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

[cara susanna]

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I order copies of the CPT workbooks from medical media. It works pretty well.

 

[Fan_of_Meehl]

I thought I wrote this at first 😂 We got complaints about this too and were told to use other printers in different areas of the clinic or limit to ~10-15 pages at a time (yeah right…). I have a compressed tour, so I just print everything when everyone else is gone.

You know it's bad as a doctoral-level psychologist when the janitors, the maintenance workers, and the secretaries act like they are 'higher' up on the hierarchy than you are.

 

[Fan_of_Meehl]

I order copies of the CPT workbooks from medical media. It works pretty well.

Will have to try that. I still need to occasionally make photocopies of other materials though and I never do crap like trying to copy 100+ pages at a time or anything. I'll do it maybe in batches of 30 - 50 pages at a time for the big jobs so as not to tie up the copier/printer which everyone in the office has to share.

 

[deleted1129370]

This week has been great. I submitted my letter of resignation on Tuesday, have been growing my wait list to 8 people thus far so now I have a pipeline of patients to either fill cancelled appointments or to fill the remaining slots when I am in my private practice full time, and I submitted my formal complaint against my program manager for the retaliation that started this how fiasco.

 

[cara susanna]

Oh man, our VISN just sent out an email with their plan for managing employee burnout and this is so perfect, so VA, that I had to share:

Unmanageable workload: Implement Chief Well-Being Officer (CWO)

 

[WisNeuro]

Oh man, our VISN just sent out an email with their plan for managing employee burnout and this is so perfect, so VA, that I had to share:

Unmanageable workload: Implement Chief Well-Being Officer (CWO)

Was there a asterisk?

*CWO position chosen randomly and confers no extra pay or allocated time to fulfill duties of the position. In case of CWO burnout, please implement plan C, pizza party and $5 coupons to the Canteen.

 

[Sanman]

Oh man, our VISN just sent out an email with their plan for managing employee burnout and this is so perfect, so VA, that I had to share:

Unmanageable workload: Implement Chief Well-Being Officer (CWO)

How do I get that job? I don't believe we have one of those. I also prefer to be called Happiness Champion!

 

[Fan_of_Meehl]

Oh man, our VISN just sent out an email with their plan for managing employee burnout and this is so perfect, so VA, that I had to share:

Unmanageable workload: Implement Chief Well-Being Officer (CWO)

Employee from the front lines response:

"Are you TRYING to further demoralize us?"

I can see it now, CWO implements 'Wellness Checks' in your office if you fail a chart audit.

CWO mandates 'McMindfulness' Mondays from 12:00-1:00pm (replacing the lunch break) to develop 'self-care skills'

The list goes on...

And on...

How the HECK does that address 'unmanageable workload????'

It's not burnout, it's moral injury.

I GUARANTEE you that if a CWO is implemented at our facility, they will pick a GS-13 clinical psychologist (currently with a full caseload) and elevate them out of clinical care and into the role of 'Chief Wellness Officer' (seeing zero patients).

Which, of course, means MORE workload for the remaining psychologists in patient care.

 

[Sanman]

Employee from the front lines response:

"Are you TRYING to further demoralize us?"

I can see it now, CWO implements 'Wellness Checks' in your office if you fail a chart audit.

CWO mandates 'McMindfulness' Mondays from 12:00-1:00pm (replacing the lunch break) to develop 'self-care skills'

The list goes on...

And on...

How the HECK does that address 'unmanageable workload????'

It's not burnout, it's moral injury.

I GUARANTEE you that if a CWO is implemented at our facility, they will pick a GS-13 clinical psychologist (currently with a full caseload) and elevate them out of clinical care and into the role of 'Chief Wellness Officer' (seeing zero patients).

Which, of course, means MORE workload for the remaining psychologists in patient care.

Forget that. This workload is traumatic. I want disability! I served this country as a VA employee! Also endless EAP sessions.

 

[deleted1038433]

This thread cheers me up when I get down about doing this work. I might be okay with a CWO at my VA if it was one of you folks providing more space to talk about how it really is.

 

[Fan_of_Meehl]

This thread cheers me up when I get down about doing this work. I might be okay with a CWO at my VA if it was one of you folks providing more space to talk about how it really is.

Screw it. I'm running for the 'Cut the Bull Sh!* Champion' (CTBS) position.

 

[PsychPhDone]

Employee from the front lines response:

"Are you TRYING to further demoralize us?"

I can see it now, CWO implements 'Wellness Checks' in your office if you fail a chart audit.

CWO mandates 'McMindfulness' Mondays from 12:00-1:00pm (replacing the lunch break) to develop 'self-care skills'

The list goes on...

And on...

How the HECK does that address 'unmanageable workload????'

It's not burnout, it's moral injury.

I GUARANTEE you that if a CWO is implemented at our facility, they will pick a GS-13 clinical psychologist (currently with a full caseload) and elevate them out of clinical care and into the role of 'Chief Wellness Officer' (seeing zero patients).

Which, of course, means MORE workload for the remaining psychologists in patient care.

I just want McFlurry

 

[erg923]

Oh man, our VISN just sent out an email with their plan for managing employee burnout and this is so perfect, so VA, that I had to share:

Unmanageable workload: Implement Chief Well-Being Officer (CWO)

I think someone else said it, but to add insult to this, I am 99% sure this will be an internal candidate who formerly had a caseload whose caseload will be shifted to others so that they can counsel others about the... "unmanageable caseloads."

 

[erg923]

I think someone else said it, but to add insult to this, I am 99% sure this will be an internal candidate who formerly had a caseload whose caseload will be shifted to others so that they can counsel others about the "unmanageable caseloads."

I once interviewed for the Suicide Prevention Coordinator at my former VA... many years ago now (2015, 2016?). I knew the former person and she was nice, competent, etc. Position took months (or course) after her leaving to even interview for. I remember asking questions toward the end of the interview. I don't remember what I specifically asked, but I do remember hearing a pseudo-chuckle from 2 people after my question who responded:

"Oh?...oh, no...The Suicide Prevention Coordinator doesn't see any patients."

Like, WTF!

Ironically, was kind of what I wanted to hear at the point in my VA tenure.... but I was still really shocked.

Mind you, this was maybe a year after the Shinseki access scandal that rocked the VA.

 

[AbnormalPsych]

Just wait for the mandatory training modules on your wellness

 

[Fan_of_Meehl]

I once interviewed for the Suicide Prevention Coordinator at my former VA... many years ago now (2015, 2016?). I knew the former person and she was nice, competent, etc. Position took months (or course) after her leaving to even interview for. I remember asking questions toward the end of the interview. I don't remember what I specifically asked, but I do remember a pseudo-chuckle from 2 people after my question who responded:

"Oh?...oh, no...The Suicide Prevention Coordinator doesn't see any patients."

Like, WTF!

Ironically, was kind of what I wanted to hear at the point in my VA tenure.... but I was still really shocked.

Mind you, this was maybe a year after the Shinseki access scandal that rocked the VA.

Exactly.

What has been happening, over the 10+ years I have been at my particular VA, is that there has been a proliferation of new mental health positions (for licensed MH providers) who do not see patients (SP coordinators, admin positions that were never needed before, etc.) and the facility has absolutely cannibalized the true provider (caseload-carrying, patient seeing) positions (never replacing the people in those positions, just closing them out). The result has been a net significant decrease in the number of providers who see patients, at least heavily contributing to so-called 'access issues.' To make matters worse, as the 'primary therapist' full-time positions (with semi-permanent caseloads of patients) have been eliminated, there has been a proliferation of 'specialty' positions (e.g., Pain Psychologist). Now, the Pain Psychologist conducting a single trial or course of therapy (8-10 weekly sessions) with a patient with chronic pain represents an important clinical service, no doubt. But that Pain Psychologist doesn't carry a semi-permanent caseload, per se...once they have spent those 8-10 sessions with a client...that's it...they probably will never see them again and they don't carry long-term cases. The numbers of full-time clinical staff with caseloads has gotten ridiculously small. I mean, I think there are something like 140+ staff members in the 'mental health product line' and I can count only like, I dunno, 7 or 8 psychologists/therapists who carry a full caseload and are mapped 95% (or thereabouts) clinical time. That ratio is insane. What if you asked the average Congressperson, 'About what percentage of staff in the 'mental health product line' at a VA hospital are seeing patients regularly and carry caseloads of clients?' I'll bet that Congressperson would respond with something like 70%, or at least 50%. 8/140 = ~6%. It is absolutely pathetic. There are so many staff in mental health who never or almost never interact/assess/see patients these days that it is UNREAL. And everyone I know who is unfortunate enough to actually have to see patients all day and carry a caseload is looking to retire, resign, or find some way to get promoted out of patient care.

 

[erg923]

Exactly.

