VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Sanman]

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I have a colleague who's super sick but has to come in to do a training that they can't reschedule, and of course they can't telework even though it's a virtual training. If I get sick, I will be SO mad.

What happens if they call out sick? Can't is a strong word.

 

[cara susanna]

What happens if they call out sick? Can't is a strong word.

It's a yearly EBP rollout workshop, they would not be able to finish the training.

 

[Fan_of_Meehl]

It's a yearly EBP rollout workshop, they would not be able to finish the training.

There are two COMPLETELY different 'worlds' when it comes to VA staff experiences.

Either you're a provider with a caseload...or you're not.

Work life for group A is NOTHING like work life for group B.

 

[Sanman]

It's a yearly EBP rollout workshop, they would not be able to finish the training.

We need to have better processes for these things. There should be back ups available if someone is out sick.

 

[psy.d. 2021]

We need to have better processes for these things. There should be back ups a available if someone is out sick.

The ebp rollouts are way too strict. That includes attendance rules and the entire consultation process afterward IMO. It doesn't necessarily have to be six months. The recording of sessions is onerous from an admin perspective and I don't even really know if it does a lot... do we really think these trainers are going to fail people? At least from my perspective it seems unlikely.

 

[Fan_of_Meehl]

The ebp rollouts are way too strict. That includes attendance rules and the entire consultation process afterward IMO. It doesn't necessarily have to be six months. The recording of sessions is onerous from an admin perspective and I don't even really know if it does a lot... do we really think these trainers are going to fail people? At least from my perspective it seems unlikely.

The CPT training I had several years ago was fine. There were two others I did after that one that had me swearing that I would NEVER sign up for all that headache again (in context of trying to practice full-time at VA). The VA 'leadership'/supervisors tolerate two broad levels of sophistication / competency (extremes) with respect to psychotherapy practice: (a) absolutely no standards/ oversight or whatsoever (b) extreme/ rigid levels of structure/ oversight in context of this sort of training experience. Psychologically speaking, I think that implementation and enforcement of (b) is some kind of crazy overcompensating way of attempting to expiate themselves from the guilt of tolerating (a) all the time.

The definition of 'evidence-based psychotherapy' (from the APA's own website, the field at large, etc.) is not and has never been 'must be a manualized, every-session-agenda-pre-scripted-out, protocol-for-syndrome complete recipe approach. Manualized protocols are great. I use them all the time. But they represent the apex and highest level of structure/effort in psychotherapy and the strictest focus on a single categorical DSM-5 category/diagnosis or syndrome. The protocol-for-syndrome approach has had its heydey but it is not the optimal approach for the patient population (the average patient, that is) presenting these days at VA outpatient clinics. Disorders of internalizing distress (MDD, GAD, PTSD, dysthymia) are highly overlapping and respond to very similar mechanisms of change in therapy including arousal-reduction strategies, behavioral activation/exposure, and various forms of cognitive restructuring at various levels (automatic thoughts, intermediate beliefs, schemas). Of course, the trauma-specific and trauma-distinctive elements of PE/CPT are important but--importantly--are only critical in patients who actually have significant trauma-related elements to their case formulation. We never talk about it openly but there is so much mis- over-diagnosis of PTSD these days (a prescribing provider in PCMHI throws a PCL-5 at a veteran and all of a sudden gives a PTSD diagnosis that sticks on the basis of that alone) is out of control. The influence of motivation to attain and maximize service-connection percentages and secondaries (tied, for example, to PTSD) is unreal these days. I have witnessed a significant shift over the past five years alone away from providers (outside of a small few) taking any responsibility to acknowledge, work-up, or diagnose trauma-related conditions as a result. 'PTSD evaluations' (so to speak) are treated as the equivalent of 'child custody evaluations' in the outpatient VA mental health world to the point where nobody wants to touch them with a 10 ft pole and will just pass the patient along to other people. These days, the spectre/possibility of PTSD is raised by one provider, and then they are sent to another provider to 'evaluate for PTSD' or 'R/O PTSD' (passing the buck)--or trauma is just completely ignored as an issue in the patient. Now the unfortunate receiving provider has the unenviable to impossible task of 'proving a negative' or proving they don't have a condition that they are fully motivated to be seen as having and the criteria for which are almost 100% based on self-report. This is a poor fit for a protocol-for-syndrome system of treatment. Under such a system, there is pressure to 'finalize' the categorical diagnosis prior to offering/beginning a course of CBT. This is such a monumental error by our system that creates so much inefficiency in service-delivery it is unreal. So many people just presenting for 'the diagnosis' or to 'document how bad their current symptoms are' and then 'ghosting' the clinic by no-showing or cancelling their way out of treatment is incredibly common these days. And it all seems to be accelerating.

