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

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summerbabe said:
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 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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My annual leave was paid out at the end of internship (VA) before starting my fellowship (VA), although I had a week or two in-between due to the timing of everything. I'm pretty sure I just lost my sick leave. My annual and sick leave from fellowship both transferred over seamlessly to my staff position, which was nice, because I think I took maybe 2 or 3 sick days across the entirety of postdoc.
 
Mine transferred from internships to postdoc, although I too had to print out hardcopy and also email my last statements from the old position, and bring them to my new place. It took some time (go figure) but they added the small balance back in eventually .
 
Thanks all. I actually am taking a staff position at my same facility with the blessing of the postdoc preceptor, training director, and most of the faculty who are happy to keep good trainees around in a more permanent fashion. It's a hard to fill staff position and it will give me a lot more flexibility with the baby (compressed schedule, telework) than is traditionally given to trainees. I've also been told in writing my leave will come with me. It's still unclear about the parental leave but it seems more likely as staff than postdoc. Hopefully 6 months is enough time to figure it out but I'm not holding my breath. It's a relief not to have to worry about postdoc timelines and from a licensure/ABPP standpoint a formal postdoc not an issue in my state/speciality.
 
I couldn't resist. Generally for MH dept, it should be in CPRS in 24 hours. Though HBPC guidelines allow us up to 72 hours due to traveling and being away from the computer.
 
Before I left the VA, we had to have a "note" in within a day, but that was usually just a placeholder. Full report needed to be in within 2 weeks, but we were generally at about a week or less for that. Non-VA I never had a firm deadline from higher ups, but I always had it in within a week.
 
cara susanna said:
I never let this thread stay off of page 1 for too long. 😉

Would people please tell me their facility's policy on note completion deadlines? Thanks!
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We're supposed to have notes in by the end of the shift, but I think technically we have 24 hours.
 
RejectClinical said:
24 hours for therapy notes and 72 hours for neuropsych reports
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72 hours for the full report? Oof. It's definitely doable, but that's pretty stringent, and would be next to impossible with trainees. It's also amazing to me how much variability there is on report deadlines across settings.

Here: 24 hours for individual notes, 48 hours for group notes, 10 days for neuropsych reports.
 
AcronymAllergy said:
72 hours for the full report? Oof. It's definitely doable, but that's pretty stringent, and would be next to impossible with trainees. It's also amazing to me how much variability there is on report deadlines across settings.

Here: 24 hours for individual notes, 48 hours for group notes, 10 days for neuropsych reports.
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Yeah, with trainees, we sometimes go over the 1 week mark. Although, if the report needs a lot of work, I'd tend to just write my own for the chart, and edit and help the trainee with an unofficial report. Only had to do that a handful of times, though.
 
WisNeuro said:
Yeah, with trainees, we sometimes go over the 1 week mark. Although, if the report needs a lot of work, I'd tend to just write my own for the chart, and edit and help the trainee with an unofficial report. Only had to do that a handful of times, though.
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I've done this before in a time crunch as well, and suspect it might be the only way to consistently make the situation work with trainees if there's a 72-hour deadline. Then again, I know some (inpatient) rotations way back when I was on internship required trainees enter reports by the end of the day.
 
AcronymAllergy said:
I've done this before in a time crunch as well, and suspect it might be the only way to consistently make the situation work with trainees if there's a 72-hour deadline. Then again, I know some (inpatient) rotations way back when I was on internship required trainees enter reports by the end of the day.
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For inpatient, that was our rule on fellowship as well.
 
cara susanna said:
I never let this thread stay off of page 1 for too long. 😉

Would people please tell me their facility's policy on note completion deadlines? Thanks!
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I think we're supposed to have something in cprs by the end of the day, and if it's a holding note, full note within 24h. I don't do neyropsych so no reports.
 
Anyone else getting harassed about productivity recently? We have been and our re-opening plans are not even sorted out yet. Just curious what others have been experiencing.
 
Sanman said:
Anyone else getting harassed about productivity recently? We have been and our re-opening plans are not even sorted out yet. Just curious what others have been experiencing.
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Have been hearing about this elsewhere, but not as much here. Although a number of months ago, it did seem like leadership was very concerned about monitoring the number of encounters providers were having per day.

Maybe there are widespread access issues cropping up, and the default response strategy for that seems to be, "blame the providers for not seeing enough patients!"
 
Fan_of_Meehl said:
At the VA, the answer is to ALWAYS blame the providers. Can't blame the system (that could imply 'leadership' might be responsible). Can't blame the veterans, it's political suicide. Besides, it's easy to blame the providers since they're responsible for nearly everything.
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It's like they want me to leave for private practice.
 