What has been happening, over the 10+ years I have been at my particular VA, is that there has been a proliferation of new mental health positions (for licensed MH providers) who do not see patients (SP coordinators, admin positions that were never needed before, etc.) and the facility has absolutely cannibalized the true provider (caseload-carrying, patient seeing) positions (never replacing the people in those positions, just closing them out). The result has been a net significant decrease in the number of providers who see patients, at least heavily contributing to so-called 'access issues.' To make matters worse, as the 'primary therapist' full-time positions (with semi-permanent caseloads of patients) have been eliminated, there has been a proliferation of 'specialty' positions (e.g., Pain Psychologist). Now, the Pain Psychologist conducting a single trial or course of therapy (8-10 weekly sessions) with a patient with chronic pain represents an important clinical service, no doubt. But that Pain Psychologist doesn't carry a semi-permanent caseload, per se...once they have spent those 8-10 sessions with a client...that's it...they probably will never see them again and they don't carry long-term cases. The numbers of full-time clinical staff with caseloads has gotten ridiculously small. I mean, I think there are something like 140+ staff members in the 'mental health product line' and I can count only like, I dunno, 7 or 8 psychologists/therapists who carry a full caseload and are mapped 95% (or thereabouts) clinical time. That ratio is insane. What if you asked the average Congressperson, 'About what percentage of staff in the 'mental health product line' at a VA hospital are seeing patients regularly and carry caseloads of clients?' I'll bet that Congressperson would respond with something like 70%, or at least 50%. 8/140 = ~6%. It is absolutely pathetic. There are so many staff in mental health who never or almost never interact/assess/see patients these days that it is UNREAL. And everyone I know who is unfortunate enough to actually have to see patients all day and carry a caseload is looking to retire, resign, or find some way to get promoted out of patient care.

Yo! Paragraphs, chief?

 

[Sanman]

Exactly.

What has been happening, over the 10+ years I have been at my particular VA, is that there has been a proliferation of new mental health positions (for licensed MH providers) who do not see patients (SP coordinators, admin positions that were never needed before, etc.) and the facility has absolutely cannibalized the true provider (caseload-carrying, patient seeing) positions (never replacing the people in those positions, just closing them out). The result has been a net significant decrease in the number of providers who see patients, at least heavily contributing to so-called 'access issues.' To make matters worse, as the 'primary therapist' full-time positions (with semi-permanent caseloads of patients) have been eliminated, there has been a proliferation of 'specialty' positions (e.g., Pain Psychologist). Now, the Pain Psychologist conducting a single trial or course of therapy (8-10 weekly sessions) with a patient with chronic pain represents an important clinical service, no doubt. But that Pain Psychologist doesn't carry a semi-permanent caseload, per se...once they have spent those 8-10 sessions with a client...that's it...they probably will never see them again and they don't carry long-term cases. The numbers of full-time clinical staff with caseloads has gotten ridiculously small. I mean, I think there are something like 140+ staff members in the 'mental health product line' and I can count only like, I dunno, 7 or 8 psychologists/therapists who carry a full caseload and are mapped 95% (or thereabouts) clinical time. That ratio is insane. What if you asked the average Congressperson, 'About what percentage of staff in the 'mental health product line' at a VA hospital are seeing patients regularly and carry caseloads of clients?' I'll bet that Congressperson would respond with something like 70%, or at least 50%. 8/140 = ~6%. It is absolutely pathetic. There are so many staff in mental health who never or almost never interact/assess/see patients these days that it is UNREAL. And everyone I know who is unfortunate enough to actually have to see patients all day and carry a caseload is looking to retire, resign, or find some way to get promoted out of patient care.

I agree with the sentiment, but your example is flawed. When it comes to congress (a group of people who spend more time fundraising than actually working), I think they would be more accurate than most people in the real world. After all, they work the same way.

 

[cara susanna]

Cancellation via VEText is like Schroedinger's cancellation.

Sometimes I wonder if the private sector would allow that - accidentally cancelling an appt, but then still getting to be seen after showing up.

 

[PsychPhDone]

Cancellation via VEText is like Schroedinger's cancellation.

Sometimes I wonder if the private sector would allow that - accidentally cancelling an appt, but then still getting to be seen after showing up.

Part of my session zero stuff includes a discussion of never using vetext to cancel or confirm but nobody listens. 😎

 

[cara susanna]

Being forced to attend Whole Health after Whole Health training that tells me the same thing over and over again (and the concepts weren't exactly new even the first time around) has broken me.

 

[erg923]

Hi! Im Troy MClure.....

 

[Sanman]

Being forced to attend Whole Health after Whole Health training that tells me the same thing over and over again (and the concepts weren't exactly new even the first time around) has broken me.

View attachment 376103

Did they teach you how to do diaphragmatic breathing? Did someone suggest yoga to destress?

 

[WisNeuro]

Did they teach you how to do diaphragmatic breathing? Did someone suggest yoga to destress?

Are you sure you're Work/Life balancing the right way? Maybe try ReikiSpotting. It's my new technique that combines Reiki and Brainspotting. Twice the pseudosceince jargon. Twice the placebo effect. Only $1200 for my 2/hour workshop.

 

[Sanman]

Are you sure you're Work/Life balancing the right way? Maybe try ReikiSpotting. It's my new technique that combines Reiki and Brainspotting. Twice the pseudosceince jargon. Twice the placebo effect. Only $1200 for my 2/hour workshop.

Do I then get a ReikiSpotting certification? Definitely charging $400/hr for sessions after that.

 

[cara susanna]

Did they teach you how to do diaphragmatic breathing? Did someone suggest yoga to destress?

I learned the importance of setting collaborative goals and meeting patients where they're at. You know, brand new concepts to mental health staff.

Imagine if we had mandatory annual trainings on, like, the importance of EBPs and how to talk to patients about them, etc. But, nope, hypnosis!

 

[WisNeuro]

Do I then get a ReikiSpotting certification? Definitely charging $400/hr for sessions after that.

Yes, but the certification is only good for one year, after which you need the "refresher" course for recertification. Only $900 for a one hour powerpoint presentation that I update slightly year over year.

 

[Fan_of_Meehl]

Being forced to attend Whole Health after Whole Health training that tells me the same thing over and over again (and the concepts weren't exactly new even the first time around) has broken me.

View attachment 376103

So saith the Shamans of Sloganeering.

Go for a walk.

Do not walk in front of trains.

Eat your veggies.

So saith our 'Whole Health' overlords.

 

[thebalmofhurtminds]

Someone thought they would be funny and give me an aneurysm by sending me a TikTok where the person identified themselves as a trauma and brainspotting specialist and then described a basic grounding technique that they somehow tied to brainspotting.

 

[deleted1129370]

I belong to some Facebook groups for networking/referrals and I just see a flood of posts like "ISO of therapist who is BIPOC, anti-capitalist, gender fluid, licensed in CA and has PSYPACT, is EMDR certified who also does brainspotting." And all the while I sit there smiling thinking to myself "I have better odds at winning tonight's Powerball than that person has finding that unicorn."

 

[AcronymAllergy]

This story seems at least somewhat relevant to this thread:

https://www.washingtonpost.com/politics/2023/08/27/faa-pilots-health-conditions-va-benefits/

Some of the statements the various officials and other sources make are (surprisingly) pretty strong.

 

[Fan_of_Meehl]

This story seems at least somewhat relevant to this thread:

https://www.washingtonpost.com/politics/2023/08/27/faa-pilots-health-conditions-va-benefits/

Some of the statements the various officials and other sources make are (surprisingly) pretty strong.

The statements aren't strong enough. Believe it or not...it's actually worse.

And it's not just the overreporting/misattribution/malingering/fraud angle. It's everything. All these (never discussed, never admitted, never studied) problems that we can't talk about interact and reciprocally worsen one another. Symptom over-reporting, 'access' to psychotherapy, 'recruitment/retention' problems (for psychologists). There is no leadership. This will all come out in the coming decades. No one is at the wheel. No one is in the pilot's seat. It is unimaginably corrupt, inept, inefficient, and even profane (considering the many BILLIONS of dollars (increasing every year) dumped into this organization. And the only reason it isn't front page news is the Aegis (shield), sociopolitically, that protects the organization from anyone ever asking tough questions about anything related to veterans. No veteran would ever mis-state anything. Ever. They're not humans. They're not fallible. They don't respond to monetary incentives. No veteran would ever be motivated by money (understandibly) to try to continue to feed/clothe their family, or try to improve their situation. Again, they're not human beings, they're marble statues/ caricatures that we pretend to worship, but don't really care about. If we really cared about them, we wouldn't be afraid to tell them the truth (or, at least, not collusively lie to and for them) and try to actually help them in straightforward ways and cut all the political BS. Facts are stubborn things (as ole John Adams once wrote) and reality will seep out into the public awareness eventually. But not for a good long while yet.

Here's the current actual state of affairs at VA with respect to outpatient mental health psychotherapy. Not the slogans. Not the bullet points. Not the ideological BS, the actual situation:

- Outpatient therapists (mostly psychologists) are tired of having all authority stripped from them and all responsibility being dumped on them. They are tired of being held responsible for implementing a theoretical 'model' of care (see below) that is failing in every way and there is absolutely zero accountability and leadership being practiced in the organization. Clinicians are leaving. Excellent clinicians. Well-trained and credentialed (some with ABPP's) clinicians who actually care about providing the best clinical science-based treatments for veterans who are really seeking psychotherapy. They are leaving for private practice, retirement, or...other non-clinical positions if their buddies higher up can manage to create one for them.

