VA Mental Health Provider Venting / Problem-solving / Peer Support Thread
Started by Fan_of_Meehl
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Yeah I'd assume they're thinking more about how do I live and if my SC may be reduced by treatment then I'll just go without.
Theoretically, you also could use some of that money to hire a therapist private pay and never have those records divulged.
Theoretically, you also could use some of that money to hire a therapist private pay and never have those records divulged.
Maybe they also need Tungsten to live! Tungsten!
(I 100% agree with you, btw—just couldn’t help myself!)
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I can't take his money! I can't print my own money! I have to WORK for money! Why don't I just lay down and die??
PsynofTimes
Full Member
So I left for private practice a few months ago, and then I lost my password for this site and was so busy with the transition that it took me quite a while to go through the reset process. So far, so good - I have a lot of anxiety about not having sick leave, but I try to keep myself very busy the rest of the time to make up for that. So far I haven't taken any. My salary is slowly ticking up. I feel better, day in and day out, and have more cognitive/emotional bandwidth for other things. I think it's been a good move, and the determinant of that will be what my salary looks like on a more longitudinal basis.
Sanman
O.G.
I am glad to hear it is working out. Hopefully it meets your salary expectations. That said, other question is,whether you are happier. The older I get, the more I feel that old school private practice got it right with regard to overall career satisfaction. While there can be benefits to hospital practice, APA really led us down a rabbit hole that it could not deliver on long term with the specialization and healthcare systems focus.
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PsynofTimes
Full Member
I tend to agree, after having spent all of my career in hospitals and other similar healthcare systems. They definitely had benefits in terms of loan repayment, learning EBPs, and making collegial connections, so I wouldn't throw it all away. But I think it works for the early part of one's career, and maybe the end of it as well to get retirement benefits. I am quite a bit happier and I feel more centered and less overwhelmed. I'm not angry and frustrated all the time. My family is functioning better because I'm around more, both physically and also just more present psychologically. Money still is a concern, though - I was doing quite well with the VA salary, and I have only met or exceeded it recently. I do know it takes awhile for private practice pay to catch up since you have to wait until you have enough old insurance payouts to make up for the ones that are still in the queue. The trend looks good, but the jury's still out.
Just let everyone know that you are open to consultation requests for "PTSD evaluations." I'm sure they'll take you up on it.
I have had more CBT-CP cases and I have to admit I am not hating it like I usually do. I had someone share that pacing has helped them find more balance. They are able to do a cherished activity again, and it felt nice to help them get that back.
I am still not adding my name to the list of providers who do it, but it was a lovely experience.
I am still not adding my name to the list of providers who do it, but it was a lovely experience.
I need to check in with colleagues on this one. How many of you (or your VA clinics) are getting pressured to consider "Modius Spero, developed by Neurovalens, is an FDA-authorized, non-invasive home-use neuromodulation device indicated for treating symptoms associated with PTSD in adults aged 22 and older, for use alongside a comprehensive treatment plan under the direction of a healthcare professional."
There is a company that is apparently pushing this device and asking providers to 'prescribe' it to patients to treat PTSD. Despite the national center folks (semi-officially, unofficially, officially(?)) saying that it is 'not evidence-based' and, of course, pointing to the VA/DoD Expert Consensus Guidelines and the first-line treatments (meds, PE/CPT/EMDR), there appears to be a level of 'taking this seriously' by administration that is...unsettling.
The company's web page on 'the science' behind the device (and, characteristically, vague descriptions of mechanism of action):
neurovalens.com
How does it work?
"The Modius technology works by activating regions of the brain that control sleep and circadian regulation to treat insomnia. It does this by delivering small and safe electrical pulses to the skin behind the ear. This technology is known as electrical vestibular system stimulation (VSS)."
And--of course--there is this press release by the esteemed American Psychological Association:
www.apaservices.org
"The company Neurovalens received FDA approval for its at-home wearable device, Modius Speroopens in new window. The headset is ordered by a qualified health care professional for a patient (age 22 and older); the headset provides gentle, noninvasive brain stimulation designed to be used for 30 minutes a day. In a clinical trial, two-thirds of adults with PTSD who used the Modius Spero headset reported a clinically meaningful reduction in symptoms. The device will be available to veterans through the U.S. Department of Veterans Affairs as part of a clinician directed care plan later this summer."
