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

[deleted1129370]

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Same situation at my VA. I understand that the availability of full-time telework jobs in private practice is siphoning off a lot of would-be VA applicants, but it seems like that doesn't account for the recruiting difficulties entirely. It's a really interesting problem to me.

It doesn't 🙂

 

[Fan_of_Meehl]

That's how I feel - I'm also in a position that's perfect for me and a senior psychologist in our clinic (which is mildly hilarious because I haven't been here that long) but feeling just burnout related to systems issues that will not be resolved. Recruitment is also an issue and hopefully senior leadership will eventually grant higher pay because we are NOT filling psychologists jobs.

We are at critical 'skeleton-crew' level staffing as well for psychologists.

 

[Sanman]

That's how I feel - I'm also in a position that's perfect for me and a senior psychologist in our clinic (which is mildly hilarious because I haven't been here that long) but feeling just burnout related to systems issues that will not be resolved. Recruitment is also an issue and hopefully senior leadership will eventually grant higher pay because we are NOT filling psychologists jobs.

Did you guys get a special pay rate? If not, that is on your psychology chief and mental health service. Beyond that, the VA is banking on things like EDRP and PSLF to lure in early career folks. Late career folks have the good pension. Mid career are being thrown under the bus.

 

[Sanman]

VA not making full use of workforce incentives granted under PACT Act, AFGE warns | Federal News Network

 

[AcronymAllergy]

Yeah, VA has been very late to the game with compensation in general, but they've done a better job remaining at least quasi-competitive with most physician specialty salaries (and showing more respect for physicians in general) than with psychologists. I imagine much of that relates to what WisNeuro mentioned--for a long time, the VA was seen as a great opportunity, with solid pay, for psychologists (at least early- to mid-career). That's much less the case now. Before I left, we lost multiple applicants to other job offers that paid more, had fewer administrative headaches, and got back to the applicant more quickly about their status. Even when people accepted offers, it took 6+ months to actually hire (because psychologists couldn't be direct-hired), so they'd often just take another position instead.

VA seems to be coming around a bit now, but they're behind the eight ball. And IMO, they deserve it, as they've taken psychologists for granted for many years. Offering bonuses on par with physicians in terms of % of salary would be a good first step (in addition to making the special pay rates more permanent and universal). I also think all VA training directors should be GS14, but that's another battle.

Although to be fair, there are also a small number of VA psychologists (as with any specialty) who very much take advantage of the VA system to coast into unfathomable levels of unproductivity, and who are often among the most vocally against any efforts regarding productivity benchmarks, which gives a bad name to all VA psychologists. As psychologists, we can't expect/request more pay if we're constantly losing a system money because we're seeing 8 therapy patients/week and taking two-hour lunch breaks every day.

 

[summerbabe]

Same situation at my VA. I understand that the availability of full-time telework jobs in private practice is siphoning off a lot of would-be VA applicants, but it seems like that doesn't account for the recruiting difficulties entirely. It's a really interesting problem to me.

Agreed - I am connected with a couple of different systems and the primary new talent that are being brought in at entry level, in-person BHIP/PCMHI jobs largely appear to be fresh PsyD grads (who likely have significant debt and are probably receiving EDRP).

I was just starting grad school 10 years ago but it seems like the overall job market for clinicians is way better now.

A few more VA specific factors IMO:
- Competitive pay & private sector perks as mentioned by others.
- USAJobs is easy enough to navigate once you get a hang of the process but applying for jobs and never hearing back or even being able to contact hiring managers with questions is surely a turnoff.
- It's usually unnecessarily hard for trainees who would be open to a VA career (even if it's brief) to move into staff positions because positions are not available upon internship completion (e.g., local hiring freeze), jobs are not available at suitable geographic locations or the hiring process is too cumbersome/requires too much applicant flexibility (e.g., wait between internship/postdoc completion and making money again due to long onboarding processes).
- Lots of rural VAs will struggle even more due to local migration trends and lack of replacement options when people leave positions (even if pay is incentivized).
- Essentially zero ability to negotiate on your own behalf, which is especially bad for people who don't need VA benefits such as govt health insurance for a family member with significant medical needs.
- Lack of flexibility, especially if people have caretaking responsibilities that don't work well a standard VA schedule.
- Low/no desire to work with the veteran population, either through lack of exposure or desire. Most VAs don't do a ton of practicum training (including many with internship/fellowship programs), which would be crucial in exposing grad students to this population and system during a formative period of the their career development.