- The numbers of veterans presenting for and (ostensibly) seeking 'help' for their MH conditions (esp. PTSD) continue to accelerate whilst the leaders continue to fail to provide adequate staffing for mental health therapy, preferring instead to create cushy non-clinical positions for their friends who can now do most of their work for them. It's a sweet gig, if you can get it, I suppose. But they are cannibalizing direct-care caseload-bearing full-time psychology positions (and not backfilling them) in order to dilute their adminstrative workloads and reward their political cronies for their 'loyalty' to the inner party.

- Given the above, we have so-called 'access' issues. But, here's the truth--here's the adult conversation that we cannot even have at VA because it is run by children--or, cynical people pretending to be child-like in their idealism/faux-ignorance. Money motivates people and influences behavior, especially behavior as trivial as circling '4's' on a symptom self-report measure rather than zero's, one's or two's. It's one thing if you're a social worker who has never been properly trained as a behavior analyst. However, it takes an epic exhibition of being disingenuous to be someone (like many psychologists in leadership positions are) fully trained in the importance of consequences in their effect on human behavior and to pretend like you don't understand this issue. These people have laid aside their 'clinician' cloak and donned the purple and gold of politician/Prince (or Princess, as the case may be). They must be assigning Machiavelli as required reading in grad school these days.

- I have been full-time in psychotherapy in this organization for years. I was well-trained as an effective, active cognitive-behavioral therapist (fully versed in protocol treatments in the anxiety disorders since the mid-1990's) so...I kind of know what I'm doing. I was trained intensively by people who publish some of the top textbooks (and training materials) on how to implement cognitive and cognitive behavioral therapy. I also had experience prior to trying to do this at the VA so I know what the average psychotherapy patient is like (outside the VA system). Here's the thing: the majority (probably the vast majority) of veterans presenting (ostensibly) for 'therapy' are not actually (if you look at their behavior, their place on the transtheoretical model for readiness for behavior change) here for therapy. They are saying one thing and their behavior is saying the opposite. Or, they are in legitimately in pre-contemplation. It's everyone else's fault. They need more money. They need 'caregiver support' for PTSD. They need $40,000 service animals. They need medical marijuana. They need excuses. They need me to write a letter saying that they are permanently 'unemployable.' They need me to write a letter saying they need 100%. They need ANYTHING other than an expert behavioral consultant trying to help them identify thoughts/beliefs and/or behaviors that are contributing to their problems. They need anything OTHER THAN actual active psychotherapy. They say they need 'help'/psychotherapy but their behavior says the opposite. Not doing self-monitoring or homework, even the lowest response effort ones we can devise. Not coming to appointments. No-showing, cancelling, coming late, leaving early. There is no copay for free therapy (not even $5). There is no fee for no-showing/cancelling. Again, behavior is a function of its consequences. There is no end to the auditioning for higher service-connection benefits or any other things (caregiver support, unemployability, etc.). I would estimate that only about 10%-15% are actually here for therapy and ready for therapy and, therefore, are actually an efficient use of a therapist's skills/efforts. The 'dirty-little-secret,' the truth about the so-called 'access crisis' is that it doesn't exist. Fundamentally, there are no access issues with respect to psychotherapy. There are systems issues that waste, on an epic scale, the limited resource of skilled psychotherapy due to failures in leadership. Period.

- 'Leadership' would be shocked to hear this and would say I'm delusional. They're delusional (or pretending to be). They don't WANT to know the true causes of the 'access' issues because they don't want to take responsibility for actually publicly identifying and addressing these sorts of problems. They are terrified of 'looking bad.' They are not interested in doing or being 'good.' They are interested in 'not looking bad.' This is not leadership. It's pure politics, plain and simple. And it will continue due to the structural pathology of the system. It will continue because taxpayers are forced to shell out many BILLIONS of dollars to be wasted on a system that burns out and runs off psychology ABPP's under mountains of work while (I crap you not) other staff members organize and participate in 'cornhole tournaments'--by God, the jokes write themselves in this clownish hellhole--(for staff, not veterans) during working hours and get paid for playing and socializing because their duties are so non-existent that they actually have to come up with formal staff-entertainment (carnivals) so they don't get so bored at work. It's profane.

As far as the 'access' issue is concerned, I have solutions. Specific solutions. I've done natural 'experiments' with respect to what 'works' (in getting people in, and getting people out of therapy, appropriately) in this system and actually have data that can be verified on what works and what doesn't work. Hard, verifiable data. Easy to examine. Easy to verify. Data that paints a crystal clear picture. No one is interested in these data. No one actually wants solutions. I offer specific solutions and only get back a bunch of BS excuses, deflections, and clouds of squid ink ejected into the air to cover a retreat from this topic of conversation.

You know how 'productivity' is measured (with respect to 'feedback' on how well you're doing as a therapist in this system). For performance evaluations? For promotions? It is 100% RVU based. So, the more bloated/backed up your caseload is, the more time you spend yapping with your veterans up to 55 minutes per session, the less effective you are getting people in/out? You got great 'productivity.' Even though you're seeing people, on average, between 3 and 6 months in between 'psychotherapy' sessions. It is fraudulent. You're not 'doing psychotherapy' but you have 100+ 'clients' whom you see and just chat with once every few months and you have 'awesome' productivity.

Here is actual productivity: Number of unique veterans (per time period, say, one year) in your individual clinics MINUS the number of veterans (unique) who are STILL scheduled to see you in a future psychotherapy appointment and MINUS the number of veterans that you 'pawned off' on other providers by abusing the consultation system (basically, sent to other providers to their caseloads). It takes 5th grade arithmetic and maybe an hour (just because of how clunky CPRS is) for me to calculate this for my clinics for the past year. And this is ACTUAL 'productivity' of a clinician...how many people do you effectively and appropriately 'process' in and out of your clinics per year.

But here's the thing. You have to ACTUALLY be able to schedule people weekly (or fortnightly) for therapy. This bullcrap of seeing them once a month or less frequently is NOT therapy and you will have people 'attending' 'psychotherapy' appointments for the rest of their lives. It turns out (empirically...provably) that if you schedule ALL your veterans for weekly/biweekly therapy, this forces people to either (a) engage in the therapy, or (b) passively drop out of the therapy (because no one is going to place their service-connection in peril by actually admitting they don't want therapy). But this causes no-shows and cancellations (as the veterans passively drop out of therapy). This hurts your 'productivity.' MSA's (secretaries) start complaining about your people no-showing and canceling because it's more work for them (and secretaries run VA). So, politically, that's 'bad.' And it hurt's your RVU-based 'productivity.' And, it turns out, it's actually A LOT of work to actually do weekly active psychotherapy with folks.

I hear rumblings that there is an 'episode of care' model that we're getting ready to move to. Hurray. It will probably be ham-fisted and authoritarian in its implementation. One size fits all (with all the attendant problems). Rationing of care. It's unintelligent.

We need a system that effectively separates out those who are here for therapy (as defined by their BEHAVIOR, not self-report) so that we're only doing weekly therapy with people who are actually there for weekly therapy.

We need to have a VALID measure of clinician 'productivity' (similar to the above).

We need to essentially 'outlaw,' by policy/procedure, the scheduling/re-scheduling of any 'psychotherapy' courses where the time between sessions is anything but weekly/fornightly. You can set a monthly followup after implementing a real course of weekly psychotherapy but no more monthly 'check-ins' as 'psychotherapy.'

We need to have people actually supervising the clinical adequacy of psychotherapeutic care delivered by their subordinates and peers. The bi-annual 'peer reviews' are a sick joke.

We need leaders who actually make tough calls. Who actually listen to their subordinates on the front lines. Who actually make decisions and change institutional practices in the direction that would actually address the real problems. We're not going to get that. It's not the VA culture (which is the opposite of that).

We need research that actually directly addresses the issues causing the so-called 'access problem' even if it raises uncomfortable sociopolitical issues or may (God forbid) involve the possibility of making a politician/'leader' uncomfortable.

At VA 'Institutions of Excellentology' (or whatever they're called) they are dabbling in the black-magic multivariate arts of scrying the multiverse for signs of latent constructs associated with veteran's self-report on PCL-5's (what a joke) but none of them (as far as I can tell, if they have, point me to the document/article) have actually looked at the average rate of influx/efflux of patients into a psychotherapist's clinic in a year. What is the appropriate 'panel size' for psychotherapy? What is the rate of flow in/out of the average full-time clinician's caseload in VA? Should the inflow be higher or lower? Should the outflow be higher or lower? How do people 'leave' caseloads, by percentage/empirically? What percentage agree to terminate psychotherapy? What percentage passively drop out via no-shows and cancellations? What percentage 'leave' clinician A's caseload because they 'dumped' the patient on clinician B? What 'scams' are being set up in clinics for patients to be 'passed around' and 'touched' as unique patients (e.g., via multiple unnecessary referrals/services) in order to artificially inflate their 'numbers of uniques?' Leadership is absolutely TERRIFIED of studying and publishing these data because they would make them 'look bad.' Well...too bad. This needs to end.