Is this a different proposed mechanism of action than the ubiquitous (in VA settings) 'alpha stim' treatment delivered by OT?
I've heard rumors that this Modius Spero device costs $2000 per device (but the taxpayer would, of course, pay for it).
The empirical support for this is extremely preliminary, scant, methodologically-weak, and--of course--sponsored by the company that stands to benefit enormously from a financial standpoint if they can convince VA providers to prescribe this device to all their patients.
The study that was shared with us was entitled a 'Randomized Clinical Trial' and, of course, everyone is calling it an 'RCT' (which, traditionally has referred to Randomized Controlled Trials. Big difference. Actual experimental control conditions/arms are kinda important for... reasons. Any trial with patients is a 'clinical' trial. See the slick Sophistic/ marketing trick, there?
Paging Dr. Anton Mesmer.
Is this on anyone else's radar at present?
There is a company that is apparently pushing this device and asking providers to 'prescribe' it to patients to treat PTSD. Despite the national center folks (semi-officially, unofficially, officially(?)) saying that it is 'not evidence-based' and, of course, pointing to the VA/DoD Expert Consensus Guidelines and the first-line treatments (meds, PE/CPT/EMDR), there appears to be a level of 'taking this seriously' by administration that is...unsettling.
The company's web page on 'the science' behind the device (and, characteristically, vague descriptions of mechanism of action):
The Science Behind Neurovalens’ Sleep Technologies
Discover the science of Modius Sleep, an advanced sleep technology that uses neurostimulation for non-invasive sleep improvement and better quality rest.
neurovalens.com
How does it work?
"The Modius technology works by activating regions of the brain that control sleep and circadian regulation to treat insomnia. It does this by delivering small and safe electrical pulses to the skin behind the ear. This technology is known as electrical vestibular system stimulation (VSS)."
And--of course--there is this press release by the esteemed American Psychological Association:
FDA approves two new nonmedication treatment options for PTSD
An at home-wearable device and a new in-office treatment are now available.
www.apaservices.org
"The company Neurovalens received FDA approval for its at-home wearable device, Modius Speroopens in new window. The headset is ordered by a qualified health care professional for a patient (age 22 and older); the headset provides gentle, noninvasive brain stimulation designed to be used for 30 minutes a day. In a clinical trial, two-thirds of adults with PTSD who used the Modius Spero headset reported a clinically meaningful reduction in symptoms. The device will be available to veterans through the U.S. Department of Veterans Affairs as part of a clinician directed care plan later this summer."
Is this a different proposed mechanism of action than the ubiquitous (in VA settings) 'alpha stim' treatment delivered by OT?
I've heard rumors that this Modius Spero device costs $2000 per device (but the taxpayer would, of course, pay for it).
The empirical support for this is extremely preliminary, scant, methodologically-weak, and--of course--sponsored by the company that stands to benefit enormously from a financial standpoint if they can convince VA providers to prescribe this device to all their patients.
The study that was shared with us was entitled a 'Randomized Clinical Trial' and, of course, everyone is calling it an 'RCT' (which, traditionally has referred to Randomized Controlled Trials. Big difference. Actual experimental control conditions/arms are kinda important for... reasons. Any trial with patients is a 'clinical' trial. See the slick Sophistic/ marketing trick, there?
Paging Dr. Anton Mesmer.
Is this on anyone else's radar at present?
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I actually know the research team behind the RCT and they are really solid, so I'm willing to give it a chance once we have more research. But it's definitely not at the point of evidence-based.
So the people on the team are solid but the research is not (but methodological / design improvements are being planned in the future around critical testing / validation of this form of intervention as an efficacious treatment for PTSD?).
I'm just trying to understand.
Has there been VA research into this device? On veteran populations? With PTSD?
The article shared with us was a Nature Mental Health article by Colvonen et al. (2026) entitled, 'Electrical vestibular system stimulation versus sham for treatment of PTSD: A double-blind, randomized clinical trial.'
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I don't have access to the article and am interested, care to share backchannel?
