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

[cara susanna]

I can post it to the AACN listserv if you'd like. People will post on there for people to send to their current fellows.

That'd be awesome, thanks. I'll PM you.

---

Members don't see this ad.

 

[Fan_of_Meehl]

I lean waaaaaay too much on the fact that it's virtually impossible for the VA to fire me while also recognizing that the primary utility of metrics like RVUs is to determine whether an ACOS might be promoted to Chief of Staff and for a Medical Center Director to go to a cushier job at the VISN and so on and so forth (none of which matters to me).

So I try my bust my ass doing good patient care with my engaged veterans which is infinitely easier when I'm ignoring some policy/the SOP of the day that has little to no clinical utility for my patients. And hope I stay under the radar.

And if I get on the radar, I recognize that all kinds of things are always going wrong so it's just a matter of time before I'm off the hot seat. And realistically, the only thing VA superiors can do is inconvenience me/make me feel kinda bad (but not really).

For example, do I input formal treatment plans? Usually. But will I ever do it in MHS? Zero chance! And sometimes I'll get lazy and just include it within my therapy notes. I try not to but hey, if it happens, I'm not going to lose sleep over it.

Plus, I have absolutely zero interest in a VA promotion. Nor do I care about the possible laugably small annual bonuses (if your facility will even give them).

Someone should really author (and covertly publish) an Unofficial Survival Guide for Psychologists in Veterans Affairs Settings and you should probably a chief author, lol. Early career psychologists at VA would find it really useful (unofficially...of course).

 

[summerbabe]

Someone should really author (and covertly publish) an Unofficial Survival Guide for Psychologists in Veterans Affairs Settings and you should probably a chief author, lol. Early career psychologists at VA would find it really useful (unofficially...of course).

It would be cool to throw together an unofficial self-guided, online VA psychologist orientation, with this thread (or a condensed version) as the central component.

One of my foundational VA experiences that shaped how I approach my job was meeting a PCMHI psychologist during training who had been a decades long VA employee prior to the modernization of VA mental health.

After what was likely reshuffling and creation of nationalized MH services like BHIP, they ended up in PCMHI and while they did some access and warm handoffs apts (not as much as other PCMHI staff from what I could tell), they continued to meet with veterans from their previous caseload for hour long supportive therapy apts whenever they felt like it.

And even though this brazenly went against so many things that modern VA wants/demands, it looked like there was nothing that leadership could do to stop this (or at least those efforts were not successful) so I think they were just waiting for this person's voluntarily retirement to then fully implement PCMHI.

So we are both always a cog in the machine (I actually wouldn't mind a VA version of a Star Trek Borg designation) yet the machine isn't nearly as successful at bending you to its will as one is led to believe.

That person had a hill to die on and guess what, there wasn't much dying going on from what I observed. Except in the hearts of administrators who knew certain metrics were being sullied by that person's autonomy.

 

[Fan_of_Meehl]

It would be cool to throw together an unofficial self-guided, online VA psychologist orientation, with this thread (or a condensed version) as the central component.

One of my foundational VA experiences that shaped how I approach my job was meeting a PCMHI psychologist during training who had been a decades long VA employee prior to the modernization of VA mental health.

After what was likely reshuffling and creation of nationalized MH services like BHIP, they ended up in PCMHI and while they did some access and warm handoffs apts (not as much as other PCMHI staff from what I could tell), they continued to meet with veterans from their previous caseload for hour long supportive therapy apts whenever they felt like it.

And even though this brazenly went against so many things that modern VA wants/demands, it looked like there was nothing that leadership could do to stop this (or at least those efforts were not successful) so I think they were just waiting for this person's voluntarily retirement to then fully implement PCMHI.

So we are both always a cog in the machine (I actually wouldn't mind a VA version of a Star Trek Borg designation) yet the machine isn't nearly as successful at bending you to its will as one is led to believe.

That person had a hill to die on and guess what, there wasn't much dying going on from what I observed. Except in the hearts of administrators who knew certain metrics were being sullied by that person's autonomy.

One of the most influential yet underappreciated psychology books is Murray Sidman's Coercion and Its Fallout which was, if I recall well enough (it's been years) an accomplished applied behavior analyst's clinical experiences and observations related to the futility of attempted coercion, punishment, and basically using force to try to get people to do what you want.

Some days I dream of a bunch of all star clinicians emerging as a group collaborating to create a private alternative to VA mental health services. It'd be pretty cool.

 

[Shiori]

Fan_of_Meehl always gives me books to add to my reading list. I thoroughly enjoyed the Tyranny of Metrics, and I think it will keep burnout from creeping in as quickly.

