A Leadership Fetish

[smalltownpsych]

So many smart things being said in these recent posts. I love psychologists! The comment about how actual delivery of services leads to humility was so spot on and I had not really thought about that before so really appreciate that one. I also agree that having non-clinicians provide support services is smart as well. It can also lead to problems though and these people need close oversight with effective clinicians in order to maximize efficacy and minimize harm. I know this well since this is an area of lots of experience for me and one thing I am doing now is using MA students to do this role. They get good experience and begin to learn difference between psychotherapy and supportive roles and how to walk that line effectively and they are relatively inexpensive.

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[JawlessPiano]

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[Shiori]

Yeah, I feel like the consult process for the general mental health clinic is very nebulous. I have seen people who are stressed about moving. It doesn't feel like a great use of resources and I end up doing a very fancy, hand-wavy version of "you're supposed to feel stuff" supportive therapy.

 

[cara susanna]

Yeah, I feel like the consult process for the general mental health clinic is very nebulous. I have seen people who are stressed about moving. It doesn't feel like a great use of resources and I end up doing a very fancy, hand-wavy version of "you're supposed to feel stuff" supportive therapy.

Yeah, a lot of people don't need long-term therapy. I've even had intakes with people who were feeling better by the time they actually saw me (because our intakes often book months out).

 

[summerbabe]

I've even had intakes with people who were feeling better by the time they actually saw me (because our intakes often book months out).

No treatment condition ftw!

 

[Fan_of_Meehl]

There is a bigger issues that none of these advocates can ever handle. I do agree that the VA cannot just hire their way out of access issues. The bigger problem is setting consistent limits on patient usage. However, that is politically unpalatable. Alternatively, fire the mental health advocate and hire a paraprofessional to screen out all the garbage consults.

I'd say that it isn't just politically unpalatable/impractical...the way that the policies and procedures are written and enforced IT IS ABSOLUTELY IMPOSSIBLE. With the 'same day access' policy/procedure guarantee...so what if I 'terminate' with a veteran and process 'discharge paperwork.' The next morning (or week) they'll just walk up to the clinic desk and ask to see me and be plugged right into my clinic grid. 'Termination' is absolutely meaningless as a concept and utterly un-enforceable as a boundary in VA mental health systems. I can't even simply ALLOW a veteran to passively drop out of therapy by no-showing. I am REQUIRED (with friggin AUDITS) to place three calls and a letter and document everything no matter how insignificant the treatment need/acuity, no matter how many times I have been forced to engage in these ridiculous no-show followup stereotypies, etc. We are given no CHOICE to 'hold patients accountable.' Meanwhile, there are no co-pays, no no-show fees/penalties or any other natural consequences that the entirety of MH systems outside of VA enforce every day. Sorry to vent...not venting AT you...just had a particularly stressful day and these issues really burn me up, lol.

 

[Fan_of_Meehl]

Everyone hears that certain graduate schools look for “leadership”. Because of this, people will try to bring it up in interviews and may just use term from there

I would just add that the number one neglected 'leadership' competency is actually knowing what the f*&^ you're doing, lol. Unfortunately, that takes years of front-line experience and work to develop.

 

[Fan_of_Meehl]

No treatment condition ftw!

Spontaneous remission is a helluvan ally.

 

[Sanman]

I'd say that it isn't just politically unpalatable/impractical...the way that the policies and procedures are written and enforced IT IS ABSOLUTELY IMPOSSIBLE. With the 'same day access' policy/procedure guarantee...so what if I 'terminate' with a veteran and process 'discharge paperwork.' The next morning (or week) they'll just walk up to the clinic desk and ask to see me and be plugged right into my clinic grid. 'Termination' is absolutely meaningless as a concept and utterly un-enforceable as a boundary in VA mental health systems. I can't even simply ALLOW a veteran to passively drop out of therapy by no-showing. I am REQUIRED (with friggin AUDITS) to place three calls and a letter and document everything no matter how insignificant the treatment need/acuity, no matter how many times I have been forced to engage in these ridiculous no-show followup stereotypies, etc. We are given no CHOICE to 'hold patients accountable.' Meanwhile, there are no co-pays, no no-show fees/penalties or any other natural consequences that the entirety of MH systems outside of VA enforce every day. Sorry to vent...not venting AT you...just had a particularly stressful day and these issues really burn me up, lol.