I’ve since moved to a new VA but prior to leaving, my former MH leadership was on a major productivity kick once some new RVU dashboard came online earlier this year (versus however they previously calculated or assessed individual productivity).

Haven’t heard anything about RVUs in my current position. Probably not a coincidence that leadership appears more forward thinking here.
 
summerbabe said:
I’ve since moved to a new VA but prior to leaving, my former MH leadership was on a major productivity kick once some new RVU dashboard came online earlier this year (versus however they previously calculated or assessed individual productivity).

Haven’t heard anything about RVUs in my current position. Probably not a coincidence that leadership appears more forward thinking here.
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Omg, us too! I actually have the dashboard bookmarked. Because of it I only got "meets expectations" on my annual eval which annoyed me because, like, this is a pandemic. On the plus side, my RVUs are way better now and I'm almost at my minimum target already.

Right now, our facility is more on a kick to force everyone to do video. It's actually tied to working from home--you need to have a certain percentage video, and the percentages correspond to how many days you get. If VVC isn't working that day, which you know often happens, we have to offer Doximity. You also do need to meet a certain productivity standard to WFH, which I also find ridiculous.
 
Sanman said:
Anyone else getting harassed about productivity recently? We have been and our re-opening plans are not even sorted out yet. Just curious what others have been experiencing.
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I might be jinxing myself but I've never been bothered about productivity. Neither have my colleagues at my site. Can someone pm me instructions for finding this dashboard please?
 
PsychPhDone said:
I might be jinxing myself but I've never been bothered about productivity. Neither have my colleagues at my site. Can someone pm me instructions for finding this dashboard please?
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I never was either until we got yelled at recently. Mostly because my productivity is garbage thanks to my job description and my leadership is too lazy to set up an individual productivity goal. As a PSA, turns out my VVC clinic was not listed on the dashboard and I have not been getting credit for video visits since they built me a new clinic. Check for that.
 
Sanman said:
I never was either until we got yelled at recently. Mostly because my productivity is garbage thanks to my job description and my leadership is too lazy to set up an individual productivity goal. As a PSA, turns out my VVC clinic was not listed on the dashboard and I have not been getting credit for video visits since they built me a new clinic. Check for that.
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Lol, everyone's productivity was hit when they weren't letting us bill phone sessions, too.
 
cara susanna said:
Lol, everyone's productivity was hit when they weren't letting us bill phone sessions, too.
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That was not helpful either. Ironically, my productivity was probably better earlier in the pandemic because I was an in room supervisor for a lot of trainees in other areas of the dept and I got credit for the visits. Since January, that was dropped and I am back to my tiny closed panel of patients that can never produce outpatient productivity numbers. As a former manager that reviewed everyone else's productivity numbers at my last job, the lack of understanding by my current leadership that I cannot see more patients than exist on my HBPC team is astounding. If you wanted outpatient productivity numbers, you should have reassigned me to an outpatient clinic.
 
Sanman said:
That was not helpful either. Ironically, my productivity was probably better earlier in the pandemic because I was an in room supervisor for a lot of trainees in other areas of the dept and I got credit for the visits. Since January, that was dropped and I am back to my tiny closed panel of patients that can never produce outpatient productivity numbers. As a former manager that reviewed everyone else's productivity numbers at my last job, the lack of understanding by my current leadership that I cannot see more patients than exist on my HBPC team is astounding. If you wanted outpatient productivity numbers, you should have reassigned me to an outpatient clinic.
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That is ridiculous. Back when I was PCMHI my productivity was judged using a different standard than OPMH.
 
Sanman said:
I never was either until we got yelled at recently. Mostly because my productivity is garbage thanks to my job description and my leadership is too lazy to set up an individual productivity goal. As a PSA, turns out my VVC clinic was not listed on the dashboard and I have not been getting credit for video visits since they built me a new clinic. Check for that.
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'Leadership.'

They don't even read the VA's own policies/procedures regarding things like appropriate labor mapping. Too much work...hell, it might take them a total of 5 mins of conversation with their supervisee, milliseconds (or longer, depending on the supervisor) of interneuronal messaging within their CNS), and an additional 10 mins of 4th grade arithmetic and typing a few sentences into a document.

That would be asking waaaaaaaaaay too much.

/sarcasm
 
Sanman said:
That would suggest that there was only mismanagement at one VA 🤣
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I'm beginning to think that the most reliably observed phenomenon in the universe is piss-poor and deplorable 'leadership' across all VA sites. The specifics may vary slightly site-to-site but I've never witnessed a system that was so capable of mis-educating people how to properly supervise or lead others.
 