 

[Shiori]

I'm getting a small taste of leadership. I can't say that I'm a fan. I'm meeting some really cool people though.

 

[summerbabe]

I'm getting a small taste of leadership. I can't say that I'm a fan. I'm meeting some really cool people though.

Sounds like my experience with certain illicit substances (allegedly)

 

[Sanman]

For the next time you guys watch the ICARE video, Am I the only one that thinks the psychologist office seems nicer than anything you have seen in a while? Certainly significantly larger than most offices I have been in and she does no appear to share it. Where is this office and how can I get one?

 

[cara susanna]

For the next time you guys watch the ICARE video, Am I the only one that thinks the psychologist office seems nicer than anything you have seen in a while? Certainly significantly larger than most offices I have been in and she does no appear to share it. Where is this office and how can I get one?

Well, I imagine her job running a group about the different types of IEDs is very specialized. I bet we're talking GS-14 here.

 

[Sanman]

Well, I imagine her job running a group about the different types of IEDs is very specialized. I bet we're talking GS-14 here.

How long do you think a group of veterans sit around naming IEDs without someone calling VA police to report the threat?

 

[cara susanna]

I know that I've brought this up before, but it's just such CLUNKY dialogue and I hate it. There has to be some other way of her revealing her extensive military knowledge! Thinking about it, it's also kind of hilarious that she pretty much opens her clinical interview (I assume this is an intake since this dude is new to the VA) with "What was your MOS?"

 

[Sanman]

I know that I've brought this up before, but it's just such CLUNKY dialogue and I hate it. There has to be some other way of her revealing her extensive military knowledge! Thinking about it, it's also kind of hilarious that she pretty much opens her clinical interview (I assume this is an intake since this dude is new to the VA) with "What was your MOS?"

He was in the office at least 30 seconds and she did not administer the Columbia. Are we sure this is the example central office really wants to send providers?

 

[summerbabe]

I know that I've brought this up before, but it's just such CLUNKY dialogue and I hate it. There has to be some other way of her revealing her extensive military knowledge! Thinking about it, it's also kind of hilarious that she pretty much opens her clinical interview (I assume this is an intake since this dude is new to the VA) with "What was your MOS?"

It's super cringe and inauthentic.

I'm not military, don't look like I would have been military, 100% talk/act like a civilian, never used a firearm, etc.

And I lean into that and just try to be myself and show that I care by doing things like actually listening and trying to help my patients with their problems. Novel, right?

When something military specific or firearm-related comes up that's relevant for treatment, I tell them I don't know squat but I'd super appreciative if they could explain it to me. And then we're good.

 

[Fan_of_Meehl]

I know that I've brought this up before, but it's just such CLUNKY dialogue and I hate it. There has to be some other way of her revealing her extensive military knowledge! Thinking about it, it's also kind of hilarious that she pretty much opens her clinical interview (I assume this is an intake since this dude is new to the VA) with "What was your MOS?"

It's as cringe as cringe gets. It's not a realistic excerpt of a clinician skilled at establishing rapport with veterans...it's more akin to 'marketing, PR, and infomercials' In my opinion, she comes off as a bit smug, assuming, and too sure of herself and presenting as "I'm "one of you" since I know what the acronyms 'IED' and 'MOS' stand for." The average jaded PTSD having veteran would NOT cotton to that approach in my opinion.

 

[Fan_of_Meehl]

It's super cringe and inauthentic.

I'm not military, don't look like I would have been military, 100% talk/act like a civilian, never used a firearm, etc.

And I lean into that and just try to be myself and show that I care by doing things like actually listening and trying to help my patients with their problems. Novel, right?

When something military specific or firearm-related comes up that's relevant for treatment, I tell them I don't know squat but I'd super appreciative if they could explain it to me. And then we're good.

Agreed. Authenticity and not presuming you 'get' military culture is what puts veterans at ease, not pretending to be 'one of them' or trying to convince them you know what you're doing.

 

[cara susanna]

It's super cringe and inauthentic.

I'm not military, don't look like I would have been military, 100% talk/act like a civilian, never used a firearm, etc.

And I lean into that and just try to be myself and show that I care by doing things like actually listening and trying to help my patients with their problems. Novel, right?

When something military specific or firearm-related comes up that's relevant for treatment, I tell them I don't know squat but I'd super appreciative if they could explain it to me. And then we're good.

Yup, same here. I actually don't think it's great when the VA tries to have military culture--not only does it feel inauthentic, some of that can actually be quite triggering to our patients. Like, when I worked in an MST clinic many of my patients were triggered by military stuff because they lost their military careers.