 

[SikeThatsTheWrongNumber]

- Essentially zero ability to negotiate on your own behalf, which is especially bad for people who don't need VA benefits such as govt health insurance for a family member with significant medical needs.

Recruitment incentives can be negotiated now. Someone at our VA managed to negotiate over $100,000 (essentially a sign-on bonus).

 

[Sanman]

Recruitment incentives can be negotiated now. Someone at our VA managed to negotiate over $100,000 (essentially a sign-on bonus).

That is a shocking number. I am surprised that the sign on was that large for a non-prescriber.

 

[Fan_of_Meehl]

Recruitment incentives can be negotiated now. Someone at our VA managed to negotiate over $100,000 (essentially a sign-on bonus).

Were they a psychologist or an SES level assassin?

 

[summerbabe]

Recruitment incentives can be negotiated now. Someone at our VA managed to negotiate over $100,000 (essentially a sign-on bonus).

I, summerbabe, would like to thank my supervisor, chief of psychology, co-workers, and support staff for an amazing three years that have been full of valuable personal and professional growth. I would not be the psychologist that I am today without your support. With that said, I am announcing my intent to enter the transfer portal to explore other opportunities.

 

[cara susanna]

Did you guys get a special pay rate? If not, that is on your psychology chief and mental health service. Beyond that, the VA is banking on things like EDRP and PSLF to lure in early career folks. Late career folks have the good pension. Mid career are being thrown under the bus.

Yes, but it was less than half of what was requested and not nearly enough. Psychology leadership and I believe division leadership are pushing for medical center leadership to grant another that would be more commensurate with the market.

We've literally had candidates turn down offers because they would be taking a pay cut. It's a huge problem and, unfortunately, we need to feel the pain for leadership to be motivated.

 

[Sanman]

Yes, but it was less than half of what was requested and not nearly enough. Psychology leadership and I believe division leadership are pushing for medical center leadership to grant another that would be more commensurate with the market.

We've literally had candidates turn down offers because they would be taking a pay cut. It's a huge problem and, unfortunately, we need to feel the pain for leadership to be motivated.

Yeah, this is unfortunately the way it works. Until staff leave and hiring fails, they never make the changes. It can be years of a mess before it is fixed.

 

[deleted1129370]

 

[deleted1038433]

Yeah, this is unfortunately the way it works. Until staff leave and hiring fails, they never make the changes. It can be years of a mess before it is fixed.

I think I might try putting my foot down with my supervisor on new referrals. It seems clear to me that we should not be seeing more patients than we have slots to treat or nobody gets better. Anybody have success with trying to informally cap their case load with their immediate supervisor?

Anybody have success with reducing case referrals in other ways? I have tried many times explaining my case load and my role to my BHIP psychiatrists. Their perspective is that they have to keep referring after a patient asks multiple times for individual therapy even when said patient's life is on fire and they don't have the ability to engage in time-limited weekly outpatient therapy. They literally want me to see these people once a month for as long as they want therapy and won't accept that that is not my role. My perspective is that "individual therapy is not clinically indicated at this time due to low readiness for making behavioral changes and competing life demands" is a complete sentence we should all feel comfortable saying to our patients and/or documenting in their chart as rationale for not providing therapy.

 

[Fan_of_Meehl]

I think I might try putting my foot down with my supervisor on new referrals. It seems clear to me that we should not be seeing more patients than we have slots to treat or nobody gets better. Anybody have success with trying to informally cap their case load with their immediate supervisor?