Colvonen did a presentation on their research recently, here's their information about future directions:
Considering the safety profile of Modius Spero, VSS makes a practical and effective tool for treating PTSD symptomology and insomnia
Possible uses at VA:
• Increasing access to individuals who have trouble finding a trauma-focused therapist?
• Increasing access to individuals not ready for trauma focused treatment?
• Augmentation trials for CBT-I and trauma focused therapy?
What am I personally working on:
• QI Project: Veteran awaiting 1:1 care at VA hospital
• QI Project: Better understand national VA effectiveness of Modius prescriptions
• Multi Site VSS alone, WET Alone, and VSS + WET with STRONG STAR
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Heck,
We're currently seeing wait times of between 3-4 months to accessing PE/CPT/EMDR.
It would be interesting to be able to offer 12 weeks of this device and see if it reduces their PCL-5 scores in the meantime (while awaiting tx) or as an alternative to trauma-focused EBP's.
Can compliance with daily device use be automatically measured/uploaded/monitored (like they do with CPAP usage?)
I'm all for trying it out, though I predict:
1) actual follow-through with 30min daily device usage will be variable/problematic
2) it will be found to be substantially less effective in treating PTSD in veterans than non-veterans
3) a series of ad hoc speculative hypotheses will be advanced to attempt to 'explain' #2 (above) but consideration of effects of service-connection being enmeshed with clinical services in the veteran population will be conspicuously absent from consideration.
But I'd love to be wrong.
For any/all of these massed, brief, somatic, techy, self-administered, etc. treatments of PTSD in veterans, medium to long-term outcome monitoring is critical.
I have seen many veterans evince rapid reductions in PCL scores in PE/CPT/EMDR only to 'rebound' to PCL scores at or higher pre-tx scores in just a few months.
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Just saw the 1hr presentation by Colvonen on the somatic txs sharepoint. Was interesting and responsibly done. Noted issues with partial breaking of the blind, lacks of CAPS for outcome monitoring, and lack of follow-up longer-term.
I will say that my impression of Dr. Colvonen was that of high credibility, integrity, and sophistication.
One question pts are sure to have even if it helps is 'do I have to continue to wear the device 30min every single day for the rest of my life to continue to benefit?'
I was impressed they've done a cross-lagged panel design (yet to be published) indicating sleep improvement (ISI) precede later ptsd sx (PCL) improvements, but not vice versa. More in line with a network/systems model of ptsd than the 'latent disease' model.
One thing I noticed was that the pre-tx screening CAPS to establish the ptsd diagnosis (done by phone?) was either done by the principal investigator himself or by a 'designee.' Although these 'designees' were 'trained in the use of the CAPS,' I didn't see anywhere where their broader training (as clinicians) were noted. Bachelors? Masters? Doctoral? Licensed clinicians? Interns?
Edit: another tidbit from the presentation, the device is only good for one course of 12wk treatment. After that time, electrodes 'burn out' (effectively) and a NEW device would have to be issued. And the device cost is in the 'several thousands (?). $3000 per headset. Wow. That buys a lot of PE/CPT.
With guaranteed payment by the taxpayer, that company stands to make a LOT of $$$.
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I'm glad you have a favorable impression. That was the presentation I was referencing. I can definitely say that Colvonen's not someone who's going to push a device if it doesn't work, and he greatly respects both evidence-based treatment and, specifically, PTSD treatment principles. I learned a LOT about sleep and PTSD from him and his research. He also developed a really cool treatment that combines CBT-I and PE.
Yeah, my impression was 100% class act. Glad folks like him are doing some of the VA research.
I'll need to look a little deeper when I get a chance, but my first impressions are that I'd be worried about the breaking of blinds, and the sham condition was...underwhelming. And, I wouldn't be surprised if those two things were closely related.
Yeah, that's definitely a concern. Like I said, I will need more research before I consider recommending this device (and even then, I would push therapy first).
The results are worth pursuing further, but those concerns, and the sham effect on sx, would make me think it's not ready for widespread clinical use just yet. Especially if other, more established, and much cheaper treatments are readily available.