 

[PsychPhDone]

For the next time you guys watch the ICARE video, Am I the only one that thinks the psychologist office seems nicer than anything you have seen in a while? Certainly significantly larger than most offices I have been in and she does no appear to share it. Where is this office and how can I get one?

She doesn't shut the door though

 

[Fan_of_Meehl]

She doesn't shut the door though

We never shut doors in Hollywood...

 

[cara susanna]

She doesn't shut the door though

Next time I watch this video I'm keeping an eye out for that.

Really, if they want us to watch this EVERY SINGLE YEAR they should give us less to nitpick.

 

[Shiori]

Do we feel like it is better or worse than their animated videos for DEI?

 

[WisNeuro]

Next time I watch this video I'm keeping an eye out for that.

Really, if they want us to watch this EVERY SINGLE YEAR they should give us less to nitpick.

I'm nostalgic for the training video that was a Western genre.

 

[cara susanna]

Do we feel like it is better or worse than their animated videos for DEI?

Oh man, I tried to skip through the videos this year and they kept saying my training was incomplete, even after I went back and watched them (some multiple times). Never trying that again.

 

[summerbabe]

Oh man, I tried to skip through the videos this year and they kept saying my training was incomplete, even after I went back and watched them (some multiple times). Never trying that again.

For the last few TMS I've had like this, I found that if you drag the video time marker cursor thing to a few seconds before the end of each clip and then let it auto play through til the end of the video all the way, it should satisfy that requirement.

Or if you navigated away too early, it'll show that section/module/video as incomplete so hopefully you can just navigate to that specific video (or at whole module).

This strategy is also why I have absolutely zero recall of an animated DEI video lol.

 

[Shiori]

I was so excited about TMS trainings until they required so many bad ones. Now the experience of logging in makes me sad. Why do I need to know the many ways to lift a patient when I will never lift a patient? If my patient falls, they're staying on the floor until help comes. That is a 10 second video.

 

[cara susanna]

I was so excited about TMS trainings until they required so many bad ones. Now the experience of logging in makes me sad. Why do I need to know the many ways to lift a patient when I will never lift a patient? If my patient falls, they're staying on the floor until help comes. That is a 10 second video.

The toxic exposures one was ridiculous. It wasn't just irrelevant, it felt outside of my scope to the point where I was uncomfortable.

 

[Fan_of_Meehl]

For the last few TMS I've had like this, I found that if you drag the video time marker cursor thing to a few seconds before the end of each clip and then let it auto play through til the end of the video all the way, it should satisfy that requirement.

Or if you navigated away too early, it'll show that section/module/video as incomplete so hopefully you can just navigate to that specific video (or at whole module).

This strategy is also why I have absolutely zero recall of an animated DEI video lol.

"Fight LAME with LAME," I always say...I'm stealing this strat

 

[PsychPhDone]

The toxic exposures one was ridiculous. It wasn't just irrelevant, it felt outside of my scope to the point where I was uncomfortable.

Did anyone have to do the training to learn how to call a code, especially for a fire, in Atlanta? And you aren't in Atlanta?

 

[Shiori]

How do you all do intakes? We've been tinkering with different styles, but I can't get a good rhythm. It was suggested that we just do therapy orientation, general rapport building, and risk assessment for the first session, but I won't see clients again after the intake for about 2 months. Things like the BPS and the more traditional intake questions are done in 1 hour blocks across time when they come back. I think the spirit of this approach is to weed out people who don't need therapy, but it feels inefficient and drawn out. If they do come back, we schedule 2, 4, etc sessions each time to eventually build up to a dose of care.

 

[cara susanna]

How do you all do intakes? We've been tinkering with different styles, but I can't get a good rhythm. It was suggested that we just do therapy orientation, general rapport building, and risk assessment for the first session, but I won't see clients again after the intake for about 2 months. Things like the BPS and the more traditional intake questions are done in 1 hour blocks across time when they come back. I think the spirit of this approach is to weed out people who don't need therapy, but it feels inefficient and drawn out. If they do come back, we schedule 2, 4, etc sessions each time to eventually build up to a dose of care.

Review of policies and procedures, standard clinical interview with psychosocial and Columbia, then shared decision making and some broad treatment planning. This usually results in EBP assignment (ideally), assignment to an individual therapist for an active episode of care, group referral, referral outside like to community care or Vet Center, or the patient declines therapy.