Only option...have a kid and take your 3 months parental leave in the hopes that the riff raff forget about you and drop off your caseload.

 

[cara susanna]

I'd say that it isn't just politically unpalatable/impractical...the way that the policies and procedures are written and enforced IT IS ABSOLUTELY IMPOSSIBLE. With the 'same day access' policy/procedure guarantee...so what if I 'terminate' with a veteran and process 'discharge paperwork.' The next morning (or week) they'll just walk up to the clinic desk and ask to see me and be plugged right into my clinic grid. 'Termination' is absolutely meaningless as a concept and utterly un-enforceable as a boundary in VA mental health systems. I can't even simply ALLOW a veteran to passively drop out of therapy by no-showing. I am REQUIRED (with friggin AUDITS) to place three calls and a letter and document everything no matter how insignificant the treatment need/acuity, no matter how many times I have been forced to engage in these ridiculous no-show followup stereotypies, etc. We are given no CHOICE to 'hold patients accountable.' Meanwhile, there are no co-pays, no no-show fees/penalties or any other natural consequences that the entirety of MH systems outside of VA enforce every day. Sorry to vent...not venting AT you...just had a particularly stressful day and these issues really burn me up, lol.

Yeah, I actually asked my supervisor why I should bother to enter treatment completion notes if they apparently don't do anything.

 

[PsyDr]

Wait, do they give you a CPT RVU for making these calls and letters?

 

[WisNeuro]

Wait, do they give you a CPT RVU for making these calls and letters?

 

[Sanman]

Wait, do they give you a CPT RVU for making these calls and letters?

 

[PsyDr]

Is it something covered under admin time?

Or is this something that falls under: we expect you to account for every minute of your day, but you're not allotted any time to do this work.

Has anyone tried: "This is not within the scope of my profession"

 

[WisNeuro]

Is it something covered under admin time?

Or is this something that falls under: we expect you to account for every minute of your day, but you're not allotted any time to do this work.

Has anyone tried: "This is not within the scope of my profession"

The Powers That Be in Regional Office and higher at the VA care not for your attempt at logic!

 

[Sanman]

Is it something covered under admin time?

Or is this something that falls under: we expect you to account for every minute of your day, but you're not allotted any time to do this work.

Has anyone tried: "This is not within the scope of my profession"

So, this would technically be covered under admin time as the average employee is like 0.9 clinical for a 1.0 FTE. However, no one really does the proper labor mapping to figure out the admin needs. Heck, a few of us in the same position have different (0.8-0.9 clinical time) amounts for admin time for the same job at the same facility.

 

[Fan_of_Meehl]

So, this would technically be covered under admin time as the average employee is like 0.9 clinical for a 1.0 FTE. However, no one really does the proper labor mapping to figure out the admin needs. Heck, a few of us in the same position have different (0.8-0.9 clinical time) amounts for admin time for the same job at the same facility.

If they followed their own rules on labor mapping, things like conferring with colleagues on cases, hitting the literature, reviewing / interpreting test results, etc. are all supposed to be factored into CLINICAL time, not ADMIN time. They don't even read their own rules.

 

[AcronymAllergy]

Is it something covered under admin time?

Or is this something that falls under: we expect you to account for every minute of your day, but you're not allotted any time to do this work.

Has anyone tried: "This is not within the scope of my profession"

Yep, as others have said, it's technically covered under admin time, with most FT clinicians being mapped for about 90% of their time for patient care. That being said, VA is notorious for never providing enough admin time in the face of ever-increasing administrative burden. I would say it was the norm rather than the exception that folks stayed late to finish notes. And not just in mental health. At my last VA, primary care providers probably had it the worst in terms of needing to stay late multiple hours. Even the neurologist would stay late multiple hours per day, and apparently when he told this to his supervisors in an attempt to figure out a solution, he was told he wasn't working hard enough. He left soon after.