Fan_of_Meehl said:
I'm beginning to think that the most reliably observed phenomenon in the universe is piss-poor and deplorable 'leadership' across all VA sites. The specifics may vary slightly site-to-site but I've never witnessed a system that was so capable of mis-educating people how to properly supervise or lead others.
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Perhaps it has something to do with the fact I currently have more management experience than my current supervisors, who were recently promoted. There was little effort to pick the best candidate for the job. Those that have been at the VA the longest were picked. Then again, I can make more with a side PP than my supervisor does...so I didn't want that job anyway.
 
Fan_of_Meehl said:
At the VA, the answer is to ALWAYS blame the providers. Can't blame the system (that could imply 'leadership' might be responsible). Can't blame the veterans, it's political suicide. Besides, it's easy to blame the providers since they're responsible for nearly everything.
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But also at the VA, the answer among providers is ALWAYS to blame their leadership. There's a lot of comments on here about how awful leadership is, or how people have leadership experience elsewhere and therefore know why their leadership sucks. Assumptions of laziness, inability to manage. But not a lot of consideration of the possibility that VA leadership is navigating a lot of different aspects of the job that can be challenging, like balancing plates. I'm not saying that leadership is perfect or infallible, but it's not as simple of a job as a lot of people think it is.
 
Psycycle said:
But also at the VA, the answer among providers is ALWAYS to blame their leadership. There's a lot of comments on here about how awful leadership is, or how people have leadership experience elsewhere and therefore know why their leadership sucks. Assumptions of laziness, inability to manage. But not a lot of consideration of the possibility that VA leadership is navigating a lot of different aspects of the job that can be challenging, like balancing plates. I'm not saying that leadership is perfect or infallible, but it's not as simple of a job as a lot of people think it is.
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No one said the job was not challenging. That is why they get the (not so) big bucks. If you fill out the application, be ready to do the job properly. If I can figure out the correct course of action, surely the person being paid more than I can as well. I'm not saying I don't feel bad for them. However, their life choices are up to them. Part of being a seasoned manager is avoiding an untenable position.
 
Psycycle said:
But also at the VA, the answer among providers is ALWAYS to blame their leadership. There's a lot of comments on here about how awful leadership is, or how people have leadership experience elsewhere and therefore know why their leadership sucks. Assumptions of laziness, inability to manage. But not a lot of consideration of the possibility that VA leadership is navigating a lot of different aspects of the job that can be challenging, like balancing plates. I'm not saying that leadership is perfect or infallible, but it's not as simple of a job as a lot of people think it is.
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As a trainee I've been really impressed by all the psychologists I've encountered in leadership, and a lot of the MDs. As a psychologist I'm probably biased, and as a trainee I'm not liable to have the more contentious/demanding encounters with leadership that staff do, but I've learned a lot and admire most of the folks in leadership at my VA. It's a pretty thankless role (what is it like a 10% pay bump for a 50% increase in stress?), and when it's done well it really seems to make staff so much happier and the clinic run smoother.
 
Sanman said:
No one said the job was not challenging. That is why they get the (not so) big bucks. If you fill out the application, be ready to do the job properly. If I can figure out the correct course of action, surely the person being paid more than I can as well. I'm not saying I don't feel bad for them. However, their life choices are up to them. Part of being a seasoned manager is avoiding an untenable position.
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No one is asking you to feel bad for them. What I’m saying is that maybe staff don’t know all the factors that lead to decision making. What makes you think you know the correct course of action when you don’t know the factors in decision making? Why do you think you’re in a position to know whether they are doing the job properly? You only know your position and the others around you. Not the whole picture.
 
beginner2011 said:
As a trainee I've been really impressed by all the psychologists I've encountered in leadership, and a lot of the MDs. As a psychologist I'm probably biased, and as a trainee I'm not liable to have the more contentious/demanding encounters with leadership that staff do, but I've learned a lot and admire most of the folks in leadership at my VA. It's a pretty thankless role (what is it like a 10% pay bump for a 50% increase in stress?), and when it's done well it really seems to make staff so much happier and the clinic run smoother.
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I agree. No doubt there is bad leadership. But I’ve had excellent psychologists as leadership in the VA.
 
Psycycle said:
But also at the VA, the answer among providers is ALWAYS to blame their leadership. There's a lot of comments on here about how awful leadership is, or how people have leadership experience elsewhere and therefore know why their leadership sucks. Assumptions of laziness, inability to manage. But not a lot of consideration of the possibility that VA leadership is navigating a lot of different aspects of the job that can be challenging, like balancing plates. I'm not saying that leadership is perfect or infallible, but it's not as simple of a job as a lot of people think it is.
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My take: working in leadership, you're of course never going to please everyone. And VA does have a lot of different administrative/bureaucratic burdens and hurdles to overcome. For example, you want the clerks in your section to handle scheduling new patients a certain way, but the clerks are all under a different service and have their own leadership, so you can't enact the new policy unless their leadership buys in, and their leadership is balking for various political reasons. I personally would say VA middle management has it the absolute worst--they don't have the ability to make substantial changes without buy-in from upper-level leadership, so they get the brunt of the complaints from frontline staff; and they can't force staff to adhere to various VA and facility directives, so they get the brunt of the complaints from upper-level leadership when their service line/employees/etc. aren't meeting whatever criteria are set. There can also be a lot of resistance/inertia at the provider level.