 

[Fan_of_Meehl]

How do you all do intakes? We've been tinkering with different styles, but I can't get a good rhythm. It was suggested that we just do therapy orientation, general rapport building, and risk assessment for the first session, but I won't see clients again after the intake for about 2 months. Things like the BPS and the more traditional intake questions are done in 1 hour blocks across time when they come back. I think the spirit of this approach is to weed out people who don't need therapy, but it feels inefficient and drawn out. If they do come back, we schedule 2, 4, etc sessions each time to eventually build up to a dose of care.

With all the ridiculous control-freak top-down micromanagement of every single documentation aspect of outpatient psychotherapy I am in shock that no one has mandated content of the intakes yet.

My favorite stupid rule is "THOU SHALT NOT MAKETH IT TO THINE FOURTH SESSION WITHOUT A COMPLETED MENTAL HEALTH SUITE TREATMENT PLAN LEST THY AUDITOR CATCHETH THEE SLIPPIN' AND THY FLESH BE CONSIGNED TO PERISH AND DISSOLVE IN HELLFIRE AND DAMNATION FOR ALL OF ETERNITY."

 

[Shiori]

I gave up using MHS because it takes half the session to load and crashes. I just copy and paste my treatment plan from my own much more user-friendly templates with all the MHS language already embedded. There is not enough of an incentive to struggle with it, and I just don't have time. I'm getting faster, but MHS is not a priority over going home on time.

 

[summerbabe]

I gave up using MHS because it takes half the session to load and crashes. I just copy and paste my treatment plan from my own much more user-friendly templates with all the MHS language already embedded. There is not enough of an incentive to struggle with it, and I just don't have time. I'm getting faster, but MHS is not a priority over going home on time.

I think I've written about how I never open MHS anymore before but this got me thinking.

We need to start a shadow campaign to get people away from MHS. Figure out your sphere of influence at work and start targetting those people.

Plus, if Cerner ever comes online, MHS will surely not be transitioned over so any current data on usage/adherence won't even matter down the line whenever the bean counters get to MHS data.

 

[Shiori]

We regularly get chastised for not using it. Mission accomplished!

 

[deleted1038433]

Some days I dream of a bunch of all star clinicians emerging as a group collaborating to create a private alternative to VA mental health services. It'd be pretty cool.

I think this is a solid idea. Any thoughts on what veterans would actually pay out of pocket for therapy (if they currently pay nothing through VA or VA-approved community care)?

 

[AbnormalPsych]

With all the ridiculous control-freak top-down micromanagement of every single documentation aspect of outpatient psychotherapy I am in shock that no one has mandated content of the intakes yet.

My favorite stupid rule is "THOU SHALT NOT MAKETH IT TO THINE FOURTH SESSION WITHOUT A COMPLETED MENTAL HEALTH SUITE TREATMENT PLAN LEST THY AUDITOR CATCHETH THEE SLIPPIN' AND THY FLESH BE CONSIGNED TO PERISH AND DISSOLVE IN HELLFIRE AND DAMNATION FOR ALL OF ETERNITY."

I am surprised at this too.

My non-VA system requires a standard intake with a pre-set template, which obviously directs content of the intake. Sometimes this is awesome, sometimes it is not.

 

[Fan_of_Meehl]

I think I've written about how I never open MHS anymore before but this got me thinking.

We need to start a shadow campaign to get people away from MHS. Figure out your sphere of influence at work and start targetting those people.

Plus, if Cerner ever comes online, MHS will surely not be transitioned over so any current data on usage/adherence won't even matter down the line whenever the bean counters get to MHS data.

So, we literally have people (and I am almost certain they are clinical psychologists (who should be seeing patients) who review our charts (auditors) to 'catch' us not having the MH Suite 'plan' in by the THIRD session. They are getting paid to audit other psychologist's charts and play 'gotcha games' instead of seeing patients. It's ridiculous.

There have been plenty of patient charts where the patient presents to the Urgent Care clinic expressing significant current suicidality and is admitted to the inpatient unit. Guess what the C-SSRS's of those patients say...'No, No, No, No.' All 'no's' on everything, LOL. So...that happens all the time but we are paying psychologists to audit my charts (instead of seeing patients) to ensure that the MH Suite plan (basically, I put something like, 'Individual cognitive behavioral therapy with psychologist to address PTSD and related issues' or something like that) is completed in MHS and published to CPRS as soon as the third visit is completed. This place is insane.

 

[Fan_of_Meehl]

I think this is a solid idea. Any thoughts on what veterans would actually pay out of pocket for therapy (if they currently pay nothing through VA or VA-approved community care)?

Oh...I'd say about $0.00.

