Here is a nice breakdown of some of the different factors:
www.apa.org
This. Especially the last part. Have you SEEN some of the stuff on tictok and snapchat related to DID? It's like a steroid for cluster b.
No I’ve been too scared to go on tik tok (the endless videos freak me out) and people still use snapchat?? I thought that went away in college.
whether demand outstrips supply is a policy decision, not a built in feature of a single payer (medicare) or socialized (VA) system. There is no reason as a society that we can't both provide mental health care for all, and ensure that there is adequate staffing. Private insurances do whatever they can to limit access to care, unless they are stopped by policy decisions (e.g. MH parity). Its all about budgets and priorities.
Agreed.
I tell you what would be a legitimate (and good) 'policy decision' regarding 'supply and demand' of therapists in a system (and maybe this is what JustNoticing was meaning, I dunno): To intelligently reallocate existing staff duties (or hire additional staff) to meet the actual demand for services within the organization. For example, instead of having a great number of 'mental health line' positions be positions where licensed providers don't actually have to see patients for mental health services but--rather--spend most of their time e-mailing, sitting in meetings, doing the 'chores' of their higher ups, and playing on their iPhones...have these people (with LCSW's or other 'clinical' degrees and licenses) actually see some patients even if it is just a 1/2 or 1/4 caseload...THAT would be a good 'policy decision' that would, indeed, appropriately address 'supply and demand' issues for therapists in that organization. For myriad reasons (we could write books about) that will NEVER happen in such systems due to the screwed up motivational structures of the individuals hand-picked to be promoted in such systems. What ACTUALLY HAPPENS in such systems is that whenever demand exceeds supply (e.g., clinics are too clogged with patients) the only two responses from leadership are: (1) bitch out the providers (blame the providers) for having too large a caseload and not waving magic wands to cure everybody and convince people that they don't need or have a right to their 'free' psychotherapy services; and/or (2) sit in meetings coming up with 'brilliant' ideas and closing down clinical positions to fund non-clinical positions to help them out with their PR campaigns to implement their non-solutions like pom-pom waving, slogan-infused, PR campaigns to publicly signal how virtuous and saintly and hard working they are in 'addressing' the problem of patients not feeling that they are getting what they need. #BeThere #WeAreAllInThisTogether
The VA answer, of course, is to create a "Patient Access Champion" to wax philosophical on ways in which existing providers can cram in more patients. Who needs a whole 30 minutes for lunch anyway?
I have had a high deductible plan with an HSA for years. At first, I didnt like it but the truth is I really wasn’t paying medical bills ever anyway. A couple doctor visits over the course of my life and some labs every year or so to make sure my cholesterol is still too high although I haven’t had a blood test since I switched to a plant based diet so curious about that. My main reason for health insurance is so I don’t go bankrupt when I eventually do have a big medical expense.
not creating incentives/programs to train more mental health providers or make it an appealing profession that people want to go into are absolutely policy decisions. Just as how we treat teachers are policy decisions.
So here's what I think is wrong with this assessment since I've been in a first-line leadership position, albeit non-VA. I do agree that a small caseload is a good thing for leaders to have, but when that caseload is too big, like 1/2 the time, you end up with mandatory meetings and patient care all interspersed with each other in maddening little patches of time, because lower management doesn't control the meeting times. So a day might look like this: 9-10 patient, 10-11 meeting, 11-12 patient, 12-1 meeting, 1-4 patients, 4-5 administrative time. It makes it almost impossible to sit down and really think through clinic function. And being in first-line leadership is tough because the real heft of the decision-making isn't allowed at that level. The administrative stuff and weirdness is definitely not just a VA thing although I recognize that your frustrations are about the VA because you work there. But this chain of command stuff is across the board in private hospitals as well. That said, the leaders in these positions aren't necessarily just doing what they do because they are innately terrible people. There's pressures on them to do things (work miracles) that are impossible. The pressure comes from their management and also the public eye. To take it back to the VA, this running narrative of Veterans always being the victims gets exhausting, I recall, from the time I did work there. I remember a conversation about the sheer amount of money that got wasted from them no-showing to things like colonoscopies that required multiple teams of expensive providers to be present. There's an episode of Scrubs (or maybe multiple) that pitches Dr. Cox and Dr. Kelso against each other. Earlier on it's always Dr. Cox who is the hero, doing unauthorized procedures on patients, while Dr. Kelso is the the demon who won't pay for stuff. But the reality is that someone has to be responsible for the money of it all. Someone has to be responsible for the "optics" of it all. I'm not saying that people aren't self-serving, but it's not the whole picture.
Yeah...I wasn't saying that I think that the service chiefs (a.k.a. the department heads) necessarily need to carry a half-caseload or more of clients. I was speaking more to all the 'Champion This' and 'Champion That' BS bureaucratic positions that are proliferating at an alarming rate within the VA system while actual clinical positions are being eliminated (or not filled and allowed to just expire). At our facility, there are TONS of LCSW's who are in non-clinical BS positions who could be seeing patients. That's more of what I was talking about.
Yeah I don’t know anything about the non-clinical positions in the VA, having been out of the system for five years I think at this point.
My perspective is whatever that saying is, something like you’re not stuck in traffic, you are the traffic. I also think we should not commit the fundamental attribution error when looking at the leadership of an organization: we do not see the context. And I can tell you that in my position I have frequently felt frustrated, angry, and overwhelmed at the higher level decision making that seems to make no sense to me. But I can also see my staff feeling upset at some decisions, but not understanding the context and I can’t explain the context because it violates the privacy of another employee, for example. The combination of the two leads me to the conclusion that we should never say that we know the “reality” of a situation. I left the VA because I was being held back from growing in my career. That I DID know, and I see myself as responsible to the best degree possible for my career satisfaction. If my current job gets bad, I will absolutely jump ship again.
I tell my clients who are creative that the critics are always wrong, but that is about art and music not healthcare delivery systems. 😁