VAs also universally seem to be short on space, but are also seemingly highly-resistant to viable solutions (e.g., allowing more telework so that one office could "house" two or three different providers).

 

[cara susanna]

Yup, a lot of the therapists in our clinic do documentation and other admin work outside VA hours. I am not one of them, but I am 1) very efficient 2) consider "done" to be more important than "good" 3) do the bare minimum for certain administrative requirements that I don't deem clinically useful or relevant and 4) have more admin time due to other responsibilities. Oh, and I'm also very stringent about session length and always try to end session before the hour is up to give time for documentation. I think that's a big factor, from what I've seen the people who are drowning are the ones who go up to the full hour or even a few min after.

 

[PsyDr]

I'm just surprised that no one says, "That is not something covered under my license, or scope of practice. You hired me as a psychologist, not a clerk." You keep allowing that stuff, you'll be sweeping the floors eventually.

Then again, it's not like I know much about being an employee.

 

[Fan_of_Meehl]

I'm just surprised that no one says, "That is not something covered under my license, or scope of practice. You hired me as a psychologist, not a clerk." You keep allowing that stuff, you'll be sweeping the floors eventually.

Then again, it's not like I know much about being an employee.

I already sweep floors, remove trash, dust, and I even had to clean the toilet myself in my last office that had a private bathrooom.

 

[Sanman]

I'm just surprised that no one says, "That is not something covered under my license, or scope of practice. You hired me as a psychologist, not a clerk." You keep allowing that stuff, you'll be sweeping the floors eventually.

Then again, it's not like I know much about being an employee.

Plenty of people say these things. It is simply that usually no one cares what they are saying. At the end of the day, the only thing that matters is who is doing a performance review and what they happen to care about that day. The only real choice an employee has is quit or do not quit. That is why I am a big proponent of things like Psypact. Even if you dislike telehealth and never use it a day in your life, being able to setup a telehealth practice from your home is leverage.

 

[PsyDr]

I already sweep floors, remove trash, dust, and I even had to clean the toilet myself in my last office that had a private bathroom.

Sadly, I can't tell if you are serious or not.

Plenty of people say these things. It is simply that usually no one cares what they are saying. At the end of the day, the only thing that matters is who is doing a performance review and what they happen to care about that day. The only real choice an employee has is quit or do not quit. That is why I am a big proponent of things like Psypact. Even if you dislike telehealth and never use it a day in your life, being able to setup a telehealth practice from your home is leverage.

I'm guessing it's a reciprocal problem, with people agreeing to do menial tasks to avoid getting in trouble at work, and then work assigning increasingly more menial tasks because of the lower prestige. There's probably some limit to this system, because I doubt they're getting neurosurgeons to do that. But neurology is.

 

[AcronymAllergy]

I'm just surprised that no one says, "That is not something covered under my license, or scope of practice. You hired me as a psychologist, not a clerk." You keep allowing that stuff, you'll be sweeping the floors eventually.

Then again, it's not like I know much about being an employee.

Unfortunately, like Sanman said, it's less that people don't say it (which they, at times very vocally, did) as it is management either not caring or not being able to do anything about it. Anytime providers would try to push back and give some of these tasks to the clerks, the clerks (whose leadership, in my experience, had disproportionate amounts of power in VA and also automatically rejected ever being given "new" tasks) said no, and that was the end of it.

VA also stipulates per SOPs that some of these duties are, for some reason, the responsibility of the licensed independent provider.

Some of the requirements are greater for MH than other specialties (like for no-shows).

There were some things people pushed back on. For example, I pushed back anytime leadership tried to tell me how to practice (e.g., by telling me how my scheduling grid should be structured), or by trying to compromise the training experience of trainees. For other things, like moving furniture, cleaning your office, or (sometimes) rescheduling patients, it was often easier to do it yourself rather than navigate the tortuous process of formally entering a request.

