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

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Sanman said:
What is the treatment plan for veteran continually avoids psychotherapy sessions when given concrete goals that he needs to meet and then reschedules for a few weeks later attempting to avoid discussion of said goals. However, I can't discharge him because he remains on our primary care team, so he or his wife will just call me in crisis a few weeks later anyway if not followed regularly.
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Many such cases at VA. Hierarchy of goals:

1) safety: keep veteran from killing himself or others and/or going to prison
2) therapy attendance: good faith effort to engage in discussion/px-solving around attendance
3) therapy engagement: attempt motivational interviewing around ambivalence toward bx change; socialization to psychotherapy process

Sounds like half my caseload, the portion I refer to as 'hanging around the doorsteps of therapy (or pretending to) but not coming inside.'

As far as how the MHS overlords want that written up I have no clue, lol
 
Fan_of_Meehl said:
Many such cases at VA. Hierarchy of goals:

1) safety: keep veteran from killing himself or others and/or going to prison
2) therapy attendance: good faith effort to engage in discussion/px-solving around attendance
3) therapy engagement: attempt motivational interviewing around ambivalence toward bx change; socialization to psychotherapy process

Sounds like half my caseload, the portion I refer to as 'hanging around the doorsteps of therapy (or pretending to) but not coming inside.'

As far as how the MHS overlords want that written up I have no clue, lol
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Indeed. Already engaging in steps 1-3 as I inherited this dude (and a few others) since I took this position a few years ago. Problem was created long before I got there when everyone decided giving people with PTSD who are agoraphobic a monthly stipend and access to a medical team who comes to your home was a good idea. The VA just does not seem to like it if I documented that.
 
Fan_of_Meehl said:
I actually have had a couple of clients (who were at the point of retirement) say their goal for psychotherapy was 'to get my disability up to 100% so I can make it financially.' Fun sessions.
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Whenever I hear that I always think "oh, I'm so glad you're seeing me for therapy then!"

Also, I didn't know the person Sanman is discussing would be eligible for CG support. Here, at least, the criteria aren't easy to meet.
 
cara susanna said:
Whenever I hear that I always think "oh, I'm so glad you're seeing me for therapy then!"

Also, I didn't know the person Sanman is discussing would be eligible for CG support. Here, at least, the criteria aren't easy to meet.
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No idea how he and his wife got it. She even works and receives CG support funds. The most functional person I have ever seen receive it. FYI, he knows the system well.
 
Sanman said:
No idea how he and his wife got it. She even works and receives CG support funds. The most functional person I have ever seen receive it. FYI, he knows the system well.
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Most impressive. I've had a few patients, including one who also knows the system extremely well, apply for it and be denied. I've even seen appeals go up to the VISN level and get denied.
 
Sanman said:
No idea how he and his wife got it. She even works and receives CG support funds. The most functional person I have ever seen receive it. FYI, he knows the system well.
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Come to think of it, over the years I haven't seen much of a correlation between service-connection percentages and legit impairment. Some '100% disabled' folks ran their own businesses whilst some at 30% were recently psychiatrically hospitalized and were homeless.
 
cara susanna said:
Most impressive. I've had a few patients, including one who also knows the system extremely well, apply for it and be denied. I've even seen appeals go up to the VISN level and get denied.
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Yeah, "reduce avoidance" becomes are hard clinical goal to incentivize when the government literally pays you to sit at home and pays your wife to run your errands.
 
WisNeuro said:
Umm, personal valet service at the VA, dedicated booth in the canteen, and free mani/pedis for life then.
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The last one seems viable. Definitely not the first two things. My folks don't slum it with the unwashed masses who must travel to the VA to see a healthcare provider. They expect the healthcare providers to come to them. I have had folks turn down referrals for that reason alone (not talking about the ones with legit travel issues).
 
Sanman said:
What is the treatment plan for veteran continually avoids psychotherapy sessions when given concrete goals that he needs to meet and then reschedules for a few weeks later attempting to avoid discussion of said goals. However, I can't discharge him because he remains on our primary care team, so he or his wife will just call me in crisis a few weeks later anyway if not followed regularly.
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A dog with an official looking unofficial vest.
 