Anybody have success with reducing case referrals in other ways? I have tried many times explaining my case load and my role to my BHIP psychiatrists. Their perspective is that they have to keep referring after a patient asks multiple times for individual therapy even when said patient's life is on fire and they don't have the ability to engage in time-limited weekly outpatient therapy. They literally want me to see these people once a month for as long as they want therapy and won't accept that that is not my role. My perspective is that "individual therapy is not clinically indicated at this time due to low readiness for making behavioral changes and competing life demands" is a complete sentence we should all feel comfortable saying to our patients and/or documenting in their chart as rationale for not providing therapy.

Essentially, no.

I have focused on what I can control (i.e., what I do with patients once they get to me).

Unfortunately, because I do not engage in the chickenshnizzle 'reindeer referral games' that most people do (i.e., finding ways to play 'tag, you're it' and send as many cases to others as you can to get them off your caseload), my only recourse is to be as competent and efficient as I can to hold veterans accountable in therapy and, thereby, force them to either 'doodoo or get off the pot,' as they say, in professional psychotherapy. This has been incredibly effective in keeping my caseload cleared out. Unfortunately, when people have seen that I have space in my caseload (even though I have been taking on more than average numbers of clients, they frown on me and load me up with even more referrals/work. Recently, I have been scheduled for FIVE intakes per week plus any additional 'within-team' referrals that others just hand off to me. It's not sustainable and now--in a matter of just the past several weeks, I've gone from having availability in my schedule to being slam booked up through March 2024. I saw it coming because I have more than two brain cells to rub together and can use logic and arithmetic. I warned my 'leadership' chain via email, laying out exactly what was about to happen. I was the one functional clinic still getting people in/out but...no longer. Now that I am 'booked solid' for several months, my entire model of getting people in and out efficiently (which critically depends on being able to schedule courses of WEEKLY psychotherapy (to run off people who aren't serious and to effectively treat/heal those who are)) has been rendered totally impossible to implement and now...like a snowball taking on layers of ice...my clinics are doomed to get just as backed up as everyone else's (all those who have been sending extra cases/work to me for the past year and a half) and to keep getting MORE AND MORE backed up as time goes on. What we gonna do now, boss? huh?

They are gonna propose horse**** (and call it 'brilliant leadership') like:
- let's throw 30+ people into a 'group' and call it 'psychotherapy' (even though the VA/DoD guidelines call out groups as ineffective)
- let's eliminate intake slots and intake clinics (I hear that they're actually getting ready to do that here)
- let's start doing 30 minute visits

Pretty much anything other than let's hold 'leaders' and individual clinicians (even if they are your booty buddy) accountable for getting folks in and out of their clinics.

Whatever, the whole thing is gonna collapse and 'leadership' will still blame the providers, especially the ones working hard to keep their caseloads cleared out.

No one has any accountability above the level of caseload-bearing clinician. No one lifts a finger to look at flow of patients in/out of and between caseloads. People who are 'buddy buddy' get treated very different than people who aren't their friends or politically connected/favored.

I'm getting ready to sum up all the unique cases I've had in my caseload in the past year and a half and include that info in an email to 'leadership' indicating that now I can't even effectively treat the 'real' cases of PTSD whom I could potentially help with treatment because they have seen fit to flood my clinics with 2x, 3x, or even 4x the number of intakes/ new cases per unit time than other clinicians. I ran the numbers earlier and I can keep my clinics 'cleared out' even taking 1.5 to 2x the number of intakes other people are taking. But, Jesus, I can't take 4x - 5x the number of intakes. NO ONE could. But...do they put even the slightest bit of pressure on the other clinicians to be productive in getting people in/out? Do they provide any oversight to their work and feedback? Nope. To them, 'supervision' is looking at bullcrap 'metrics' that don't even tell you the real story of what's actually going on. There is no leadership in mental health at VA.