 

[Fan_of_Meehl]

I already sweep floors, remove trash, dust, and I even had to clean the toilet myself in my last office that had a private bathrooom.

With the bathroom whoever 'assihned' would either:

A) come by my office and disturb me right at the beginning of my shift EVERY single morning to fully clean it and try to pull me into lengthy conversations/ visits when I was trying to finalize prep for my 1st patient (that is, when they wouldn't be knocking on my door DURING sessions expecing me, I guess to have a 15 min intermission in treatment while they clean the bathroom...I mean, we wouldn't want to inconvenience the janitors, would we?)

Or

B) they would go MONTHS without ever cleaning the bathroom despite my repeated emails up and down the chain of command. I can't tell you how many times I asked them if they couldn't just, you know, clean it once or twice a week (didn't need a daily full cleaning) or at least once a month. Of course I ended up buying and bringing in my own toilet cleaning supplies but I never knew if/when they were going to come by and clean it. Also bought my own vacuum cleaner for the carpet (Dirt Devil, lol). We spent an entire year dealing with the bald faced lie that they 'didn't have the key' to get into my office.

 

[Sanman]

I already sweep floors, remove trash, dust, and I even had to clean the toilet myself in my last office that had a private bathrooom.

I mean me too. However every time I complain and say that it is not in my scope of practice, my wife just shoots me a dirty look and tells me it is (I work from home people)!

 

[chicandtoughness]

Yeah. Some of the low intensity 'telephone coaching' and smartphone apps interventions have their place/utility in therapy but they will never replace actual therapists for our population for MANY reasons.

I saw this and couldn't resist, one of the hills I will die on. BetterHelp, TalkSpace, all of these silly online Telehealth apps run by Silicon Valley VC firms with no background in mental health services... I hate it. HATE IT.

The mental health leadership fetish is actually the reason why I'm leaving this field and going into pure clinical work.

 

[R. Matey]

I saw this and couldn't resist, one of the hills I will die on. BetterHelp, TalkSpace, all of these silly online Telehealth apps run by Silicon Valley VC firms with no background in mental health services... I hate it. HATE IT.

The mental health leadership fetish is actually the reason why I'm leaving this field and going into pure clinical work.

For this, the Onion is a decent salve: 15-Year-Old Finds Summer Job As BetterHelp Therapist

 

[bcliff]

I've never set foot in a VA so I'll take your word for it, but I have definitely seen waste in individual therapy at the places I've worked as well and I do wonder if a stronger commitment to EPBs would limit this. That said, I think people want supportive therapy even after acute symptom remission and it's hard to figure out who's going to pay for it.

IMO, working with people who have made progress and are doing well to exit therapy (of their own volition) and more fully engage in their own lives and their own reciprocal relationships is a really important skill that we offer -- I don't think it's that different than a physician decreasing or discontinuing a medication (e.g., wanting to be in therapy forever is different than needing to be in therapy forever).

To that effect, I think that some well meaning providers, possibly with relatively less training and confidence in their clinical decision making, may be more likely to keep patients in therapy unnecessarily -- While limiting access for other patients, I can also imagine supportive therapy ad infinitum iatrogenically impeding a patient's interest and ability in navigating the give-and-take of typical, reciprocal social relationships (e.g., my therapist doesn't care if I don't ask them how their day is going).

ETA: I previously worked in the VA and am grateful to have already forgotten how encouraging the system is of perpetual psychotherapy. 🙃

 

[R. Matey]

IMO, working with people who have made progress and are doing well to exit therapy (of their own volition) and more fully engage in their own lives and their own reciprocal relationships is a really important skill that we offer -- I don't think it's that different than a physician decreasing or discontinuing a medication (e.g., wanting to be in therapy forever is different than needing to be in therapy forever).

To that effect, I think that some well meaning providers, possibly with relatively less training and confidence in their clinical decision making, may be more likely to keep patients in therapy unnecessarily -- While limiting access for other patients, I can also imagine supportive therapy ad infinitum iatrogenically impeding a patient's interest and ability in navigating the give-and-take of typical, reciprocal social relationships (e.g., my therapist doesn't care if I don't ask them how their day is going).