I believe that a large portion of this discontent and resistance is due to a lack of communication between upper-level leadership and front-line staff, with the latter being told what to do or what the changes are but not why. So when leadership decides to focus on a single metric or series of metrics, to frontline staff it just seems random (which sometimes it is), and there isn't always an attempt to personalize these metrics to different providers based on the services they provide. It's also difficult to get rid of problematic leadership, just like it can be with employees; rather than being dismissed, they seem to just get shuffled around. Complaints about leadership obviously aren't unique to VA. But I would say in general, it seems VA frontline providers complain more about the seemingly random requirements they're expected to meet. And the way different clinics can be divided along services or professions rather than practice location/setting can add to inefficiency. VA also tends to be fairly top-heavy, so clinicians (or sometimes folks with little to no clinical experience) are promoted into more administrative roles (e.g., all the various "champions"), at which point they start enacting more initiatives for the now-shrinking full-time clinical staff. In other settings, you may hear more complaints about things like excessive or unreasonable productivity standards. Other settings also have the ability to turn away patients, although may then have more concerns about profitability.
 
Psycycle said:
No one is asking you to feel bad for them. What I’m saying is that maybe staff don’t know all the factors that lead to decision making. What makes you think you know the correct course of action when you don’t know the factors in decision making? Why do you think you’re in a position to know whether they are doing the job properly? You only know your position and the others around you. Not the whole picture.
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What I have encountered (over and over again) and, yes, in psychologist leaders as well is whenever concerns/questions are raised (which is exceedingly rare given the organizational climate and its tendency to punish critical discussion), the immediate responses appear directly geared toward shutting down any and all discussion. They even pre-emptively say things like, 'We're going to discuss X {some new politically/administratively unjustifiable burden on the providers}, now there's no point in saying we shouldn't be doing things this way because {the higher ups say we're going to do it and so we're going to do it}.' So, we're not really going to 'discuss' anything; we're going to receive our marching orders.

However, as I am tried making the point to them (before giving up entirely), even if 'there's nothing that we can do about it' in terms of 'reversing' some mandate from Central Office (I agree, we're not going to do that), it is still worthwhile for the front-line psychologists to be able to COMMUNICATE to their leadership (and one another) challenges, rationale (or lack thereof), implementation barriers, frustrations (and potential solutions), ethical/legal/moral dilemmas (which are frequent), and the challenge of reconciling often conflicting policies/procedures, and efforts to manage role conflicts and conflicts among various duties in the day to day clinical practice in VA outpatient settings. What I have universally experienced is the immediate tendency to 'shut down' any and all discussion. A competent and high-quality leader WANTS TO HEAR about such things from her/his subordinates because, otherwise, they are flying blind when sitting in meetings with the other 'higher-ups' and deciding local policy/procedure and can, therefore, be an articulate advocate for his/her psychology staff. Moreover, it really contributes to provider burnout to not even be able to articulate your concerns to leadership without being shut down. Finally, one psychologist may have innovated (because we have to) a decent solution to a role conflict or other clinical problem and it would be worthwhile for them to be able to share it with the group.

A couple of case examples of what I consider a failure in MH leadership all the way up and down the organization are how things like 1) caregiver support (for MH problems) and 2) service dogs have been handled over the years. And, yes, I know about the recently made public monograph on the two-arm study but that topic is worthy of its own discussion thread.

Regarding 'caregiver support' (as a paid benefit to spouses) to 'treat/manage' mental health conditions like PTSD and depression (most frequently requested). Nine or ten years ago when this was just rolling out to VA hospitals, it was obvious to any clinician worth their salt that this was a terrible idea from a mental health recovery perspective. There is no literature on using a paid family member as a 'caregiver' to treat PTSD. In fact, a very good argument can be made that it is actually iatrogenic (for reasons I can spell out if I need to). But I didn't (still don't) see any evidence of any real articulated opposition to the idea from leadership in mental health. If they DID articulate any meaningful dissenting views, why couldn't they have just shared that with us, say, in private one-on-one meetings or in service meetings? For example, 'Folks, I know this doesn't comport with the professional/scientific literature but I have raised my concerns to leadership in X meeting but we are still being given the directive.' Nope. That's not what we get. We get them 'selling' the idea to us (like it's a used car) and we're supposed to 'sell' it to veterans and/or go along with the practice. Now (finally) several years later, the organization is realizing what a bad idea caregiver support for PTSD is and they have completely re-vamped the program to handle it very differently. Would have been nice if the organization had listened 10 years ago.