Once I cipher up the numbers (I can add, too...another arcane feat which 'leadership' also appears incapable of doing) of TOTAL cases that have been sent to me (and effectively dealt with) over the course of 1.5 years since entering my current position, I intend to send the email saying...'Gee, I've been able to handle a rate of influx of patients that would be equivalent to 280 patients handled per year (just guessing this number, haven't determined it yet)...ask yourself, if EVERY outpatient clinician could 'handle' 280 new patients per year, from start to finish, would we even HAVE access issues? What are the numbers for everyone else? Why have none of you looked into this?

I mean, it's not going to be effective...merely cathartic.

 

[summerbabe]

I think I might try putting my foot down with my supervisor on new referrals. It seems clear to me that we should not be seeing more patients than we have slots to treat or nobody gets better. Anybody have success with trying to informally cap their case load with their immediate supervisor?

Anybody have success with reducing case referrals in other ways? I have tried many times explaining my case load and my role to my BHIP psychiatrists. Their perspective is that they have to keep referring after a patient asks multiple times for individual therapy even when said patient's life is on fire and they don't have the ability to engage in time-limited weekly outpatient therapy. They literally want me to see these people once a month for as long as they want therapy and won't accept that that is not my role. My perspective is that "individual therapy is not clinically indicated at this time due to low readiness for making behavioral changes and competing life demands" is a complete sentence we should all feel comfortable saying to our patients and/or documenting in their chart as rationale for not providing therapy.

I largely believe there's nothing I can do about referrals or my caseload since limiting access to care is such a no-no so I try to work on the back end. But I would definitely still voice concerns to your supervisor. Maybe they will be receptive or have some ideas.

Options are limited but I try the following:
- do an initial treatment planning session and terminate with some people after talking up things like homework and how 'hard' therapy will be
- refer to things like peer support, rec therapy, Whole Health and activity groups/peer groups at the Vet Center if they still want more mental health services but decline or feel iffy about an EBP approach (build up your connections to these other services at your facility if you haven't already)
- better yet, educate med prescribers about those options if you are friendly with them & think they would be receptive to potentially avoid some future referrals
- terminate quickly with people, including getting in and documenting required no-show calls/letter so you can formally discharge people who aren't engaging asap
- I try to make peace with seeing people who I can't shake from my caseload and aren't doing productive therapy. Those people also tend to get 30-40 min sessions if I can help it.

Good luck!

 

[Sanman]

I think I might try putting my foot down with my supervisor on new referrals. It seems clear to me that we should not be seeing more patients than we have slots to treat or nobody gets better. Anybody have success with trying to informally cap their case load with their immediate supervisor?

Anybody have success with reducing case referrals in other ways? I have tried many times explaining my case load and my role to my BHIP psychiatrists. Their perspective is that they have to keep referring after a patient asks multiple times for individual therapy even when said patient's life is on fire and they don't have the ability to engage in time-limited weekly outpatient therapy. They literally want me to see these people once a month for as long as they want therapy and won't accept that that is not my role. My perspective is that "individual therapy is not clinically indicated at this time due to low readiness for making behavioral changes and competing life demands" is a complete sentence we should all feel comfortable saying to our patients and/or documenting in their chart as rationale for not providing therapy.

I am a little different in that I am not grid based and don't have an MSA scheduling my cases (have to do it myself). That said, you can try speaking directly to your supervisor if they are reasonable. If not, better to befriend your MSA and directly manage your patients. Set the expectation of weekly of biweekly therapy, give priority to existing cases, tell veterans you speak to for intake that your next session will X months away and would they like a referral, schmooze the MSA and buy them a Christmas gift. In general, I manage get those above me to limit their expectations of me and tend to keep them in the dark on details they don't need to know. Barring that, I walk away and take another job. I find it takes 3-5 years for management to really ramp up the expectations to unreasonable. That said, I have the ability to walk away if I want as I have a private practice slush fund ready. Keep in mind that the complaints mentioned about corners being cut for the sake of productivity is often worse on the private side as an employee.

 

[summerbabe]

I largely believe there's nothing I can do about referrals or my caseload since limiting access to care is such a no-no so I try to work on the back end. But I would definitely still voice concerns to your supervisor. Maybe they will be receptive or have some ideas.