I think the "Day Reckoning" with all this may have come between 2011 and 2013? I recall vey specific covos on internship where this was not an issue....AT ALL!

Then, I recall 2014 and beyond. MHS gained traction in 2016 but I didn't really pay attention because I was PCMHI, and it was still an non-issue and non-starter then. Then I left! Now its like MHS 5.0??? Good luck guys!

By the way...did I ever tell you guys stories from my former supervisor who was a VA Staff Psychologist from 1967-2005? I think I did? Wait until you hear his stories from before 2001. Would blow your mind....
 
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erg923 said:
I think the "Day Reckoning" with all this may have come between 2011 and 2013? I recall vey specific covos on internship where this was not an issue....AT ALL!

Then, I recall 2014 and beyond. MHS gained traction in 2016 but I didn't really pay attention because I was PCMHI, and it was still an non-issue and non-starter then. Then I left! Now its like MHS 5.0??? Good luck guys!

By the way...did I ever tell you guys stories from my former supervisor who was a VA Staff Psychologist from 1967-2005? I think I did? Wait until you hear his stories from before 2001. Would blow your mind....
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Did he happen to know why so many VA hospitals are next to golf courses? I have heard epic stories of old lunch breaks.
 
Fan_of_Meehl said:
Reduce avoidance is a very valid and very streamlined approach to treating PTSD and any anxiety disorder. I like having the flexibility to work collaboratively with clients to decide on (and tweak) the specific parameters of working toward that goal. The problem with MHS is that it presumes you can work out all the details of how every clinical intervention and HW assignment will go for the next 3 to 6 months and that just ain't how therapy works, especially with VA populations.
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SO true! Glad I am not alone in feeling this way
 
Fan_of_Meehl said:
I've brought up a couple of points regarding MH Suite in meetings and got nothing but, "Yeah, but we gotta do it" several times:

1) you cannot point me to ANY resources in the professional literature (books, journal articles, training program curricula) where this new approach (using MHS) has been referenced, explicated, discussed, or critiqued. Nothing. Nada. You also, when asked, cannot provide any examples of how you would use the program to address anything but the most narrow of clinical targets (e.g., smoking cessation or weight loss). Try a veteran with comorbid PTSD, MDD, SUDS, personality disorder who is in pre-contemplation with respect to behavior change, suspicious of meds but with significant suicidal ideation. The MHS champion gave us as the example of a treatment target 'veteran will pay their rent on time each month.'

2) the MHS stuff, especially the problem, goal, objective, intervention, specific target date, specific drop in %age self-report or symptoms paradigm is NOT how expert CBT practitioners even practice. Read their books, train with them and you'll see.

Edit: oh yeah, I just had to share this one: the other example of a treatment goal provided in official MHS training was this: 'veteran will name thee high-risk situations associated with risk of relapse' with a target date for completion something like three months hence. I **** you not. Anyone with a modicum of common sense realizes that such a treatment goal can and should be accomplished, at most, in a single session (likely the same session in which the goal is devised, making it pointless to even list as a goal) and, actually, with a semi-competent therapist and reasonably willing client, would require between 2 and 15 minutes of actual therapy time to accomplish.

So,
Problem: excessive alcohol use
Goal: decrease alcohol use and reduce risk of relapse
Objective: be able to name three situations which are high risk for relapse
Intervention: individual psychotherapy to help veteran identify high risk situations
Responsible person: Ignor H. Amos Ph.D.
Target date: (specific date three months from now)

Obviously, it would take more time to do treatment planning/documentation around this objective than to just accomplish the objective same session...the epitome of clinical inefficiency.
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I’m a masters level provider in a CMHC and have never worked in a VA so I’ve not seen MHS. But I just want to say that the EHR my agency uses has the Wiley Practice Planner treatment guides imported into our treatment planning module and we also have to create treatment plans in the exact manner you describe, choosing pre-populated problems (with defined Sx), goals, objectives and interventions. All from the Wiley guides. So the VA is not alone in using this treatment planning approach. I can relate to your frustration :laugh:
 
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Psycycle said:
I’ve always seemed to find that Barbara McMoneybags shows up with eye strain and I find out a few sessions later that she really is struggling with trauma from an assault that she never disclosed before. That’s more my reason for picking up admin/teaching, varying the program.
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--
 
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AbnormalPsych said:
Cross post from the day in, day out slog thread (don't kill or ban me mods, please).