We need to evolve to more of a flexible, transdiagnostic, process-based CBT and case-formulation driven approach that explicitly assesses and addresses patient-side barriers to engagement in progress in therapy (factors related to safety, attendance, engagement, self-monitoring, focus, etc.) as well as a more individualized CBT case formulation-driven approach. We also need to get rid of the monthly supportive therapy sessions forever nonsense and enforce an episode-of-care model mandating weekly sessions (for, say, 10 - 20 weeks).

 

[psy.d. 2021]

The CPT training I had several years ago was fine. There were two others I did after that one that had me swearing that I would NEVER sign up for all that headache again (in context of trying to practice full-time at VA). The VA 'leadership'/supervisors tolerate two broad levels of sophistication / competency (extremes) with respect to psychotherapy practice: (a) absolutely no standards/ oversight or whatsoever (b) extreme/ rigid levels of structure/ oversight in context of this sort of training experience. Psychologically speaking, I think that implementation and enforcement of (b) is some kind of crazy overcompensating way of attempting to expiate themselves from the guilt of tolerating (a) all the time.

The definition of 'evidence-based psychotherapy' (from the APA's own website, the field at large, etc.) is not and has never been 'must be a manualized, every-session-agenda-pre-scripted-out, protocol-for-syndrome complete recipe approach. Manualized protocols are great. I use them all the time. But they represent the apex and highest level of structure/effort in psychotherapy and the strictest focus on a single categorical DSM-5 category/diagnosis or syndrome. The protocol-for-syndrome approach has had its heydey but it is not the optimal approach for the patient population (the average patient, that is) presenting these days at VA outpatient clinics. Disorders of internalizing distress (MDD, GAD, PTSD, dysthymia) are highly overlapping and respond to very similar mechanisms of change in therapy including arousal-reduction strategies, behavioral activation/exposure, and various forms of cognitive restructuring at various levels (automatic thoughts, intermediate beliefs, schemas). Of course, the trauma-specific and trauma-distinctive elements of PE/CPT are important but--importantly--are only critical in patients who actually have significant trauma-related elements to their case formulation. We never talk about it openly but there is so much mis- over-diagnosis of PTSD these days (a prescribing provider in PCMHI throws a PCL-5 at a veteran and all of a sudden gives a PTSD diagnosis that sticks on the basis of that alone) is out of control. The influence of motivation to attain and maximize service-connection percentages and secondaries (tied, for example, to PTSD) is unreal these days. I have witnessed a significant shift over the past five years alone away from providers (outside of a small few) taking any responsibility to acknowledge, work-up, or diagnose trauma-related conditions as a result. 'PTSD evaluations' (so to speak) are treated as the equivalent of 'child custody evaluations' in the outpatient VA mental health world to the point where nobody wants to touch them with a 10 ft pole and will just pass the patient along to other people. These days, the spectre/possibility of PTSD is raised by one provider, and then they are sent to another provider to 'evaluate for PTSD' or 'R/O PTSD' (passing the buck)--or trauma is just completely ignored as an issue in the patient. Now the unfortunate receiving provider has the unenviable to impossible task of 'proving a negative' or proving they don't have a condition that they are fully motivated to be seen as having and the criteria for which are almost 100% based on self-report. This is a poor fit for a protocol-for-syndrome system of treatment. Under such a system, there is pressure to 'finalize' the categorical diagnosis prior to offering/beginning a course of CBT. This is such a monumental error by our system that creates so much inefficiency in service-delivery it is unreal. So many people just presenting for 'the diagnosis' or to 'document how bad their current symptoms are' and then 'ghosting' the clinic by no-showing or cancelling their way out of treatment is incredibly common these days. And it all seems to be accelerating.

We need to evolve to more of a flexible, transdiagnostic, process-based CBT and case-formulation driven approach that explicitly assesses and addresses patient-side barriers to engagement in progress in therapy (factors related to safety, attendance, engagement, self-monitoring, focus, etc.) as well as a more individualized CBT case formulation-driven approach. We also need to get rid of the monthly supportive therapy sessions forever nonsense and enforce an episode-of-care model mandating weekly sessions (for, say, 10 - 20 weeks).