There is so much to say about the service dog issue I'll try to be as brief as possible and focus on just one really frustrating part. The new idea of considering the service dog a 'prosthetic' to be 'prescribed' by a MH provider (and they came up with a new term/concept of the 'Mental Health Mobility Dog.' We are supposed to get with our 'interprofessional team' when a veteran makes a request for a 'Mental Health Mobility Dog' for his PTSD and do an 'evaluation' and if we believe that the mobility dog is the 'optimal' (their words) intervention to address his 'mental health mobility issue' then we are to write a prescription (to 'prescribe,' their word) and articulate how it is necessary to their mental health treatment plan. This is so that they can qualify to have the VA pay lifetime insurance/equipment costs for the dog. Setting aside for the moment the legal/ethical issues involved in 'prescribing' animals (for which there is no serious literature or training programs to teach folks how to do this, nor are there any references or resources in the clinical and scientific literature that operationally define such an 'assessment' procedure--in fact, it seems to be simply a (golden) rubber-stamping procedure in which everyone who wants a dog gets a dog or there will be hell to pay. And if the 'assessment' is merely a background check and review to make sure the person isn't a homeless debilitated alcoholic who hates dogs then it's trivial and doesn't require a doctoral level psychologist to complete it. Who's going to say 'no' to a veteran requesting this? Under what conditions WOULD you say no? I mean, what exactly does a 'dog prescriber' do in terms of their assessment procedures and deliberations before 'deciding' to prescribe the dog? I can take down from my bookshelf Stahl's prescriber guide and see quite clearly the things a competent medication prescriber needs to take into account, the knowledge necessary to prescribe, and the responsible execution of that duty to prescribe. The dog? What is wrong with the term 'recommend?' I'll stop, but you get the point. Where was the 'leadership' in psychology within the VA organization on this one. Did they articulate similar concerns? Where is the evidence for this? They sure as hell haven't communicated this to the rank-and-file. I imagine that when this comes down and we 'receive' 'further guidance' from on high that the 'discussion' on the topic will take the predictable form of: (1) Here is what you are to do; (2) you must comply (or else); (3) there's no point in raising concerns, objections, or ethical dilemmas about it, we have to do it so just do it.

I should also say that I'm equally disappointed in the psychology leadership/luminaries in the field OUTSIDE of the VA for failing to speak up on such issues. Back in the day when the 'recovered memory' nonsense was rampant, at least back then the leaders of the field (many of them) had the bravery to do the right thing and voice unpopular opinions regarding how this was indeed nonsense (no matter how popular in the tabloids and news). I don't see anything of the sort happening on some of these other fads recently like emotional support/ service animals as treatments for mental health conditions or caregiver support. We should expect better. We should at least expect a decent expression of their struggles (as leaders) to communicate to other non-psychologists the issues that we struggle with (and to listen to us, as we struggle to implement some of this nonsense).
 
AcronymAllergy said:
My take: working in leadership, you're of course never going to please everyone. And VA does have a lot of different administrative/bureaucratic burdens and hurdles to overcome. For example, you want the clerks in your section to handle scheduling new patients a certain way, but the clerks are all under a different service and have their own leadership, so you can't enact the new policy unless their leadership buys in, and their leadership is balking for various political reasons. I personally would say VA middle management has it the absolute worst--they don't have the ability to make substantial changes without buy-in from upper-level leadership, so they get the brunt of the complaints from frontline staff; and they can't force staff to adhere to various VA and facility directives, so they get the brunt of the complaints from upper-level leadership when their service line/employees/etc. aren't meeting whatever criteria are set. There can also be a lot of resistance/inertia at the provider level.

I believe that a large portion of this discontent and resistance is due to a lack of communication between upper-level leadership and front-line staff, with the latter being told what to do or what the changes are but not why. So when leadership decides to focus on a single metric or series of metrics, to frontline staff it just seems random (which sometimes it is), and there isn't always an attempt to personalize these metrics to different providers based on the services they provide. It's also difficult to get rid of problematic leadership, just like it can be with employees; rather than being dismissed, they seem to just get shuffled around. Complaints about leadership obviously aren't unique to VA. But I would say in general, it seems VA frontline providers complain more about the seemingly random requirements they're expected to meet. And the way different clinics can be divided along services or professions rather than practice location/setting can add to inefficiency. VA also tends to be fairly top-heavy, so clinicians (or sometimes folks with little to no clinical experience) are promoted into more administrative roles (e.g., all the various "champions"), at which point they start enacting more initiatives for the now-shrinking full-time clinical staff. In other settings, you may hear more complaints about things like excessive or unreasonable productivity standards. Other settings also have the ability to turn away patients, although may then have more concerns about profitability.
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Thank you for this nuanced approach. I strongly agree. It’s more complex than just “stupid leadership.” Sometimes it is that. Sometimes it’s other factors.
 