Maybe it will all slowly collapse/disintegrate over the next decade or two. I tell ya, it will open up some massive opportunities in private practice if these billions of dollars shoveled into the inefficacious VA system get redirected to competent private companies providing real care.

In the meantime, I am getting experience in what really works (and doesn't work) with this population presenting for care. I am developing my own understanding (through direct experience) with what models actually work (and don't). I can do it. I can teach it. It works. But no one in 'leadership' is interested. That's cool.

Edit: Thinking a bit more deeply on it, the equation for actual productivity would be something like:

(number of uniques in your clinics - number 'sent' to other providers (to go into their caseload)) / number of uniques still on your schedule (on the books for future appointments)

This is a formula/ratio that a 5th grader could calculate and interpret.

Why is no one interested in this statistic? Why has no one even done a DESCRIPTIVE, informal study on this statistic?

You have to make it a bit of a ratio because you need to account for size of caseload.

There is a certain number of cases that you can process in/out of your clinic (appropriately) in a year. Why in the hell has no 'leader' in the VA system empirically examined this? It's so trivially easy to do. Answer: it would make us 'look bad.' Well...it IS bad. Time to be adults and face up to this reality and start cleaning this place up.

 

[Fan_of_Meehl]

I learned the importance of setting collaborative goals and meeting patients where they're at. You know, brand new concepts to mental health staff.

Imagine if we had mandatory annual trainings on, like, the importance of EBPs and how to talk to patients about them, etc. But, nope, hypnosis!

For clients who have no-showed or canceled >50% of their scheduled therapy appointments, I have insisted that we (a) attempt to address their reported 'barriers' to attendance and (b) created formal documented goals such as 'will attend 50% or more (at least 3 out of 6) scheduled psychotherapy sessions on time.' I'm not even kidding.

 

[deleted1038433]

The statements aren't strong enough. Believe it or not...it's actually worse.

And it's not just the overreporting/misattribution/malingering/fraud angle. It's everything. All these (never discussed, never admitted, never studied) problems that we can't talk about interact and reciprocally worsen one another. Symptom over-reporting, 'access' to psychotherapy, 'recruitment/retention' problems (for psychologists). There is no leadership. This will all come out in the coming decades. No one is at the wheel. No one is in the pilot's seat. It is unimaginably corrupt, inept, inefficient, and even profane (considering the many BILLIONS of dollars (increasing every year) dumped into this organization. And the only reason it isn't front page news is the Aegis (shield), sociopolitically, that protects the organization from anyone ever asking tough questions about anything related to veterans. No veteran would ever mis-state anything. Ever. They're not humans. They're not fallible. They don't respond to monetary incentives. No veteran would ever be motivated by money (understandibly) to try to continue to feed/clothe their family, or try to improve their situation. Again, they're not human beings, they're marble statues/ caricatures that we pretend to worship, but don't really care about. If we really cared about them, we wouldn't be afraid to tell them the truth (or, at least, not collusively lie to and for them) and try to actually help them in straightforward ways and cut all the political BS. Facts are stubborn things (as ole John Adams once wrote) and reality will seep out into the public awareness eventually. But not for a good long while yet.

Here's the current actual state of affairs at VA with respect to outpatient mental health psychotherapy. Not the slogans. Not the bullet points. Not the ideological BS, the actual situation:

- Outpatient therapists (mostly psychologists) are tired of having all authority stripped from them and all responsibility being dumped on them. They are tired of being held responsible for implementing a theoretical 'model' of care (see below) that is failing in every way and there is absolutely zero accountability and leadership being practiced in the organization. Clinicians are leaving. Excellent clinicians. Well-trained and credentialed (some with ABPP's) clinicians who actually care about providing the best clinical science-based treatments for veterans who are really seeking psychotherapy. They are leaving for private practice, retirement, or...other non-clinical positions if their buddies higher up can manage to create one for them.

- The numbers of veterans presenting for and (ostensibly) seeking 'help' for their MH conditions (esp. PTSD) continue to accelerate whilst the leaders continue to fail to provide adequate staffing for mental health therapy, preferring instead to create cushy non-clinical positions for their friends who can now do most of their work for them. It's a sweet gig, if you can get it, I suppose. But they are cannibalizing direct-care caseload-bearing full-time psychology positions (and not backfilling them) in order to dilute their adminstrative workloads and reward their political cronies for their 'loyalty' to the inner party.

- Given the above, we have so-called 'access' issues. But, here's the truth--here's the adult conversation that we cannot even have at VA because it is run by children--or, cynical people pretending to be child-like in their idealism/faux-ignorance. Money motivates people and influences behavior, especially behavior as trivial as circling '4's' on a symptom self-report measure rather than zero's, one's or two's. It's one thing if you're a social worker who has never been properly trained as a behavior analyst. However, it takes an epic exhibition of being disingenuous to be someone (like many psychologists in leadership positions are) fully trained in the importance of consequences in their effect on human behavior and to pretend like you don't understand this issue. These people have laid aside their 'clinician' cloak and donned the purple and gold of politician/Prince (or Princess, as the case may be). They must be assigning Machiavelli as required reading in grad school these days.

- I have been full-time in psychotherapy in this organization for years. I was well-trained as an effective, active cognitive-behavioral therapist (fully versed in protocol treatments in the anxiety disorders since the mid-1990's) so...I kind of know what I'm doing. I was trained intensively by people who publish some of the top textbooks (and training materials) on how to implement cognitive and cognitive behavioral therapy. I also had experience prior to trying to do this at the VA so I know what the average psychotherapy patient is like (outside the VA system). Here's the thing: the majority (probably the vast majority) of veterans presenting (ostensibly) for 'therapy' are not actually (if you look at their behavior, their place on the transtheoretical model for readiness for behavior change) here for therapy. They are saying one thing and their behavior is saying the opposite. Or, they are in legitimately in pre-contemplation. It's everyone else's fault. They need more money. They need 'caregiver support' for PTSD. They need $40,000 service animals. They need medical marijuana. They need excuses. They need me to write a letter saying that they are permanently 'unemployable.' They need me to write a letter saying they need 100%. They need ANYTHING other than an expert behavioral consultant trying to help them identify thoughts/beliefs and/or behaviors that are contributing to their problems. They need anything OTHER THAN actual active psychotherapy. They say they need 'help'/psychotherapy but their behavior says the opposite. Not doing self-monitoring or homework, even the lowest response effort ones we can devise. Not coming to appointments. No-showing, cancelling, coming late, leaving early. There is no copay for free therapy (not even $5). There is no fee for no-showing/cancelling. Again, behavior is a function of its consequences. There is no end to the auditioning for higher service-connection benefits or any other things (caregiver support, unemployability, etc.). I would estimate that only about 10%-15% are actually here for therapy and ready for therapy and, therefore, are actually an efficient use of a therapist's skills/efforts. The 'dirty-little-secret,' the truth about the so-called 'access crisis' is that it doesn't exist. Fundamentally, there are no access issues with respect to psychotherapy. There are systems issues that waste, on an epic scale, the limited resource of skilled psychotherapy due to failures in leadership. Period.

- 'Leadership' would be shocked to hear this and would say I'm delusional. They're delusional (or pretending to be). They don't WANT to know the true causes of the 'access' issues because they don't want to take responsibility for actually publicly identifying and addressing these sorts of problems. They are terrified of 'looking bad.' They are not interested in doing or being 'good.' They are interested in 'not looking bad.' This is not leadership. It's pure politics, plain and simple. And it will continue due to the structural pathology of the system. It will continue because taxpayers are forced to shell out many BILLIONS of dollars to be wasted on a system that burns out and runs off psychology ABPP's under mountains of work while (I crap you not) other staff members organize and participate in 'cornhole tournaments'--by God, the jokes write themselves in this clownish hellhole--(for staff, not veterans) during working hours and get paid for playing and socializing because their duties are so non-existent that they actually have to come up with formal staff-entertainment (carnivals) so they don't get so bored at work. It's profane.

As far as the 'access' issue is concerned, I have solutions. Specific solutions. I've done natural 'experiments' with respect to what 'works' (in getting people in, and getting people out of therapy, appropriately) in this system and actually have data that can be verified on what works and what doesn't work. Hard, verifiable data. Easy to examine. Easy to verify. Data that paints a crystal clear picture. No one is interested in these data. No one actually wants solutions. I offer specific solutions and only get back a bunch of BS excuses, deflections, and clouds of squid ink ejected into the air to cover a retreat from this topic of conversation.

You know how 'productivity' is measured (with respect to 'feedback' on how well you're doing as a therapist in this system). For performance evaluations? For promotions? It is 100% RVU based. So, the more bloated/backed up your caseload is, the more time you spend yapping with your veterans up to 55 minutes per session, the less effective you are getting people in/out? You got great 'productivity.' Even though you're seeing people, on average, between 3 and 6 months in between 'psychotherapy' sessions. It is fraudulent. You're not 'doing psychotherapy' but you have 100+ 'clients' whom you see and just chat with once every few months and you have 'awesome' productivity.