I'd agree with all of this with one caveat. When you speak of mandating weekly sessions with a supposed limit, what I wouldn't want, and I've heard happens in at least one other VA, is where if someone is "reaching" that limit, you, the psychologist, has to "present" the case to some sort of team to determine if additional care is prudent? That's BS. That's between me and the patient.

 

[Fan_of_Meehl]

I'd agree with all of this with one caveat. When you speak of mandating weekly sessions with a supposed limit, what I wouldn't want, and I've heard happens in at least one other VA, is where if someone is "reaching" that limit, you, the psychologist, has to "present" the case to some sort of team to determine if additional care is prudent? That's BS. That's between me and the patient.

Agreed. I was totally speaking within the context of the practitioner utilizing a 'course' of therapy (one course at a time) approach rather than continuous therapy without end. Weekly therapy doesn't lend itself to 'forever therapy' (which is why we need to do it).

 

[cara susanna]

I'd agree with all of this with one caveat. When you speak of mandating weekly sessions with a supposed limit, what I wouldn't want, and I've heard happens in at least one other VA, is where if someone is "reaching" that limit, you, the psychologist, has to "present" the case to some sort of team to determine if additional care is prudent? That's BS. That's between me and the patient.

Idk, it depends on your team. We have to do that, but our team almost always approves it. There are some practitioners though who need to think more about therapy limits and have conversations with patients even if they are difficult (I doubt any of them are on SDN). I don't think in itself it's a bad idea, but the decision needs to be clinically indicated regardless.

I agree that some EBP rollouts are too strict. I've heard bad things about PE especially.

 

[Fan_of_Meehl]

Idk, it depends on your team. We have to do that, but our team almost always approves it. There are some practitioners though who need to think more about therapy limits and have conversations with patients even if they are difficult (I doubt any of them are on SDN). I don't think in itself it's a bad idea, but the decision needs to be clinically indicated regardless.

I agree that some EBP rollouts are too strict. I've heard bad things about PE especially.

I just think that the whole system would operate FAR more effectively if we focused on solid foundational training on core CBT/professional assessment/ case-formulation/ and case-formulation-driven CBT interventions flexibly utilizing core empirically-supported principles of behavior change (ESP's). The approach that 90%+ of providers/clinics take in my opinion is far too (a) dependent upon 'finalizing the diagnostic determinations/ workup' prior to offering a particular (diagnosis-specific) 'EBP' protocol treatment (by protocol or syndrome) and (b) vulnerable to disruption when the veteran engages in therapy-interfering behavior such as cancelling/no-showing, failing to complete homework exercises, failing to be responsive to therapist attempts to keep them 'on topic' during sessions, or exhibits acting out/ crisis (including self- and other-harm actions), or relapse (if alcohol/drugs are involved). This structure then places pressure on the therapist to either (a) give up and send them back to group and/or monthly check ins, or (b) continue to try to 'salvage' and implement the protocol--once started--for fear of abandoning the structure of the protocol too early--even in the face of the patient appearing not to meet criteria for the disorder (PTSD) upon closer 'inspection' during the attempted implementation of the protocol treatment for that disorder (how many courses of CPT involve the veteran unable to identify or work with stuck points and therefore must be abandoned when it becomes clear that those stuck points either do not exist or the veteran is for some reason unable to identify and express them in the therapy?). I think we need a 'back-to-basics' approach to therapy (in almost all cases, requiring weekly sessions and courses of case-formulation driven therapy utilizing ESP's--Judith Beck has a decent book on this as do authors such as Jesse Wright and David Tolin and countless others). In this approach, say you figure out that the veteran can't identify a thought in their head (or express it) by session 2. Okay, fine, you can then pivot flexibly back to more of a re-orientation phase and help the veteran re-conceptualize and articulate their goals for therapy in cognitive-behavioral terms. Maybe they say, 'I avoid leaving the house, sit with my back to the wall, I never go out eating with my wife,' etc. Fine, we can pivot to an excellent behavioral activation for PTSD cognitive-behavioral workbook--now the 'barrier' of 'I can't identify my stuck points or problematic patterns of thinking'--is effectively nullified and you can continue on for up to 10 more sessions (play out the remainder of 12 weekly scheduled CBT therapy sessions) and the veteran isn't 'off the hook' in terms of committing to weekly therapy focused on doing the work of self-evaluation and self-change. What happens under the current model in such situations (and they are common) is that the EBP protocol is 'abandoned' and the patient goes back into the whole endless supportive groups or monthly therapy approach.