Separate this point from the need to treat subacute residual symptoms or provide what used to be thought of as 'counseling' (e.g., navigating a difficult relationship and so on). It's a tough balance because you don't want to foster dependence in the therapeutic relationship, as you're describing, but discharging just because the protocol is done isn't necessarily the best care either, especially if the patient is continuing to express concerns. I'd wager this is less of an issue in private practice than in healthcare systems where there is pressure to get folks through the fun house because the customers are waiting.

That said, I have seen a lot of therapists hold on treated patients because of counter-transference issues, which I would agree that helps no one.

 

[bcliff]

Separate this point from the need to treat subacute residual symptoms or provide what used to be thought of as 'counseling' (e.g., navigating a difficult relationship and so on). It's a tough balance because you don't want to foster dependence in the therapeutic relationship, as you're describing, but discharging just because the protocol is done isn't necessarily the best care either, especially if the patient is continuing to express concerns. I'd wager this is less of an issue in private practice than in healthcare systems where there is pressure to get folks through the fun house because the customers are waiting.

That said, I have seen a lot of therapists hold on treated patients because of counter-transference issues, which I would agree that helps no one.

Yes -- Dosing is important, and, you're right, I can imagine a scenario where a patient may be "under-dosed" (e.g., you're eight sessions are done, get out of here). In my experience, though, I've more often encountered the inverse of "over-dosing" (e.g., you were in a car accident 5 years ago and therefore need to be in therapy for the rest of your life). The caveat to this would be institutions, like university CAPS, where patients are limited to x number of visits.

 

[R. Matey]

I've more often encountered the inverse of "over-dosing" (e.g., you were in a car accident 5 years ago and therefore need to be in therapy for the rest of your life). The caveat to this would be institutions, like university CAPS, where patients are limited to x number of visits.

For sure--especially when there is a disability claim involved. An issue for any system though is overloading providers to the point where the therapeutic dose is spaced out two or more weeks. I'd wager that doing so likely propagates unnecessarily long treatment schedules (and consequently wait times) because treatment may not be effective at that schedule.

 

[WisNeuro]

For sure--especially when there is a disability claim involved. An issue for any system though is overloading providers to the point where the therapeutic dose is spaced out two or more weeks. I'd wager that doing so likely propagates unnecessarily long treatment schedules (and consequently wait times) because treatment may not be effective at that schedule.

Or any general litigation. The "concussion clinic" business model is built around iatrogenesis and unnecessary treatment. There is no reason uncomplicated concussions need 1.5+ years of OT/SLP/psych/etc care. We have one especially bad one here where teh neuropsych community jokes "XXXXX Healthcare Concussion clinic, where concussions turn into total disabilities!"

 

[singasongofjoy]

Yeah....I didn't even know what DEI was until about a month or so ago when it gained popular media/social media attention. Evidently someone recently told me they plan to stick a "J" at the end of DEI for "justice." Again....changing up them terms will absolutely lead to those changes they so badly want to appear to be doing.

Nah, they just want an excuse to use the acronym JEDI

 

[quickpsych]

I thought I was losing it for a while, especially when pre-licensed. Had plenty of "middle managers" almost always freshly licensed LSCWs who went on and on about how their "dream" was to be a manager, supervisor, higher up, and "making it." I don't see it as much at the doctoral level but I do see a lot of doctoral level practitioners being "lead" by these green LSCWs. Nothing against LSCWs, I've worked with and trained with some truly great ones. But damn , in the past 5-6 years it's like so many want to "lead" and scoff at any direct clinical work. I've even been asked when I'm "moving up to management" somewhere...I'm good.

 

[erg923]

I thought I was losing it for a while, especially when pre-licensed. Had plenty of "middle managers" almost always freshly licensed LSCWs who went on and on about how their "dream" was to be a manager, supervisor, higher up, and "making it." I don't see it as much at the doctoral level but I do see a lot of doctoral level practitioners being "lead" by these green LSCWs. Nothing against LSCWs, I've worked with and trained with some truly great ones. But damn , in the past 5-6 years it's like so many want to "lead" and scoff at any direct clinical work. I've even been asked when I'm "moving up to management" somewhere...I'm good.