Here is actual productivity: Number of unique veterans (per time period, say, one year) in your individual clinics MINUS the number of veterans (unique) who are STILL scheduled to see you in a future psychotherapy appointment and MINUS the number of veterans that you 'pawned off' on other providers by abusing the consultation system (basically, sent to other providers to their caseloads). It takes 5th grade arithmetic and maybe an hour (just because of how clunky CPRS is) for me to calculate this for my clinics for the past year. And this is ACTUAL 'productivity' of a clinician...how many people do you effectively and appropriately 'process' in and out of your clinics per year.

But here's the thing. You have to ACTUALLY be able to schedule people weekly (or fortnightly) for therapy. This bullcrap of seeing them once a month or less frequently is NOT therapy and you will have people 'attending' 'psychotherapy' appointments for the rest of their lives. It turns out (empirically...provably) that if you schedule ALL your veterans for weekly/biweekly therapy, this forces people to either (a) engage in the therapy, or (b) passively drop out of the therapy (because no one is going to place their service-connection in peril by actually admitting they don't want therapy). But this causes no-shows and cancellations (as the veterans passively drop out of therapy). This hurts your 'productivity.' MSA's (secretaries) start complaining about your people no-showing and canceling because it's more work for them (and secretaries run VA). So, politically, that's 'bad.' And it hurt's your RVU-based 'productivity.' And, it turns out, it's actually A LOT of work to actually do weekly active psychotherapy with folks.

I hear rumblings that there is an 'episode of care' model that we're getting ready to move to. Hurray. It will probably be ham-fisted and authoritarian in its implementation. One size fits all (with all the attendant problems). Rationing of care. It's unintelligent.

We need a system that effectively separates out those who are here for therapy (as defined by their BEHAVIOR, not self-report) so that we're only doing weekly therapy with people who are actually there for weekly therapy.

We need to have a VALID measure of clinician 'productivity' (similar to the above).

We need to essentially 'outlaw,' by policy/procedure, the scheduling/re-scheduling of any 'psychotherapy' courses where the time between sessions is anything but weekly/fornightly. You can set a monthly followup after implementing a real course of weekly psychotherapy but no more monthly 'check-ins' as 'psychotherapy.'

We need to have people actually supervising the clinical adequacy of psychotherapeutic care delivered by their subordinates and peers. The bi-annual 'peer reviews' are a sick joke.

We need leaders who actually make tough calls. Who actually listen to their subordinates on the front lines. Who actually make decisions and change institutional practices in the direction that would actually address the real problems. We're not going to get that. It's not the VA culture (which is the opposite of that).

We need research that actually directly addresses the issues causing the so-called 'access problem' even if it raises uncomfortable sociopolitical issues or may (God forbid) involve the possibility of making a politician/'leader' uncomfortable.

At VA 'Institutions of Excellentology' (or whatever they're called) they are dabbling in the black-magic multivariate arts of scrying the multiverse for signs of latent constructs associated with veteran's self-report on PCL-5's (what a joke) but none of them (as far as I can tell, if they have, point me to the document/article) have actually looked at the average rate of influx/efflux of patients into a psychotherapist's clinic in a year. What is the appropriate 'panel size' for psychotherapy? What is the rate of flow in/out of the average full-time clinician's caseload in VA? Should the inflow be higher or lower? Should the outflow be higher or lower? How do people 'leave' caseloads, by percentage/empirically? What percentage agree to terminate psychotherapy? What percentage passively drop out via no-shows and cancellations? What percentage 'leave' clinician A's caseload because they 'dumped' the patient on clinician B? What 'scams' are being set up in clinics for patients to be 'passed around' and 'touched' as unique patients (e.g., via multiple unnecessary referrals/services) in order to artificially inflate their 'numbers of uniques?' Leadership is absolutely TERRIFIED of studying and publishing these data because they would make them 'look bad.' Well...too bad. This needs to end.

Maybe it will all slowly collapse/disintegrate over the next decade or two. I tell ya, it will open up some massive opportunities in private practice if these billions of dollars shoveled into the inefficacious VA system get redirected to competent private companies providing real care.

In the meantime, I am getting experience in what really works (and doesn't work) with this population presenting for care. I am developing my own understanding (through direct experience) with what models actually work (and don't). I can do it. I can teach it. It works. But no one in 'leadership' is interested. That's cool.

Edit: Thinking a bit more deeply on it, the equation for actual productivity would be something like:

(number of uniques in your clinics - number 'sent' to other providers (to go into their caseload)) / number of uniques still on your schedule (on the books for future appointments)

This is a formula/ratio that a 5th grader could calculate and interpret.

Why is no one interested in this statistic? Why has no one even done a DESCRIPTIVE, informal study on this statistic?

You have to make it a bit of a ratio because you need to account for size of caseload.

There is a certain number of cases that you can process in/out of your clinic (appropriately) in a year. Why in the hell has no 'leader' in the VA system empirically examined this? It's so trivially easy to do. Answer: it would make us 'look bad.' Well...it IS bad. Time to be adults and face up to this reality and start cleaning this place up.

I'm curious what you have found to be a good number of individual therapy cases that you see from start to finish in a year. I am specifically wondering about folks who are 100% clinical and have 20 or so hour long individual slots a week.

 

[Sanman]

The statements aren't strong enough. Believe it or not...it's actually worse.

And it's not just the overreporting/misattribution/malingering/fraud angle. It's everything. All these (never discussed, never admitted, never studied) problems that we can't talk about interact and reciprocally worsen one another. Symptom over-reporting, 'access' to psychotherapy, 'recruitment/retention' problems (for psychologists). There is no leadership. This will all come out in the coming decades. No one is at the wheel. No one is in the pilot's seat. It is unimaginably corrupt, inept, inefficient, and even profane (considering the many BILLIONS of dollars (increasing every year) dumped into this organization. And the only reason it isn't front page news is the Aegis (shield), sociopolitically, that protects the organization from anyone ever asking tough questions about anything related to veterans. No veteran would ever mis-state anything. Ever. They're not humans. They're not fallible. They don't respond to monetary incentives. No veteran would ever be motivated by money (understandibly) to try to continue to feed/clothe their family, or try to improve their situation. Again, they're not human beings, they're marble statues/ caricatures that we pretend to worship, but don't really care about. If we really cared about them, we wouldn't be afraid to tell them the truth (or, at least, not collusively lie to and for them) and try to actually help them in straightforward ways and cut all the political BS. Facts are stubborn things (as ole John Adams once wrote) and reality will seep out into the public awareness eventually. But not for a good long while yet.

Here's the current actual state of affairs at VA with respect to outpatient mental health psychotherapy. Not the slogans. Not the bullet points. Not the ideological BS, the actual situation:

- Outpatient therapists (mostly psychologists) are tired of having all authority stripped from them and all responsibility being dumped on them. They are tired of being held responsible for implementing a theoretical 'model' of care (see below) that is failing in every way and there is absolutely zero accountability and leadership being practiced in the organization. Clinicians are leaving. Excellent clinicians. Well-trained and credentialed (some with ABPP's) clinicians who actually care about providing the best clinical science-based treatments for veterans who are really seeking psychotherapy. They are leaving for private practice, retirement, or...other non-clinical positions if their buddies higher up can manage to create one for them.

- The numbers of veterans presenting for and (ostensibly) seeking 'help' for their MH conditions (esp. PTSD) continue to accelerate whilst the leaders continue to fail to provide adequate staffing for mental health therapy, preferring instead to create cushy non-clinical positions for their friends who can now do most of their work for them. It's a sweet gig, if you can get it, I suppose. But they are cannibalizing direct-care caseload-bearing full-time psychology positions (and not backfilling them) in order to dilute their adminstrative workloads and reward their political cronies for their 'loyalty' to the inner party.

- Given the above, we have so-called 'access' issues. But, here's the truth--here's the adult conversation that we cannot even have at VA because it is run by children--or, cynical people pretending to be child-like in their idealism/faux-ignorance. Money motivates people and influences behavior, especially behavior as trivial as circling '4's' on a symptom self-report measure rather than zero's, one's or two's. It's one thing if you're a social worker who has never been properly trained as a behavior analyst. However, it takes an epic exhibition of being disingenuous to be someone (like many psychologists in leadership positions are) fully trained in the importance of consequences in their effect on human behavior and to pretend like you don't understand this issue. These people have laid aside their 'clinician' cloak and donned the purple and gold of politician/Prince (or Princess, as the case may be). They must be assigning Machiavelli as required reading in grad school these days.