To add: I also believe part of the problem with some/many directives is the fact that VA is essentially as much a political organization as it is a healthcare organization. And as has already been mentioned, publicly questioning or objecting to some/many of these directives by politicians or VA leadership could be very politically detrimental, so policies are pushed more for political than evidentiary reasons. After all, not many other hospital systems have a White House complaint line.
 
AcronymAllergy said:
To add: I also believe part of the problem with some/many directives is the fact that VA is essentially as much a political organization as it is a healthcare organization. And as has already been mentioned, publicly questioning or objecting to some/many of these directives by politicians or VA leadership could be very politically detrimental, so policies are pushed more for political than evidentiary reasons. After all, not many other hospital systems have a White House complaint line.
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The VA is a public relations organization masquerading as a healthcare organization.

And I also want to say, for the record, I am not meaning my complaints to be directed at any person in a leadership position within earshot who has NOT abandoned their profession, who has not chosen money/promotions or praise from above over acknowledging the truth and doing the right thing and who has not fully surrendered themselves to the dysfunctional autocratic VA system and way of doing things. I know they're out there and obviously I don't know of their specific struggles, the things they may have sacrificed or the efforts they may have gone to in order to do a very tough job.

In my frustration, I am speaking to my direct lived experience over many years with many staff in many diverse situations.
 
Fan_of_Meehl said:
What I have encountered (over and over again) and, yes, in psychologist leaders as well is whenever concerns/questions are raised (which is exceedingly rare given the organizational climate and its tendency to punish critical discussion), the immediate responses appear directly geared toward shutting down any and all discussion. They even pre-emptively say things like, 'We're going to discuss X {some new politically/administratively unjustifiable burden on the providers}, now there's no point in saying we shouldn't be doing things this way because {the higher ups say we're going to do it and so we're going to do it}.' So, we're not really going to 'discuss' anything; we're going to receive our marching orders.

However, as I am tried making the point to them (before giving up entirely), even if 'there's nothing that we can do about it' in terms of 'reversing' some mandate from Central Office (I agree, we're not going to do that), it is still worthwhile for the front-line psychologists to be able to COMMUNICATE to their leadership (and one another) challenges, rationale (or lack thereof), implementation barriers, frustrations (and potential solutions), ethical/legal/moral dilemmas (which are frequent), and the challenge of reconciling often conflicting policies/procedures, and efforts to manage role conflicts and conflicts among various duties in the day to day clinical practice in VA outpatient settings. What I have universally experienced is the immediate tendency to 'shut down' any and all discussion. A competent and high-quality leader WANTS TO HEAR about such things from her/his subordinates because, otherwise, they are flying blind when sitting in meetings with the other 'higher-ups' and deciding local policy/procedure and can, therefore, be an articulate advocate for his/her psychology staff. Moreover, it really contributes to provider burnout to not even be able to articulate your concerns to leadership without being shut down. Finally, one psychologist may have innovated (because we have to) a decent solution to a role conflict or other clinical problem and it would be worthwhile for them to be able to share it with the group.

A couple of case examples of what I consider a failure in MH leadership all the way up and down the organization are how things like 1) caregiver support (for MH problems) and 2) service dogs have been handled over the years. And, yes, I know about the recently made public monograph on the two-arm study but that topic is worthy of its own discussion thread.

Regarding 'caregiver support' (as a paid benefit to spouses) to 'treat/manage' mental health conditions like PTSD and depression (most frequently requested). Nine or ten years ago when this was just rolling out to VA hospitals, it was obvious to any clinician worth their salt that this was a terrible idea from a mental health recovery perspective. There is no literature on using a paid family member as a 'caregiver' to treat PTSD. In fact, a very good argument can be made that it is actually iatrogenic (for reasons I can spell out if I need to). But I didn't (still don't) see any evidence of any real articulated opposition to the idea from leadership in mental health. If they DID articulate any meaningful dissenting views, why couldn't they have just shared that with us, say, in private one-on-one meetings or in service meetings? For example, 'Folks, I know this doesn't comport with the professional/scientific literature but I have raised my concerns to leadership in X meeting but we are still being given the directive.' Nope. That's not what we get. We get them 'selling' the idea to us (like it's a used car) and we're supposed to 'sell' it to veterans and/or go along with the practice. Now (finally) several years later, the organization is realizing what a bad idea caregiver support for PTSD is and they have completely re-vamped the program to handle it very differently. Would have been nice if the organization had listened 10 years ago.