"


Yes, but here's the deal with Barbara Susan (B.S.) McMoneyBags.

If I say anything perceived by this woman as remotely intrusive or confrontative or attempt any actual diagnostic interviewing or clinical intervention, my consumer satisfaction scores take a massive hit (mostly because the N is so low anyways and my patients that are doing amazing don't bother with this survey, just the ones that want to gripe).

This has a direct impact on everything. I am going to cross post (don't murder me moderators) in the VA thread, bc I am curious if the VA has this consumer satisfaction ranking after each MH visit these days. "


VA peers:
Does your annual review / job security depend on these scores in the VA these days?
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We used to have a patient satisfaction-type survey that we were required to give to patients ourselves after encounters. We needed to have a certain number completed each quarter, and the scores were part of our annual performance review. That was all stopped a few years ago.

VA does have anonymous patient satisfaction surveys that some other section/department handles. The scores impact our facility's grade, but they don't influence providers' annual reviews or job security as far as I know, at least in mental health.
 
Hi, new here. I’ll be going to a VA for internship and was told my position is contingent on a physical and possible drug screen. Was curious about what the physical and drug screen entails?
 
erg923 said:
getting a physical exam and getting a drug test
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The hardest part of the physical was doing a head stand while sorting HR forms into three separate piles. The drugs they give afterwards for the drug test are worth it though, I had a great conversation with purple elephant.

Seriously though, it is a check-up and peeing in a cup (or was it a blood test? who remembers)
 
almostphdiva said:
Hi, new here. I’ll be going to a VA for internship and was told my position is contingent on a physical and possible drug screen. Was curious about what the physical and drug screen entails?
Click to expand...
Nothing too intrusive as I recall. They do a standard physical, take some blood and, of course, screen for drugs.
 
Isn't there a barriers section in MHS? We should totally start putting that sort of stuff
WisNeuro said:
Umm, personal valet service at the VA, dedicated booth in the canteen, and free mani/pedis for life then.
Click to expand...

AbnormalPsych said:
Cross post from the day in, day out slog thread (don't kill or ban me mods, please).

"


Yes, but here's the deal with Barbara Susan (B.S.) McMoneyBags.

If I say anything perceived by this woman as remotely intrusive or confrontative or attempt any actual diagnostic interviewing or clinical intervention, my consumer satisfaction scores take a massive hit (mostly because the N is so low anyways and my patients that are doing amazing don't bother with this survey, just the ones that want to gripe).

This has a direct impact on everything. I am going to cross post (don't murder me moderators) in the VA thread, bc I am curious if the VA has this consumer satisfaction ranking after each MH visit these days. "


VA peers:
Does your annual review / job security depend on these scores in the VA these days?
Click to expand...

We have patient satisfaction surveys, but they are for management and handled by a specific committee. I've never gotten feedback about mine, with one exception in which I received a very nice compliment. We used to routinely give a measure of therapeutic alliance at my clinic on post-doc, but I think that was more for clinical than administrative purposes.

Also, that sounds awful and would probably make me end up quitting. I get VERY anxious about that sort of stuff. Sorry you have to deal with that.
 
Fan_of_Meehl said:
Nothing too intrusive as I recall. They do a standard physical, take some blood and, of course, screen for drugs.
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Ooof! Thanks for letting me know! I hate getting my blood drawn and so I primarily asked to mentally prepare LOL
 
erg923 said:
By the way...did I ever tell you guys stories from my former supervisor who was a VA Staff Psychologist from 1967-2005? I think I did? Wait until you hear his stories from before 2001. Would blow your mind....
Click to expand...