- I have been full-time in psychotherapy in this organization for years. I was well-trained as an effective, active cognitive-behavioral therapist (fully versed in protocol treatments in the anxiety disorders since the mid-1990's) so...I kind of know what I'm doing. I was trained intensively by people who publish some of the top textbooks (and training materials) on how to implement cognitive and cognitive behavioral therapy. I also had experience prior to trying to do this at the VA so I know what the average psychotherapy patient is like (outside the VA system). Here's the thing: the majority (probably the vast majority) of veterans presenting (ostensibly) for 'therapy' are not actually (if you look at their behavior, their place on the transtheoretical model for readiness for behavior change) here for therapy. They are saying one thing and their behavior is saying the opposite. Or, they are in legitimately in pre-contemplation. It's everyone else's fault. They need more money. They need 'caregiver support' for PTSD. They need $40,000 service animals. They need medical marijuana. They need excuses. They need me to write a letter saying that they are permanently 'unemployable.' They need me to write a letter saying they need 100%. They need ANYTHING other than an expert behavioral consultant trying to help them identify thoughts/beliefs and/or behaviors that are contributing to their problems. They need anything OTHER THAN actual active psychotherapy. They say they need 'help'/psychotherapy but their behavior says the opposite. Not doing self-monitoring or homework, even the lowest response effort ones we can devise. Not coming to appointments. No-showing, cancelling, coming late, leaving early. There is no copay for free therapy (not even $5). There is no fee for no-showing/cancelling. Again, behavior is a function of its consequences. There is no end to the auditioning for higher service-connection benefits or any other things (caregiver support, unemployability, etc.). I would estimate that only about 10%-15% are actually here for therapy and ready for therapy and, therefore, are actually an efficient use of a therapist's skills/efforts. The 'dirty-little-secret,' the truth about the so-called 'access crisis' is that it doesn't exist. Fundamentally, there are no access issues with respect to psychotherapy. There are systems issues that waste, on an epic scale, the limited resource of skilled psychotherapy due to failures in leadership. Period.

- 'Leadership' would be shocked to hear this and would say I'm delusional. They're delusional (or pretending to be). They don't WANT to know the true causes of the 'access' issues because they don't want to take responsibility for actually publicly identifying and addressing these sorts of problems. They are terrified of 'looking bad.' They are not interested in doing or being 'good.' They are interested in 'not looking bad.' This is not leadership. It's pure politics, plain and simple. And it will continue due to the structural pathology of the system. It will continue because taxpayers are forced to shell out many BILLIONS of dollars to be wasted on a system that burns out and runs off psychology ABPP's under mountains of work while (I crap you not) other staff members organize and participate in 'cornhole tournaments'--by God, the jokes write themselves in this clownish hellhole--(for staff, not veterans) during working hours and get paid for playing and socializing because their duties are so non-existent that they actually have to come up with formal staff-entertainment (carnivals) so they don't get so bored at work. It's profane.

As far as the 'access' issue is concerned, I have solutions. Specific solutions. I've done natural 'experiments' with respect to what 'works' (in getting people in, and getting people out of therapy, appropriately) in this system and actually have data that can be verified on what works and what doesn't work. Hard, verifiable data. Easy to examine. Easy to verify. Data that paints a crystal clear picture. No one is interested in these data. No one actually wants solutions. I offer specific solutions and only get back a bunch of BS excuses, deflections, and clouds of squid ink ejected into the air to cover a retreat from this topic of conversation.

You know how 'productivity' is measured (with respect to 'feedback' on how well you're doing as a therapist in this system). For performance evaluations? For promotions? It is 100% RVU based. So, the more bloated/backed up your caseload is, the more time you spend yapping with your veterans up to 55 minutes per session, the less effective you are getting people in/out? You got great 'productivity.' Even though you're seeing people, on average, between 3 and 6 months in between 'psychotherapy' sessions. It is fraudulent. You're not 'doing psychotherapy' but you have 100+ 'clients' whom you see and just chat with once every few months and you have 'awesome' productivity.

Here is actual productivity: Number of unique veterans (per time period, say, one year) in your individual clinics MINUS the number of veterans (unique) who are STILL scheduled to see you in a future psychotherapy appointment and MINUS the number of veterans that you 'pawned off' on other providers by abusing the consultation system (basically, sent to other providers to their caseloads). It takes 5th grade arithmetic and maybe an hour (just because of how clunky CPRS is) for me to calculate this for my clinics for the past year. And this is ACTUAL 'productivity' of a clinician...how many people do you effectively and appropriately 'process' in and out of your clinics per year.

But here's the thing. You have to ACTUALLY be able to schedule people weekly (or fortnightly) for therapy. This bullcrap of seeing them once a month or less frequently is NOT therapy and you will have people 'attending' 'psychotherapy' appointments for the rest of their lives. It turns out (empirically...provably) that if you schedule ALL your veterans for weekly/biweekly therapy, this forces people to either (a) engage in the therapy, or (b) passively drop out of the therapy (because no one is going to place their service-connection in peril by actually admitting they don't want therapy). But this causes no-shows and cancellations (as the veterans passively drop out of therapy). This hurts your 'productivity.' MSA's (secretaries) start complaining about your people no-showing and canceling because it's more work for them (and secretaries run VA). So, politically, that's 'bad.' And it hurt's your RVU-based 'productivity.' And, it turns out, it's actually A LOT of work to actually do weekly active psychotherapy with folks.

I hear rumblings that there is an 'episode of care' model that we're getting ready to move to. Hurray. It will probably be ham-fisted and authoritarian in its implementation. One size fits all (with all the attendant problems). Rationing of care. It's unintelligent.

We need a system that effectively separates out those who are here for therapy (as defined by their BEHAVIOR, not self-report) so that we're only doing weekly therapy with people who are actually there for weekly therapy.

We need to have a VALID measure of clinician 'productivity' (similar to the above).

We need to essentially 'outlaw,' by policy/procedure, the scheduling/re-scheduling of any 'psychotherapy' courses where the time between sessions is anything but weekly/fornightly. You can set a monthly followup after implementing a real course of weekly psychotherapy but no more monthly 'check-ins' as 'psychotherapy.'

We need to have people actually supervising the clinical adequacy of psychotherapeutic care delivered by their subordinates and peers. The bi-annual 'peer reviews' are a sick joke.

We need leaders who actually make tough calls. Who actually listen to their subordinates on the front lines. Who actually make decisions and change institutional practices in the direction that would actually address the real problems. We're not going to get that. It's not the VA culture (which is the opposite of that).

We need research that actually directly addresses the issues causing the so-called 'access problem' even if it raises uncomfortable sociopolitical issues or may (God forbid) involve the possibility of making a politician/'leader' uncomfortable.

At VA 'Institutions of Excellentology' (or whatever they're called) they are dabbling in the black-magic multivariate arts of scrying the multiverse for signs of latent constructs associated with veteran's self-report on PCL-5's (what a joke) but none of them (as far as I can tell, if they have, point me to the document/article) have actually looked at the average rate of influx/efflux of patients into a psychotherapist's clinic in a year. What is the appropriate 'panel size' for psychotherapy? What is the rate of flow in/out of the average full-time clinician's caseload in VA? Should the inflow be higher or lower? Should the outflow be higher or lower? How do people 'leave' caseloads, by percentage/empirically? What percentage agree to terminate psychotherapy? What percentage passively drop out via no-shows and cancellations? What percentage 'leave' clinician A's caseload because they 'dumped' the patient on clinician B? What 'scams' are being set up in clinics for patients to be 'passed around' and 'touched' as unique patients (e.g., via multiple unnecessary referrals/services) in order to artificially inflate their 'numbers of uniques?' Leadership is absolutely TERRIFIED of studying and publishing these data because they would make them 'look bad.' Well...too bad. This needs to end.

Maybe it will all slowly collapse/disintegrate over the next decade or two. I tell ya, it will open up some massive opportunities in private practice if these billions of dollars shoveled into the inefficacious VA system get redirected to competent private companies providing real care.

In the meantime, I am getting experience in what really works (and doesn't work) with this population presenting for care. I am developing my own understanding (through direct experience) with what models actually work (and don't). I can do it. I can teach it. It works. But no one in 'leadership' is interested. That's cool.

Edit: Thinking a bit more deeply on it, the equation for actual productivity would be something like:

(number of uniques in your clinics - number 'sent' to other providers (to go into their caseload)) / number of uniques still on your schedule (on the books for future appointments)

This is a formula/ratio that a 5th grader could calculate and interpret.

Why is no one interested in this statistic? Why has no one even done a DESCRIPTIVE, informal study on this statistic?

You have to make it a bit of a ratio because you need to account for size of caseload.

There is a certain number of cases that you can process in/out of your clinic (appropriately) in a year. Why in the hell has no 'leader' in the VA system empirically examined this? It's so trivially easy to do. Answer: it would make us 'look bad.' Well...it IS bad. Time to be adults and face up to this reality and start cleaning this place up.

Well, that was a long post. While I agree with most of what you said, I disagree about the privatization part. While there are many good private organization for mental health. There are plenty that are happy to defraud the government and have you bill for services ad infinitum. While the VA is beholden to political strawmen (as you point out), the private sector is beholden to profit margins (particularly as private equity enters the healthcare space). Clinical freedom in the VA, much like academic freedom at universities, was a large draw of the job in the past. Both of those things are disappearing quickly. Now, you get to choose from one or the other unless you work for yourself.

 

[Fan_of_Meehl]

I'm curious what you have found to be a good number of individual therapy cases that you see from start to finish in a year. I am specifically wondering about folks who are 100% clinical and have 20 or so hour long individual slots a week.

Past year, started with no caseload in new clinic position. In all of my individual clinics, saw a total 107 cases/uniques for psychotherapy in past year. Groups I ran would probably add at least 20 more. As of about last week, had exactly 19 clients (all weekly) scheduled for future sessions. Also 2hrs/wk blocked for intern supervision.