What I am advocating for is for the VA mental health to actually implement their vaunted 'episode of care' model that they love talking about because it sounds good but I see them mostly paying lip service to outside of the highly-structured EBP protocols (PE/CPT/EMDR/CBT-D, CBT-i, etc.). Again, protocols are great and I use them frequently but they are extremely vulnerable to disruption via therapy-interfering behaviors (intentional or unintentional) on the part of the client. This ends up with the situation where the therapy-interfering behaviors on the part of the client are reinforced (to include negative reinforcement of removal of the task demands associated with the formal protocol) and the therapist is maximally stressed out. The alternative flexible CBT approach takes the pressure off of the therapist and places it back squarely on the client (where it should be) to collaboratively but productively continue to work with the therapist to move forward for the remainder of their already-scheduled weekly course/episode of psychotherapeutic treatment.

 

[Fan_of_Meehl]

I'd agree with all of this with one caveat. When you speak of mandating weekly sessions with a supposed limit, what I wouldn't want, and I've heard happens in at least one other VA, is where if someone is "reaching" that limit, you, the psychologist, has to "present" the case to some sort of team to determine if additional care is prudent? That's BS. That's between me and the patient.

The basic approach that I have implemented myself (and would advocate for would be):

1) the scheduling/ rescheduling is totally under the control of the provider (in consultation with the patient), I am NOT in any way/shape/form advocating for some sort of supervisory, 'committee-based,' or third-party review of this decisionmaking--this would be re-engaging in the original systems-level design mistake of thinking that the people not doing the therapy are somehow in a superior position to make this sort of decision
2) I would take the approach that, at the end, say, of our 12 session course of weekly CBT even if NO progress had been made and I still have the availability to immediately re-schedule them for another course of 12 weekly CBT psychotherapy sessions and the veteran is willing to do so with at least the intention of working actively with me (even if we are still struggling with stabilization/safety, motivational interviewing, goal-setting, psychoeducation, whatever) then we would immediately do so (with no delay). If I have availability, why not? Otherwise, however, they go to the 'back of the line' and I reschedule them for the next available series of 12 weekly appointments with me--whether that is in one month, three months, or six months from now. They had their 'episode-of-care' opportunity with me and what happened during that attempted episode of care with me has been amply and honestly documented in their medical record at that point. I will be here for them to try again as soon as they can get back in for that 12 week series to try, try again.

My contention is (and I have the data to prove it, but it isn't listened to) that the above approach is far and away more 'efficient' in terms of appropriately moving psychotherapy clients through our system. We are talking about an a posteriori ('evidence-based,' and results-based) form of reasoning rather than an a priori (prior to and ignorant of actual results) approach that dominates our mental health systems design processes.

I am about ready to recommend that we hire/ detail a literal plumber to head up VA mental health planning at the systems-design level (or at least give one serious authority to apply their consultative expertise on hydrodynamics).

This is because NOBODY applies the common-sense level analysis of the reality of 'in-flow' vs. 'out-flow' (per unit time) to individual provider caseloads or clinics. At minimum, the friggin 'outflow' has to be at or higher than the cumulative 'inflow' of cases or you end up drowning and backing everything up. When the damn water level is about to rise over your head, if you're a plumber, the main priority involves paying attention to this inflow/outflow relationship. Nobody is doing that these days or they are doing it in an a priori approach of what sounds good in principle to those who aren't in the middle of the flooded basement (providers) furiously trying to keep from drowning while working on the out of control system.

- 'We need to run more groups....just do more/bigger groups. That will solve it. [does it? is anyone actually testing this theory empirically? I see plenty of people 'hide' in groups and just come out of groups days/weeks later still presenting for 'more therapy' (I'm not better yet)]

- 'We need providers to do more EBP's' (assuming that we're not already trying to do that with everyone who will agree to them)

- 'We need to find the 'right diagnosis,' the 'right clinic,' the 'right syndrome/category,' prior to actually having the person scheduled for an actual episode-of-care involving weekly therapy and accountability' [again, empirically, I've yet to see this 'work' or 'solve' the access issues]

 

[Therapist4Chnge]

Until the VA leadership is ready to have some serious conversations about service-connection, PTSD, and how clinicians are not empowered to make the necessary changes to assist their Veterans...it's all just throwing everything into a pot and then getting angry that "something is just off" about the results.

