caseloads and--you guessed it--these 'extra' gifts from other providers tend to be the high-intensity, suicidal/homicidal, personality-disordered cases no one wants to deal with. But I can't say 'no' because then I am not being a 'team player' and how dare I have availability in my schedule (even though I have that availability because during the gaps between patients I am photocopying CBT self-help manuals/worksheets, reviewing charts, doing case formulations, etc. (ACTUAL PSYCHOTHERAPY PRODUCTIVITY)).
So, the consequence for ACTUALLY being productive as a psychotherapist is more work in the VA system (and 'shaming' for being productive in getting people in/out of therapy). Now I have to find a way to 'scale back' my ACTUAL productivity as a psychotherapist so I don't burn out and so I can APPEAR more 'productive' by having every single slot filled two months plus out and I can be so 'proud' of being 'swamped' with patients.
This is one (of many) reasons why people burn out after a few years of being a full-time therapist in the VA system. Unfortunately, I think the only way to survive long-term is to find some way to change my own values to 'let myself' be a crap therapist most of the time.