Like button, thumbs up, check mark or whatever the hell it is now.....

 

[smalltownpsych]

I thought I was losing it for a while, especially when pre-licensed. Had plenty of "middle managers" almost always freshly licensed LSCWs who went on and on about how their "dream" was to be a manager, supervisor, higher up, and "making it." I don't see it as much at the doctoral level but I do see a lot of doctoral level practitioners being "lead" by these green LSCWs. Nothing against LSCWs, I've worked with and trained with some truly great ones. But damn , in the past 5-6 years it's like so many want to "lead" and scoff at any direct clinical work. I've even been asked when I'm "moving up to management" somewhere...I'm good.

People like this are why I started my own company. To tie into other thread, I think I have to add social workers to my list right under dogwalkers. 😂
Seriously though, I just hired an MSW intern yesterday so we’ll see how that works out. I could probably use a little management support especially as my business grows, but definitely need clinical skills and expertise to develop first.

 

[quickpsych]

People like this are why I started my own company. To tie into other thread, I think I have to add social workers to my list right under dogwalkers. 😂
Seriously though, I just hired an MSW intern yesterday so we’ll see how that works out. I could probably use a little management support especially as my business grows, but definitely need clinical skills and expertise to develop first.

At least you have the chance to help that intern not become dog walker level. Mold them and help them. I didn't even realize social workers existed that did talk therapy until I was in my first practicum. Then I started realizing , esp LCSWs, really moved in on the mental health scene. Whoever is their representing group/organization they've done a great PR and marketing job to insurances, healthcare facilities, and government contracts. A lot of these folks seem unable to stay in a lane. The best managing ones are the ones who don't tell others how to do their jobs. I always feel bad for LPCs, they basically got run out of town. I was advised when I finished my Masters that if I was pursing my doctorate to not even bother with getting my LPC if I was confident I was going to finish and be licensed as a psychologist. Met plenty of good LCSWs who said when they were deciding, they were steered to social work instead of counseling (or psychology related masters). Quite a few, those with self awareness, would talk about how they felt they were often flying by the seat of their pants in therapy work and really learned more from others in the field than school or from other social workers.

 

[chicandtoughness]

At least you have the chance to help that intern not become dog walker level. Mold them and help them. I didn't even realize social workers existed that did talk therapy until I was in my first practicum. Then I started realizing , esp LCSWs, really moved in on the mental health scene. Whoever is their representing group/organization they've done a great PR and marketing job to insurances, healthcare facilities, and government contracts. A lot of these folks seem unable to stay in a lane. The best managing ones are the ones who don't tell others how to do their jobs. I always feel bad for LPCs, they basically got run out of town. I was advised when I finished my Masters that if I was pursing my doctorate to not even bother with getting my LPC if I was confident I was going to finish and be licensed as a psychologist. Met plenty of good LCSWs who said when they were deciding, they were steered to social work instead of counseling (or psychology related masters). Quite a few, those with self awareness, would talk about how they felt they were often flying by the seat of their pants in therapy work and really learned more from others in the field than school or from other social workers.

All of this, 100%. I honestly regret getting my LPC/LMHC and not going the social work route. The therapy training is poor in all the programs, but the social work lobby has done wonders for its profession, especially in certain states. I couldn't even get hired in many inpatient facilities in Massachusetts because they were explicit about only hiring LCSWs and not LMHCs. This wasn't an HR quirk either - I would interview with the clinical supervisor and they would discover I had the wrong license and then, "Oh... sorry... this is for LCSWs only, no exceptions, sorry."

 

[albatross_at_crossroads]

Nah, they just want an excuse to use the acronym JEDI

Ha! I actually like this acronym and my university uses it. Seems to catch on pretty fast, and it's easier to say quickly compared to others.