I only spent a year in the VA system for internship, and I basically went rogue for my out-pt therapy rotation and it worked. I took a caseload full of Axis-II Veterans and fired most of them after ~8 sessions if they did not demonstrate adequate engagement and/or exhibit some amount of improvements. The clinic staff was shocked that I could fire Veterans as an intern, but I set clear boundaries about who was allowed to be scheduled in my clinic. I would allow for the Veteran to "re-apply" to see me after ~6 weeks of consistent group attendance. Every Veteran I saw in groups knew I would drop them if they tried to BS me, and most respected me for calling anyone out on their ****. I definitely would not have lasted in the system because I know my supervisors shielded us from some of the politics, so I know it was a bit of an odd situation. This was also during the Before Times of pre-COVID and pre-Pedo President.

It was interesting for my supervisor (DOCT) to see the results. Part of my deal with her was to cram in all of my out-pt therapy hours in prior to the Spring bc I was a neuropsych, with a neuropsych mentor who was drowning in assessments, and I pitched a plan that was mutually beneficial for all. I took the "problem" Veterans who ran through the rest of the permanent clinical staff, along with some rando Veterans to meet the case requirements for CPT and PET, and actually got a few off of caseloads for good. I don't claim to have improved everyone, but those who stuck around improved (relative to where they were), and some had very meaningful improvements; the rests weren't going to improve regardless of what I tried.

 

[Sanman]

The basic approach that I have implemented myself (and would advocate for would be):

1) the scheduling/ rescheduling is totally under the control of the provider (in consultation with the patient), I am NOT in any way/shape/form advocating for some sort of supervisory, 'committee-based,' or third-party review of this decisionmaking--this would be re-engaging in the original systems-level design mistake of thinking that the people not doing the therapy are somehow in a superior position to make this sort of decision
2) I would take the approach that, at the end, say, of our 12 session course of weekly CBT even if NO progress had been made and I still have the availability to immediately re-schedule them for another course of 12 weekly CBT psychotherapy sessions and the veteran is willing to do so with at least the intention of working actively with me (even if we are still struggling with stabilization/safety, motivational interviewing, goal-setting, psychoeducation, whatever) then we would immediately do so (with no delay). If I have availability, why not? Otherwise, however, they go to the 'back of the line' and I reschedule them for the next available series of 12 weekly appointments with me--whether that is in one month, three months, or six months from now. They had their 'episode-of-care' opportunity with me and what happened during that attempted episode of care with me has been amply and honestly documented in their medical record at that point. I will be here for them to try again as soon as they can get back in for that 12 week series to try, try again.

My contention is (and I have the data to prove it, but it isn't listened to) that the above approach is far and away more 'efficient' in terms of appropriately moving psychotherapy clients through our system. We are talking about an a posteriori ('evidence-based,' and results-based) form of reasoning rather than an a priori (prior to and ignorant of actual results) approach that dominates our mental health systems design processes.

I am about ready to recommend that we hire/ detail a literal plumber to head up VA mental health planning at the systems-design level (or at least give one serious authority to apply their consultative expertise on hydrodynamics).

This is because NOBODY applies the common-sense level analysis of the reality of 'in-flow' vs. 'out-flow' (per unit time) to individual provider caseloads or clinics. At minimum, the friggin 'outflow' has to be at or higher than the cumulative 'inflow' of cases or you end up drowning and backing everything up. When the damn water level is about to rise over your head, if you're a plumber, the main priority involves paying attention to this inflow/outflow relationship. Nobody is doing that these days or they are doing it in an a priori approach of what sounds good in principle to those who aren't in the middle of the flooded basement (providers) furiously trying to keep from drowning while working on the out of control system.

- 'We need to run more groups....just do more/bigger groups. That will solve it. [does it? is anyone actually testing this theory empirically? I see plenty of people 'hide' in groups and just come out of groups days/weeks later still presenting for 'more therapy' (I'm not better yet)]

- 'We need providers to do more EBP's' (assuming that we're not already trying to do that with everyone who will agree to them)

- 'We need to find the 'right diagnosis,' the 'right clinic,' the 'right syndrome/category,' prior to actually having the person scheduled for an actual episode-of-care involving weekly therapy and accountability' [again, empirically, I've yet to see this 'work' or 'solve' the access issues]

This is a complaint as old as time for the VA. Providers were cherry picking patients for their caseloads decades ago. You're right about lack of measurement being the main issue with access.

 

[cara susanna]

This new privacy training post-test is RIDICULOUS.