It'd have to be some sort of 'voucher' situation where they could choose the alternative to VA care but they'll never do that because the VA would go out of business so fast there would be 1/2 mile radius craters instantaneously appearing across the country where VA hospitals and CBOC's used to be.

 

[WisNeuro]

Oh...I'd say about $0.00.

It'd have to be some sort of 'voucher' situation where they could choose the alternative to VA care but they'll never do that because the VA would go out of business so fast there would be 1/2 mile radius craters instantaneously appearing across the country where VA hospitals and CBOC's used to be.

Depends on how much those vouchers are for and how timely they pay. The VA Choice program was generally a terrible deal for outside providers.

 

[futureapppsy2]

If we're talking VA videos, I have to admit that I love their PTSD treatment whiteboard ones and have used them in classes and presentations (I just ignore the EMDR one).

 

[futureapppsy2]

Review of policies and procedures, standard clinical interview with psychosocial and Columbia, then shared decision making and some broad treatment planning. This usually results in EBP assignment (ideally), assignment to an individual therapist for an active episode of care, group referral, referral outside like to community care or Vet Center, or the patient declines therapy.

I went to an (awesome) presentation recently by a VA psychologist and suicidologist who pointed out that the Columbia actually has little reliability and validity for assessing suicide risk--found that super interesting, as its often held up as a gold standard/standard of care.

 

[Fan_of_Meehl]

I went to an (awesome) presentation recently by a VA psychologist and suicidologist who pointed out that the Columbia actually has little reliability and validity for assessing suicide risk--found that super interesting, as its often held up as a gold standard/standard of care.

There is a reason why I refer to it as 'The Church of Suicide Prevention' (at VA, anyway).

This article has a lot of gems in it:

Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98–106. https://doi.org/10.1037/pro0000106

And...if medical staff in urgent care just flat out falsify the results...its 'reliability and validity for assessing suicide risk' is even worse.

 

[cara susanna]

If we're talking VA videos, I have to admit that I love their PTSD treatment whiteboard ones and have used them in classes and presentations (I just ignore the EMDR one).

Oh, I adore the White Board videos. We're shading the TMS ones. Really interesting (and sadly not surprising - of COURSE) about the Columbia.

Confession time: MHS is no longer loading for me, and I'm not motivated enough to get it fixed.

 

[summerbabe]

Confession time: MHS is no longer loading for me, and I'm not motivated enough to get it fixed.

Join us! (I know red pilling has taken on a totally different cultural meaning since the Matrix came out but still, once you decide to go anti-MHS, there's no going back)

 

[Sanman]

Here is a confession...I have never used MHS. My treatment plans go into a separate note as part of the primary care team.

 

[summerbabe]

Current confession: OPPE makes my blood boil since delegating this from managers (who self selected for that role) to peers is ridiculous. Not sure how this works in the private sector but damn does it piss me off.

Possible future confession: I have OPPE due and I'm thinking about checking all the boxes as present/satisfactory and not even open up the chart. Are there any consequences to this?

 

[WisNeuro]

Current confession: OPPE makes my blood boil since delegating this from managers (who self selected for that role) to peers is ridiculous. Not sure how this works in the private sector but damn does it piss me off.

Possible future confession: I have OPPE due and I'm thinking about checking all the boxes as present/satisfactory and not even open up the chart. Are there any consequences to this?

I actually liked peer review. We had a good group, and the constructive criticism actually helped to make some of my report writing better when I was an ECP in the VA. Small stuff here and there, but helpful.

 

[Shiori]

Yeah, I have no desire to check my colleagues' work for the things I'm being asked to evaluate. What I would love to have is an hour a month to do case consultation with other psychologists. Leadership feels it is unnecessary.

 

[Sanman]

Current confession: OPPE makes my blood boil since delegating this from managers (who self selected for that role) to peers is ridiculous. Not sure how this works in the private sector but damn does it piss me off.

Possible future confession: I have OPPE due and I'm thinking about checking all the boxes as present/satisfactory and not even open up the chart. Are there any consequences to this?

Something tells me that you would not be the only one and I always assumed this is what happens most of the time.

 

[cara susanna]

It's pretty easy to pass OPPE even if your notes are terrible. The criteria seem to be like not ignoring suicidality or risk, making sure you document informed consent, and have an appropriate treatment plan.

 

[summerbabe]

I actually liked peer review. We had a good group, and the constructive criticism actually helped to make some of my report writing better when I was an ECP in the VA. Small stuff here and there, but helpful.

I would also love actual peer review and really enjoy post-VA EBP rollout consultation but OPPE ain't it lol