 

[cara susanna]

This story seems at least somewhat relevant to this thread:

https://www.washingtonpost.com/politics/2023/08/27/faa-pilots-health-conditions-va-benefits/

Some of the statements the various officials and other sources make are (surprisingly) pretty strong.

Although there are definitely issues with the VA disability system, don't get me started on the FAA and mental health. My husband's a pilot so I know a lot about this topic, and as a mental health professional it is deeply upsetting how they view almost any mental health treatment as disqualifying.

 

[WisNeuro]

Although there are definitely issues with the VA disability system, don't get me started on the FAA and mental health. My husband's a pilot so I know a lot about this topic, and as a mental health professional it is deeply upsetting how they view almost any mental health treatment as disqualifying.

I get it, I've been through FAA HIMS training. At least on the neuro side, IMO, they're pretty lenient, and people are actually allowed to re-take the eval after a near miss. But, this is a case of sens/spec. Due to the potential risks, the FAA should be much more willing to false positive screen someone out, than to false negative someone in who may not be safe. Not a perfect system, by any means, but if they are going to err in one direction, that's the direction I want them to err towards.

 

[cara susanna]

I get it, I've been through FAA HIMS training. At least on the neuro side, IMO, they're pretty lenient, and people are actually allowed to re-take the eval after a near miss. But, this is a case of sens/spec. Due to the potential risks, the FAA should be much more willing to false positive screen someone out, than to false negative someone in who may not be safe. Not a perfect system, by any means, but if they are going to err in one direction, that's the direction I want them to err towards.

I do agree that I'd rather be safe than sorry, but I also think that the FAA's current approach only encourages people to hide their conditions and not seek treatment. I'd much rather have a pilot who's getting active treatment than one who's trying to deal on their own (or using alcohol to cope, as I've also seen a lot).

 

[cara susanna]

Finished reading the WaPo article and it definitely seems that the VA defines "disability" waaay too loosely (I mean, I would have agreed with that already, just further confirmed it for me).

 

[AcronymAllergy]

Finished reading the WaPo article and it definitely seems that the VA defines "disability" waaay too loosely (I mean, I would have agreed with that already, just further confirmed it for me).

I think the amounts and the portion about a 100% rating may surprise some people unfamiliar with the system.

I also think it's pretty shady for the evaluating physicians to encourage pilots to hide or minimize VA-related disability/diagnosis, since the pilots being evaluated could end up paying for it.

 

[Fan_of_Meehl]

For reference, here is a paragraph summarizing the criteria for a 100% disability rating for a mental health condition in the VA system. It is a one-size-fits-all (disorders) type setup and the symptoms at this level appear to be sampling from the domain of severe brain damage/dementia and severe mental illness (schizophrenia) domains but are most frequently applied to folks with anxiety, depression, and PTSD in that system. I have had plenty of veterans employed in full-time stressful/challenging jobs (high paying jobs) as well as some literally running their own businesses who have expressed outrage toward me that they are not rated at 100% and have tried to give me a hard time about it. I have refused to lie to or for them and they made their way out of my caseload:

Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.

 

[Fan_of_Meehl]

And, oh yeah, some of the clinical presentations range from bemusing to outright hilarious when they start trying to tell me all about their 'delusions/paranoia' (self-labeled/ diagnosed) and how they keep forgetting their own name.

 

[erg923]

Although there are definitely issues with the VA disability system, don't get me started on the FAA and mental health. My husband's a pilot so I know a lot about this topic, and as a mental health professional it is deeply upsetting how they view almost any mental health treatment as disqualifying.

There are some professions were there just has to be near zero tolerance for risk associated

 

[ccpsych16]

I got an email about a job fair at Psych Congress and one of the benefits of a VA career they listed was “low provider-to-patient ratios” 🙄

 

[Fan_of_Meehl]

I got an email about a job fair at Psych Congress and one of the benefits of a VA career they listed was “low provider-to-patient ratios” 🙄

I am assuming they didn't say what 'low' meant. I mean 100 is lower than 500.

 

[Sanman]

I got an email about a job fair at Psych Congress and one of the benefits of a VA career they listed was “low provider-to-patient ratios” 🙄

Completely true. There is a low ratio of providers for the number of patients. Not to be confused with low patient to provider ratio.😉

 

[erg923]

The statements aren't strong enough. Believe it or not...it's actually worse.

And it's not just the overreporting/misattribution/malingering/fraud angle. It's everything. All these (never discussed, never admitted, never studied) problems that we can't talk about interact and reciprocally worsen one another. Symptom over-reporting, 'access' to psychotherapy, 'recruitment/retention' problems (for psychologists). There is no leadership. This will all come out in the coming decades. No one is at the wheel. No one is in the pilot's seat. It is unimaginably corrupt, inept, inefficient, and even profane (considering the many BILLIONS of dollars (increasing every year) dumped into this organization. And the only reason it isn't front page news is the Aegis (shield), sociopolitically, that protects the organization from anyone ever asking tough questions about anything related to veterans. No veteran would ever mis-state anything. Ever. They're not humans. They're not fallible. They don't respond to monetary incentives. No veteran would ever be motivated by money (understandibly) to try to continue to feed/clothe their family, or try to improve their situation. Again, they're not human beings, they're marble statues/ caricatures that we pretend to worship, but don't really care about. If we really cared about them, we wouldn't be afraid to tell them the truth (or, at least, not collusively lie to and for them) and try to actually help them in straightforward ways and cut all the political BS. Facts are stubborn things (as ole John Adams once wrote) and reality will seep out into the public awareness eventually. But not for a good long while yet.

Here's the current actual state of affairs at VA with respect to outpatient mental health psychotherapy. Not the slogans. Not the bullet points. Not the ideological BS, the actual situation:

- Outpatient therapists (mostly psychologists) are tired of having all authority stripped from them and all responsibility being dumped on them. They are tired of being held responsible for implementing a theoretical 'model' of care (see below) that is failing in every way and there is absolutely zero accountability and leadership being practiced in the organization. Clinicians are leaving. Excellent clinicians. Well-trained and credentialed (some with ABPP's) clinicians who actually care about providing the best clinical science-based treatments for veterans who are really seeking psychotherapy. They are leaving for private practice, retirement, or...other non-clinical positions if their buddies higher up can manage to create one for them.

- The numbers of veterans presenting for and (ostensibly) seeking 'help' for their MH conditions (esp. PTSD) continue to accelerate whilst the leaders continue to fail to provide adequate staffing for mental health therapy, preferring instead to create cushy non-clinical positions for their friends who can now do most of their work for them. It's a sweet gig, if you can get it, I suppose. But they are cannibalizing direct-care caseload-bearing full-time psychology positions (and not backfilling them) in order to dilute their adminstrative workloads and reward their political cronies for their 'loyalty' to the inner party.

- Given the above, we have so-called 'access' issues. But, here's the truth--here's the adult conversation that we cannot even have at VA because it is run by children--or, cynical people pretending to be child-like in their idealism/faux-ignorance. Money motivates people and influences behavior, especially behavior as trivial as circling '4's' on a symptom self-report measure rather than zero's, one's or two's. It's one thing if you're a social worker who has never been properly trained as a behavior analyst. However, it takes an epic exhibition of being disingenuous to be someone (like many psychologists in leadership positions are) fully trained in the importance of consequences in their effect on human behavior and to pretend like you don't understand this issue. These people have laid aside their 'clinician' cloak and donned the purple and gold of politician/Prince (or Princess, as the case may be). They must be assigning Machiavelli as required reading in grad school these days.

- I have been full-time in psychotherapy in this organization for years. I was well-trained as an effective, active cognitive-behavioral therapist (fully versed in protocol treatments in the anxiety disorders since the mid-1990's) so...I kind of know what I'm doing. I was trained intensively by people who publish some of the top textbooks (and training materials) on how to implement cognitive and cognitive behavioral therapy. I also had experience prior to trying to do this at the VA so I know what the average psychotherapy patient is like (outside the VA system). Here's the thing: the majority (probably the vast majority) of veterans presenting (ostensibly) for 'therapy' are not actually (if you look at their behavior, their place on the transtheoretical model for readiness for behavior change) here for therapy. They are saying one thing and their behavior is saying the opposite. Or, they are in legitimately in pre-contemplation. It's everyone else's fault. They need more money. They need 'caregiver support' for PTSD. They need $40,000 service animals. They need medical marijuana. They need excuses. They need me to write a letter saying that they are permanently 'unemployable.' They need me to write a letter saying they need 100%. They need ANYTHING other than an expert behavioral consultant trying to help them identify thoughts/beliefs and/or behaviors that are contributing to their problems. They need anything OTHER THAN actual active psychotherapy. They say they need 'help'/psychotherapy but their behavior says the opposite. Not doing self-monitoring or homework, even the lowest response effort ones we can devise. Not coming to appointments. No-showing, cancelling, coming late, leaving early. There is no copay for free therapy (not even $5). There is no fee for no-showing/cancelling. Again, behavior is a function of its consequences. There is no end to the auditioning for higher service-connection benefits or any other things (caregiver support, unemployability, etc.). I would estimate that only about 10%-15% are actually here for therapy and ready for therapy and, therefore, are actually an efficient use of a therapist's skills/efforts. The 'dirty-little-secret,' the truth about the so-called 'access crisis' is that it doesn't exist. Fundamentally, there are no access issues with respect to psychotherapy. There are systems issues that waste, on an epic scale, the limited resource of skilled psychotherapy due to failures in leadership. Period.