AbnormalPsych said:
Cross post from the day in, day out slog thread (don't kill or ban me mods, please).

"


Yes, but here's the deal with Barbara Susan (B.S.) McMoneyBags.

If I say anything perceived by this woman as remotely intrusive or confrontative or attempt any actual diagnostic interviewing or clinical intervention, my consumer satisfaction scores take a massive hit (mostly because the N is so low anyways and my patients that are doing amazing don't bother with this survey, just the ones that want to gripe).

This has a direct impact on everything. I am going to cross post (don't murder me moderators) in the VA thread, bc I am curious if the VA has this consumer satisfaction ranking after each MH visit these days. "


VA peers:
Does your annual review / job security depend on these scores in the VA these days?
Click to expand...
If we have these surveys about us as specific providers, I have never heard about it.

Once, a patient said a nice thing about my team to the patient advocate and the advocate emailed me/my supervisor to pass it along. That was nice.
 
almostphdiva said:
Ooof! Thanks for letting me know! I hate getting my blood drawn and so I primarily asked to mentally prepare LOL
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My blood was drawn to check a titer for something or other. Bring your vaccination list and any recent titers you've had drawn. Pretty sure that kept my testing to the minimum.

The drug test was urine. Nobody watched me pee but they did turn off the water in the bathroom and remove the soap. That was weird.

For internship I didn't have a drug test though. Just real job.
 
PsychPhDone said:
If we have these surveys about us as specific providers, I have never heard about it.

Once, a patient said a nice thing about my team to the patient advocate and the advocate emailed me/my supervisor to pass it along. That was nice.
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I think there are random surveys distributed to random veterans and they're more about general experience. I'm not sure if they're even rating specific providers or just their overall experience with the clinic.
 
Yeah, no ratings of specific clinicians that I am aware of currently. A patient we kicked out of the our program for non-compliance with care/not letting clinicians in his home/not being home when we scheduled appts did report us to the white house complaint line for kicking him out. I totally called it when we admitted him.
 
Sanman said:
The hardest part of the physical was doing a head stand while sorting HR forms into three separate piles. The drugs they give afterwards for the drug test are worth it though, I had a great conversation with purple elephant.

Seriously though, it is a check-up and peeing in a cup (or was it a blood test? who remembers)
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Omg stop, what if someone takes you seriously 🤣🤣🤣 But yes, checkup and pee in a cup
 
A long shot but does anyone know if a year of VA internship would count for the 12 months of service needed for the 3 months of parental leave allotted to federal employees? I've googled and can't find anything except that temporary employees are excluded however, I was told explicitly by HR that interns are not considered temporary employees ( but they are massively incompetent so I don't trust that). I've looked at my appointment documents and can't tell.

I'm finishing a VA internship in July and I'm expecting at the end of October when I'll be a couple of months into a VA fellowship. I feel it's too early to tell any faculty at my hospital and our HR is just awful so I am hoping someone here might have some idea so I can start some mental planning.

Second question, if I don't qualify what options have you seen pregnant fellows take especially early in the training year? I don't want to take a ton of time (not the full 3 months) and extend my year a lot but I also don't think taking the 8 days of combined AL/SL I will have accrued at that point to be realistic either.

Any chance I could just get the baby a job in HR or as a Cerner Super User/Champion? They'd probably do as good a job as the others.
 
Grenth said:
A long shot but does anyone know if a year of VA internship would count for the 12 months of service needed for the 3 months of parental leave allotted to federal employees? I've googled and can't find anything except that temporary employees are excluded however, I was told explicitly by HR that interns are not considered temporary employees ( but they are massively incompetent so I don't trust that). I've looked at my appointment documents and can't tell.

I'm finishing a VA internship in July and I'm expecting at the end of October when I'll be a couple of months into a VA fellowship. I feel it's too early to tell any faculty at my hospital and our HR is just awful so I am hoping someone here might have some idea so I can start some mental planning.