There is so much to say about the service dog issue I'll try to be as brief as possible and focus on just one really frustrating part. The new idea of considering the service dog a 'prosthetic' to be 'prescribed' by a MH provider (and they came up with a new term/concept of the 'Mental Health Mobility Dog.' We are supposed to get with our 'interprofessional team' when a veteran makes a request for a 'Mental Health Mobility Dog' for his PTSD and do an 'evaluation' and if we believe that the mobility dog is the 'optimal' (their words) intervention to address his 'mental health mobility issue' then we are to write a prescription (to 'prescribe,' their word) and articulate how it is necessary to their mental health treatment plan. This is so that they can qualify to have the VA pay lifetime insurance/equipment costs for the dog. Setting aside for the moment the legal/ethical issues involved in 'prescribing' animals (for which there is no serious literature or training programs to teach folks how to do this, nor are there any references or resources in the clinical and scientific literature that operationally define such an 'assessment' procedure--in fact, it seems to be simply a (golden) rubber-stamping procedure in which everyone who wants a dog gets a dog or there will be hell to pay. And if the 'assessment' is merely a background check and review to make sure the person isn't a homeless debilitated alcoholic who hates dogs then it's trivial and doesn't require a doctoral level psychologist to complete it. Who's going to say 'no' to a veteran requesting this? Under what conditions WOULD you say no? I mean, what exactly does a 'dog prescriber' do in terms of their assessment procedures and deliberations before 'deciding' to prescribe the dog? I can take down from my bookshelf Stahl's prescriber guide and see quite clearly the things a competent medication prescriber needs to take into account, the knowledge necessary to prescribe, and the responsible execution of that duty to prescribe. The dog? What is wrong with the term 'recommend?' I'll stop, but you get the point. Where was the 'leadership' in psychology within the VA organization on this one. Did they articulate similar concerns? Where is the evidence for this? They sure as hell haven't communicated this to the rank-and-file. I imagine that when this comes down and we 'receive' 'further guidance' from on high that the 'discussion' on the topic will take the predictable form of: (1) Here is what you are to do; (2) you must comply (or else); (3) there's no point in raising concerns, objections, or ethical dilemmas about it, we have to do it so just do it.

I should also say that I'm equally disappointed in the psychology leadership/luminaries in the field OUTSIDE of the VA for failing to speak up on such issues. Back in the day when the 'recovered memory' nonsense was rampant, at least back then the leaders of the field (many of them) had the bravery to do the right thing and voice unpopular opinions regarding how this was indeed nonsense (no matter how popular in the tabloids and news). I don't see anything of the sort happening on some of these other fads recently like emotional support/ service animals as treatments for mental health conditions or caregiver support. We should expect better. We should at least expect a decent expression of their struggles (as leaders) to communicate to other non-psychologists the issues that we struggle with (and to listen to us, as we struggle to implement some of this nonsense).
Click to expand...

To answer your question about who's going to say no to service dogs: I'm going to say no. It is not clinically indicated and I will only prescribe them if I am forcced. I've gotten fired by patients in the past for saying no to dog requests or telling people that their dog is functioning as a safety behavior, so it's not like I'm not used to it.
 
cara susanna said:
To answer your question about who's going to say no to service dogs: I'm going to say no. It is not clinically indicated and I will only prescribe them if I am forcced. I've gotten fired by patients in the past for saying no to dog requests or telling people that their dog is functioning as a safety behavior, so it's not like I'm not used to it.
Click to expand...
Me too. And, in my estimation, this is a specific example of a politically-driven mandate from on high that has plummeted (in free fall fashion from on high) while encountering little to no opposition in its free fall down the levels of the organizational hierarchy to land square in the lap of the frontline clinician to have to handle on her/his own.
 
cara susanna said:
To answer your question about who's going to say no to service dogs: I'm going to say no. It is not clinically indicated and I will only prescribe them if I am forcced. I've gotten fired by patients in the past for saying no to dog requests or telling people that their dog is functioning as a safety behavior, so it's not like I'm not used to it.
Click to expand...

Vets are very reticent with their safety behaviors. I had someone referred to me for PE who had an ESA and a benzo script. In the discussion of gradual exposures, he absolutely refused to even consider ever doing anything without both of those things. I just had to say I could not see him for that particular treatment as he was essentially placing his improvement ceiling where he was currently at, and I don't do ongoing "supportive therapy" without clear goals and a trajectory of improvement on outcomes.
 