- 'Leadership' would be shocked to hear this and would say I'm delusional. They're delusional (or pretending to be). They don't WANT to know the true causes of the 'access' issues because they don't want to take responsibility for actually publicly identifying and addressing these sorts of problems. They are terrified of 'looking bad.' They are not interested in doing or being 'good.' They are interested in 'not looking bad.' This is not leadership. It's pure politics, plain and simple. And it will continue due to the structural pathology of the system. It will continue because taxpayers are forced to shell out many BILLIONS of dollars to be wasted on a system that burns out and runs off psychology ABPP's under mountains of work while (I crap you not) other staff members organize and participate in 'cornhole tournaments'--by God, the jokes write themselves in this clownish hellhole--(for staff, not veterans) during working hours and get paid for playing and socializing because their duties are so non-existent that they actually have to come up with formal staff-entertainment (carnivals) so they don't get so bored at work. It's profane.

As far as the 'access' issue is concerned, I have solutions. Specific solutions. I've done natural 'experiments' with respect to what 'works' (in getting people in, and getting people out of therapy, appropriately) in this system and actually have data that can be verified on what works and what doesn't work. Hard, verifiable data. Easy to examine. Easy to verify. Data that paints a crystal clear picture. No one is interested in these data. No one actually wants solutions. I offer specific solutions and only get back a bunch of BS excuses, deflections, and clouds of squid ink ejected into the air to cover a retreat from this topic of conversation.

You know how 'productivity' is measured (with respect to 'feedback' on how well you're doing as a therapist in this system). For performance evaluations? For promotions? It is 100% RVU based. So, the more bloated/backed up your caseload is, the more time you spend yapping with your veterans up to 55 minutes per session, the less effective you are getting people in/out? You got great 'productivity.' Even though you're seeing people, on average, between 3 and 6 months in between 'psychotherapy' sessions. It is fraudulent. You're not 'doing psychotherapy' but you have 100+ 'clients' whom you see and just chat with once every few months and you have 'awesome' productivity.

Here is actual productivity: Number of unique veterans (per time period, say, one year) in your individual clinics MINUS the number of veterans (unique) who are STILL scheduled to see you in a future psychotherapy appointment and MINUS the number of veterans that you 'pawned off' on other providers by abusing the consultation system (basically, sent to other providers to their caseloads). It takes 5th grade arithmetic and maybe an hour (just because of how clunky CPRS is) for me to calculate this for my clinics for the past year. And this is ACTUAL 'productivity' of a clinician...how many people do you effectively and appropriately 'process' in and out of your clinics per year.

But here's the thing. You have to ACTUALLY be able to schedule people weekly (or fortnightly) for therapy. This bullcrap of seeing them once a month or less frequently is NOT therapy and you will have people 'attending' 'psychotherapy' appointments for the rest of their lives. It turns out (empirically...provably) that if you schedule ALL your veterans for weekly/biweekly therapy, this forces people to either (a) engage in the therapy, or (b) passively drop out of the therapy (because no one is going to place their service-connection in peril by actually admitting they don't want therapy). But this causes no-shows and cancellations (as the veterans passively drop out of therapy). This hurts your 'productivity.' MSA's (secretaries) start complaining about your people no-showing and canceling because it's more work for them (and secretaries run VA). So, politically, that's 'bad.' And it hurt's your RVU-based 'productivity.' And, it turns out, it's actually A LOT of work to actually do weekly active psychotherapy with folks.

I hear rumblings that there is an 'episode of care' model that we're getting ready to move to. Hurray. It will probably be ham-fisted and authoritarian in its implementation. One size fits all (with all the attendant problems). Rationing of care. It's unintelligent.

We need a system that effectively separates out those who are here for therapy (as defined by their BEHAVIOR, not self-report) so that we're only doing weekly therapy with people who are actually there for weekly therapy.

We need to have a VALID measure of clinician 'productivity' (similar to the above).

We need to essentially 'outlaw,' by policy/procedure, the scheduling/re-scheduling of any 'psychotherapy' courses where the time between sessions is anything but weekly/fornightly. You can set a monthly followup after implementing a real course of weekly psychotherapy but no more monthly 'check-ins' as 'psychotherapy.'

We need to have people actually supervising the clinical adequacy of psychotherapeutic care delivered by their subordinates and peers. The bi-annual 'peer reviews' are a sick joke.

We need leaders who actually make tough calls. Who actually listen to their subordinates on the front lines. Who actually make decisions and change institutional practices in the direction that would actually address the real problems. We're not going to get that. It's not the VA culture (which is the opposite of that).

We need research that actually directly addresses the issues causing the so-called 'access problem' even if it raises uncomfortable sociopolitical issues or may (God forbid) involve the possibility of making a politician/'leader' uncomfortable.

At VA 'Institutions of Excellentology' (or whatever they're called) they are dabbling in the black-magic multivariate arts of scrying the multiverse for signs of latent constructs associated with veteran's self-report on PCL-5's (what a joke) but none of them (as far as I can tell, if they have, point me to the document/article) have actually looked at the average rate of influx/efflux of patients into a psychotherapist's clinic in a year. What is the appropriate 'panel size' for psychotherapy? What is the rate of flow in/out of the average full-time clinician's caseload in VA? Should the inflow be higher or lower? Should the outflow be higher or lower? How do people 'leave' caseloads, by percentage/empirically? What percentage agree to terminate psychotherapy? What percentage passively drop out via no-shows and cancellations? What percentage 'leave' clinician A's caseload because they 'dumped' the patient on clinician B? What 'scams' are being set up in clinics for patients to be 'passed around' and 'touched' as unique patients (e.g., via multiple unnecessary referrals/services) in order to artificially inflate their 'numbers of uniques?' Leadership is absolutely TERRIFIED of studying and publishing these data because they would make them 'look bad.' Well...too bad. This needs to end.

Maybe it will all slowly collapse/disintegrate over the next decade or two. I tell ya, it will open up some massive opportunities in private practice if these billions of dollars shoveled into the inefficacious VA system get redirected to competent private companies providing real care.

In the meantime, I am getting experience in what really works (and doesn't work) with this population presenting for care. I am developing my own understanding (through direct experience) with what models actually work (and don't). I can do it. I can teach it. It works. But no one in 'leadership' is interested. That's cool.

Edit: Thinking a bit more deeply on it, the equation for actual productivity would be something like:

(number of uniques in your clinics - number 'sent' to other providers (to go into their caseload)) / number of uniques still on your schedule (on the books for future appointments)

This is a formula/ratio that a 5th grader could calculate and interpret.

Why is no one interested in this statistic? Why has no one even done a DESCRIPTIVE, informal study on this statistic?

You have to make it a bit of a ratio because you need to account for size of caseload.

There is a certain number of cases that you can process in/out of your clinic (appropriately) in a year. Why in the hell has no 'leader' in the VA system empirically examined this? It's so trivially easy to do. Answer: it would make us 'look bad.' Well...it IS bad. Time to be adults and face up to this reality and start cleaning this place up.

VA scope of responsibility creep has been ongoing since 2003. I am not a big believer that it needs to be what it is has become.

It's bloated in many parts, understaffed in many parts, and overall trying to do too much in the mental health realm. There is little way out of it, at this point, though.

The idea that ones occupation alone (no matter how brief) should entitle one to a lifetime of free services that most of us could not even dream of is something I have NOT bought into. If you were drafted/conscription....different story.

 

[WisNeuro]

Completely true. There is a low ratio of providers for the number of patients. Not to be confused with low patient to provider ratio.😉

Compared to other systems, I would definitely agree that the VA has the much more favorable provider to patient ratio. The VA has its problems, but it's kind of a complete ****show for patients in most big systems. Granted, I don't ever want to be a provider in the VA again, but I do think that, on average, their patients who need MH services do FAR better than most people outside of the VA.

 

[Sanman]

Compared to other systems, I would definitely agree that the VA has the much more favorable provider to patient ratio. The VA has its problems, but it's kind of a complete ****show for patients in most big systems. Granted, I don't ever want to be a provider in the VA again, but I do think that, on average, their patients who need MH services do FAR better than most people outside of the VA.

That is simply because the VA has employees to handle this and most hospital systems in the community simply do not. The most they will do is have psychiatry throw a pill at you. The issue with the VA is not the ratio of patients to providers so much as it is a problem of unlimited free services and secondary gain. I could easily see the same 8-10 "problem children" in my program in perpetuity and make my numbers without ever doing another intake. Why? because I am in primary care and the VA has unlimited services ad no right to refuse care. The most I could do is put them on my "wait list....except that is not allowed. That said, a lot the cbocs have been understaffed for years due to the requirements to show understaffing before any position is approved.

It is literally, need 5 positons...okay, hire one new position and show us that you are still understaffed.....wait 1-2 years for labor mapping data. See, we need more positions because we are understaffed...wait the 1 person we hired quit because they are overworked. Back to square one.