Second question, if I don't qualify what options have you seen pregnant fellows take especially early in the training year? I don't want to take a ton of time (not the full 3 months) and extend my year a lot but I also don't think taking the 8 days of combined AL/SL I will have accrued at that point to be realistic either.

Any chance I could just get the baby a job in HR or as a Cerner Super User/Champion? They'd probably do as good a job as the others.
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That's a good question, and I don't know the answer off-hand. I'd recommend reaching out to OAA if you're able. I know the internship year counts toward some things (e.g., years of service when determining how much leave you accrue) but not others (e.g., just about anything related to retirement), so it seems like a toss-up.

Other options include FMLA, I believe, and/or some version of leave without pay. You may also be eligible for leave donation from other employees.
 
Grenth said:
A long shot but does anyone know if a year of VA internship would count for the 12 months of service needed for the 3 months of parental leave allotted to federal employees?
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When I started accruing 6 hours of annual leave per pay period (for employees with 3+ years of federal service), my internship and postdoc years were included, which was a pleasant surprise as I was only expecting postdoc to count.

While there's likely policy on all of this, I think many of these decisions are made correctly or incorrectly locally by HR so if you are told no, don't automatically assume that's the end.

I also think your postdoc training director will be the best resource since they likely have either experienced this and if not, could reach out to other VA training directors for guidance. And regardless of the ultimate arrangement you make, you'll need their assistance to make accommodations so it's probably better to reach out earlier than later IMO. Good luck!
 
cara susanna said:
Been using MHS and doing treatment plans a few times now. Where do they come up with these objectives??
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I haven't really used MHS myself, but I wonder if the objectives aspect is patterned after requirements for Medicare psychotherapy notes that call for things like behavioral anchors, measurable goals and progress, etc.
 
AcronymAllergy said:
I haven't really used MHS myself, but I wonder if the objectives aspect is patterned after requirements for Medicare psychotherapy notes that call for things like behavioral anchors, measurable goals and progress, etc.
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It's just, it doesn't cover everything that I would want to cover. Particularly for PTSD.
 
I know in a meeting I was in, we started talking about ensuring that all treatment plans had SMART goals. Does MHS let you free type the goals or is it a limited checkbox of stuff someone came up with because we are all too stupid to come up with JCAHO approved treatment plans on our own? I haven't really used it yet.
 
Sanman said:
I know in a meeting I was in, we started talking about ensuring that all treatment plans had SMART goals. Does MHS let you free type the goals or is it a limited checkbox of stuff someone came up with because we are all too stupid to come up with JCAHO approved treatment plans on our own? I haven't really used it yet.
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You can type goals in the veteran's words but that's it. And the objectives i don't think you can free type, although maybe i just don't know how yet.
 
cara susanna said:
You can type goals in the veteran's words but that's it. And the objectives i don't think you can free type, although maybe i just don't know how yet.
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If I remember correctly, you can. The problem is in the pragmatics of the implementation as well as the time spent in motivational interviewing, negotiating specific 'SMART goals' (and at what level of abstraction?). I may just have a weird clinic but I have found most of the veterans I encounter to have multiple problems (and diagnoses) and that between sessions important things happen (e.g., my wife just left me, I just lost my job). They're also not very clear exactly WHAT these plans are even--in theory (assuming a perfectly compliant veteran patient--supposed to look like. You know...like a treatment manual. Or...you know, like a clinical casebook of cognitive-behavioral therapy?

Also...what is a 'treatment plan?' For example, if you were doing CPT, would you just say '12 weeks of CPT for PTSD?' Or are they expecting us to break things down on a session-by-session basis? Even at the most general level ('12 weeks of CPT for PTSD'), I mean, how many of your veterans fail to do their homework, no-show, drop out, or request a different approach in the middle of it?

Also, veteran's don't (in my experience) just immediately or easily accept the highest level of structure in therapy (they tend to buck it much more than other populations, again, in my experience) probably for some very interesting and varied reasons (e.g., slow to show trust, hard to concentrate due to heavy substance use, playing games because of Axis II, the real agenda (service connection, caregiver support) differing from the stated agenda, etc.