Okay, so here's the latest insanity:
Get called in to supervisor's office and explained that the 'coding staff' have audited some of my notes/ diagnoses in the chart and found some 'inconsistencies' and problems. Won't bore you all with the details except for one. They said I was wrong ('undercoding' or 'underspecifying' the condition) for coding PTSD as, simply, 'PTSD' (without the 'Chronic') specifier in the body of my chart note. They said it needed to 'match' what was listed in the encounter (which is from ICD-10) which is listed as 'PTSD, Chronic.'
I tell my supervisor that there was a reason that the acute vs. chronic specifiers were removed from the DSM-5 system and that it is ethical/appropriate for me to use...you know...the DSM-5 system (instead of the ICD-10 system) in the body of my chart note. She agreed that I may have a point but this may be something I'm going to have to fight.
It took 10 secs to confirm that I was right (DSM-5 does not include 'chronic' as a PTSD specifier).
Do you guys list 'PTSD' in your chart notes (without adding the 'chronic' specifier) and, if so, have you ever gotten grief from the 'coding staff' for failing to be 'specific enough' in your diagnosis ('cause, you know, you only said 'PTSD' and not 'PTSD, Chronic' in the body of your chart note?)
I'm tempted to fire off a 'consultation request' email to the damn National Center on PTSD requesting help/input with the above.
'Dear Penthous--ahem--National Center,
Am I wrong for simply listing PTSD as a diagnosis in the body of my intake/ chart notes or am I supposed to put 'PTSD, Chronic' even though I know that the Acute vs. Chronic specifiers for PTSD were explicitly removed in the DSM-5 revision?'
Edit:
A couple of the other criticisms:
- I coded 90791 in notes for encounters that were 'too brief' in duration (i.e., 30 minutes face to face) and they said it had to be longer than that (I am pretty certain this is false since we had this discussion on this forum before and I even looked up the CMS criteria and there is no minimum duration); I think the coders were saying a 90791 sessions had to be 60 mins or more.
- I used a crisis intervention counseling code that I thought went up to 60 mins but the actual time with patient was 30 mins. I haven't looked it over in detail yet but I was pretty sure the code (can't remember it offhand) was for 'the first 60 mins of crisis intervention' and wasn't for 'at least 60 minutes of face to face crisis intervention.' I get to deal with all of this tomorrow morning.f
The other (bizarre) aspect of the meeting was my supervisor saying that what she does (in order to make the billing/coding people happy) is that she doesn't enter DSM diagnoses in her notes. She starts off with what is 'checked off' in the encounter (listed below the note in CPRS--these are exclusively ICD (not DSM) diagnoses), she highlights/copies the text straight from there, then pastes this into her note as 'the diagnosis.' Of course, this would mean that she never actually lists DSM (only ICD) diagnoses in her notes. She suggested that this is what I need to start doing. I know for a fact that other mental health providers are not doing this (I read the charts) and I know that they are not being hassled about it (with 'coding audits' and formal written feedback/results). A good 90% of all the notes say 'PTSD' as the diagnosis in the body of the note, not 'PTSD, Chronic' which isn't even accurate according to DSM-5 which explicitly removed the 'acute' and 'chronic' specifiers for PTSD.
I know the Uniform mental health policy/procedures says we can use DSM or ICD. However, if you know anything about the DSM-5 vs. ICD-11 diagnostic criteria for, for example, PTSD, they are completely different. All of our instruments (CAPS, PCL) are based on the 20 DSM-5 criteria, not the MUCH briefer (and different) criteria sets for ICD PTSD and Complex PTSD. So, I think I am being instructed to only use ICD diagnoses (e.g., PTSD, Chronic) which is implying that those diagnoses were arrived at using ICD criteria (not DSM criteria). I am also just simply not familiar with the ICD diagnostic system and (often) different criterion sets. Most of the clinical research and literature uses DSM.
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Never had a complaint, and I never put chronic in the note.
This OIG report on severe staffing shortages is interest (psychologists are one of the most common shortage professions). Also, some sites have huge lists of severe shortage professions--makes me wonder what's going on there: https://www.vaoig.gov/sites/default/files/reports/2026-09/vaoig-26-01046-271_-_final.pdf
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I have a strong suspicion that 'medical coding/billing' folks aren't on there.
Sanman
O.G.
VA Birmingham going for the record on shortages. Does anyone work there?
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