WisNeuro said:
Vets are very reticent with their safety behaviors. I had someone referred to me for PE who had an ESA and a benzo script. In the discussion of gradual exposures, he absolutely refused to even consider ever doing anything without both of those things. I just had to say I could not see him for that particular treatment as he was essentially placing his improvement ceiling where he was currently at, and I don't do ongoing "supportive therapy" without clear goals and a trajectory of improvement on outcomes.
Click to expand...
Yeah, and so you'll really get a kick of the statement on p.104 of 186 of the service dog study write-up where our best/brightest say, "In summary, we find no evidence that the use of a SERV or EMOT (service dog or ESA) worsened PTSD or avoidance behaviors in this study, nor did we find evidence that [they] interfere with PTSD recovery."

To which I say: (a) try taking the dog away and see what happens, (b) as I understand it, concurrent evidence based treatment of the vets (meds and psychotherapy) weren't controlled for...try taking those away too, and (c) if a clinician prescribes a dog (which is clearly a safety behavior/signal since it is DESIGNED to function as one, then this is incompatible with a CBT approach that emphasizes cognitive restructuring and exposure.

Haven't read the full monograph yet...working on it...it's a long read.
 
Fan_of_Meehl said:
Yeah, and so you'll really get a kick of the statement on p.104 of 186 of the service dog study write-up where our best/brightest say, "In summary, we find no evidence that the use of a SERV or EMOT (service dog or ESA) worsened PTSD or avoidance behaviors in this study, nor did we find evidence that [they] interfere with PTSD recovery."

To which I say: (a) try taking the dog away and see what happens, (b) as I understand it, concurrent evidence based treatment of the vets (meds and psychotherapy) weren't controlled for...try taking those away too, and (c) if a clinician prescribes a dog (which is clearly a safety behavior/signal since it is DESIGNED to function as one, then this is incompatible with a CBT approach that emphasizes cognitive restructuring and exposure.

Haven't read the full monograph yet...working on it...it's a long read.
Click to expand...

All depends on how they define "recovery." Also, any research out of the VA needs to be replicated in a sample not contaminated by the SC system before I'm ready to accept the results. I've seen way too many studies failing to account for validity coming out of the VA.
 
Everyone needs to keep in mind that most psychologists in the VA aren't in REAL leadership positions, They are in middle management.

The power of a "middle manager" to fix problems or discrepancies or bad policy within the VA system in almost nonexistent. They know this, and this is why one of my performance review standards when I was in the VA was something to the effect of: "Follows established polices and and clinical process with little to no resistance." And no, I am not even kidding. That was actually written down, and may have even sounded worse than what I paraphrased.

One of my performance review goals now is "provides thoughtful feedback to senior people leaders about the company's current and developing directives and policies." Think about that! That's the difference, folks!
 
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erg923 said:
Everyone needs to keep in mind that most psychologists in the VA aren't in REAL leadership positions, at least how they exist/function in the normal world. They are in middle management. The power of a middle manager to fix problems or discrepancies or bad policy within a system in almost nonexistent. They know this, and this is why one aspect of my performance review when I was there was something to the effect of "follows established polices and and clinical process with little to no resistance." No, I am not kidding. One of my performance review goals now in the real world is "provides thoughtful feedback to senior people leaders about the company's current and developing directives and policies." That's the difference, folks!
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For reference, the official VA Fact Sheet referencing 'mental health mobility service dogs' and outlining the process:

www.prosthetics.va.gov

VA.gov | Veterans Affairs

Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.
www.prosthetics.va.gov www.prosthetics.va.gov

Fact sheet is a pdf document in the web page
 
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Fan_of_Meehl said:
Yeah, and so you'll really get a kick of the statement on p.104 of 186 of the service dog study write-up where our best/brightest say, "In summary, we find no evidence that the use of a SERV or EMOT (service dog or ESA) worsened PTSD or avoidance behaviors in this study, nor did we find evidence that [they] interfere with PTSD recovery."

To which I say: (a) try taking the dog away and see what happens, (b) as I understand it, concurrent evidence based treatment of the vets (meds and psychotherapy) weren't controlled for...try taking those away too, and (c) if a clinician prescribes a dog (which is clearly a safety behavior/signal since it is DESIGNED to function as one, then this is incompatible with a CBT approach that emphasizes cognitive restructuring and exposure.

Haven't read the full monograph yet...working on it...it's a long read.
Click to expand...

Do you have a link to the study handy? I haven't read it yet but need to. I'd love to start a separate thread to discuss (I'm sure it's interesting to all psychologists, not just VA psychologists).
 
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