In medication treatment, what is a 'treatment plan?' I would think, something like an 8 week trial of antidepressant X for PTSD symptoms or something. I mean, they don't get into any lower level details than that. I don't see why something like cognitive-behavioral therapy for PTSD (where the person has decided NOT to accept a PE or CPT protocol, for example) so then you could do something like behavioral activation for PTSD, or taking an ACT approach, or first trying to build motivation, then teach cognitive restructuring (and all of these at this lower level of detail can simply be noted in the progress notes in the COURSE of trying cognitive-behavioral therapy for PTSD for, I dunno, 12 weeks.

There are SOOO many issues that people who don't do therapy all day, every day, with this population have even considered. All I can say is....this gonna be good...
 
Grenth said:
A long shot but does anyone know if a year of VA internship would count for the 12 months of service needed for the 3 months of parental leave allotted to federal employees? I've googled and can't find anything except that temporary employees are excluded however, I was told explicitly by HR that interns are not considered temporary employees ( but they are massively incompetent so I don't trust that). I've looked at my appointment documents and can't tell.

I'm finishing a VA internship in July and I'm expecting at the end of October when I'll be a couple of months into a VA fellowship. I feel it's too early to tell any faculty at my hospital and our HR is just awful so I am hoping someone here might have some idea so I can start some mental planning.

Second question, if I don't qualify what options have you seen pregnant fellows take especially early in the training year? I don't want to take a ton of time (not the full 3 months) and extend my year a lot but I also don't think taking the 8 days of combined AL/SL I will have accrued at that point to be realistic either.

Any chance I could just get the baby a job in HR or as a Cerner Super User/Champion? They'd probably do as good a job as the others.
Click to expand...

As a current VA fellow on parental leave I looked into this extensively. I was told by local HR that postdoctoral fellows are not eligible for the federal paid parental leave program.
I have been saving all my sick and annual leave from internship through fellowship and will be using it all together in one long leave period before returning to my fellowship position.
Also note that it is not standard for AL/SL to carry over from internship to fellowship. At least, that's what I've been told by admin at my site.
 
beginner2011 said:
As a current VA fellow on parental leave I looked into this extensively. I was told by local HR that postdoctoral fellows are not eligible for the federal paid parental leave program.
I have been saving all my sick and annual leave from internship through fellowship and will be using it all together in one long leave period before returning to my fellowship position.
Also note that it is not standard for AL/SL to carry over from internship to fellowship. At least, that's what I've been told by admin at my site.
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My leave carried over from internship to fellowship.

If you've seen one VA...
 
beginner2011 said:
As a current VA fellow on parental leave I looked into this extensively. I was told by local HR that postdoctoral fellows are not eligible for the federal paid parental leave program.
I have been saving all my sick and annual leave from internship through fellowship and will be using it all together in one long leave period before returning to my fellowship position.
Also note that it is not standard for AL/SL to carry over from internship to fellowship. At least, that's what I've been told by admin at my site.
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Also congrats! Hope it's going well
 
PsychPhDone said:
My leave carried over from internship to fellowship.

If you've seen one VA...
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You're certainly "one of the lucky ones." My understanding is that it's technically possible for it to carry over (not telling you anything new there), but it requires additional work and understanding by HR, so it usually doesn't happen. It seems to be a much more straightforward process for HR to transfer leave when going from fellowship to a position, or from one position to another.
 
cara susanna said:
I had to do something special though, like I think they had to print it out for me or something.
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I've successfully carried sick leave from internship --> postdoc --> 1st job across 3 systems. I printed out my last VATAS leave balance and then found the right HR person to restore the leave. Somebody else once told me they left the VA for like 10 years and was able to get all their sick leave back when they returned.

But I've been told that annual leave does not carry over and is instead paid out in a lump sum at a % of your hourly rate (assuming a break in service).

I just completed a transfer to a new VA without a break so I'll be curious if I get the lump sum or not.
 
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