Options are limited but I try the following:
- do an initial treatment planning session and terminate with some people after talking up things like homework and how 'hard' therapy will be
- refer to things like peer support, rec therapy, Whole Health and activity groups/peer groups at the Vet Center if they still want more mental health services but decline or feel iffy about an EBP approach (build up your connections to these other services at your facility if you haven't already)
- better yet, educate med prescribers about those options if you are friendly with them & think they would be receptive to potentially avoid some future referrals
- terminate quickly with people, including getting in and documenting required no-show calls/letter so you can formally discharge people who aren't engaging asap
- I try to make peace with seeing people who I can't shake from my caseload and aren't doing productive therapy. Those people also tend to get 30-40 min sessions if I can help it.

Good luck!

@IloveCBT

Had a few more thoughts on this topic:

- The concept of discharging in BHIP can be tricky & we may not see value in doing so since that's one more note/additional contact attempts. But I think it can be super helpful with large caseloads, including patients who aren't engaging in care.

Because when one of those people calls the VCL or shows up randomly for same-day care, that could be the difference of you needing to see them or make follow-up calls versus it getting kicked back into the overall pool of providers since they have been administratively discharged already and thus, they need to be triaged again.

So if you aren't discharging or aren't aware of how your BHIP handles discharges, definitely get with your supervisor as it can save headaches down the time and ensure that the patient load is distributed more evenly.

I also forgot one of my main tips earlier & it's to REALLY utilize specialty clinics. Sometimes I will see my work as doing brief treatment to get somebody patched to a more appropriate level of care. If BHIP is our catch all, then we should be taking advantage of our clinic's specialty services. And if they don't think it's appropriate, they can always decline.

PTSD? Let's do 2-4 sessions of coping-based pre-trauma work before they feel ready for a PTSD referral. SMI? Let's provide psychoeducation about the recovery model and education about what's available at the the PRRC or even ICMHR/MIHCM. They drink a bit too much? Hello SUD treatment! They don't have a job? Voc rehab referral.

And so on and so forth so that you hopefully can hold focus more on your BHIP appropriate therapy patients that are enjoyable to work with. Good luck! And if others have strategies that have worked for you, would love to hear them.

 

[cara susanna]

I'm temporarily teleworking and my grids are now a mess. Everything is all effed up. The MSAs can't schedule anyone without me telling them where to put them (so, in other words I have to call all of them myself). I have patients in EBP slots that shouldn't be there and patients scheduled during meetings that should be blocked off. I can't move them because I have nowhere open to put them during the same week.

Current mood:

 

[Fan_of_Meehl]

I'm temporarily teleworking and my grids are now a mess. Everything is all effed up. The MSAs can't schedule anyone without me telling them where to put them (so, in other words I have to call all of them myself). I have patients in EBP slots that shouldn't be there and patients scheduled during meetings that should be blocked off. I can't move them because I have nowhere open to put them during the same week.

Current mood:

That should be a mural required to be painted on the facade of every single Veterans Affairs hospital in the United States.

By Federal statute.

Hell, by Constitutional Amendment.

 

[Grenth]

That should be a mural required to be painted on the facade of every single Veterans Affairs hospital in the United States.

By Federal statute.

Hell, by Constitutional Amendment.

This comic is the email signature of someone in my service line. It's delightful.

 

[summerbabe]

This comic is the email signature of someone in my service line. It's delightful.

This would also be on point

 

[Sanman]

This would also be on point

View attachment 379952

Did you make that terrible pun on purpose?

 

[summerbabe]

Did you make that terrible pun on purpose?

 

[Fan_of_Meehl]

View attachment 379960

I literally was told in a meeting the other day that 'the problem' is that I am too good at my job. I was complaining about getting 300% - 400% of what another provider is receiving in 'new cases' (via consults/intakes, transfers from other providers ('within-team' consults), all the returning cases from two providers who recently left, etc..

The program manager looked me dead in the eye with that smug, supervisory arrogance and said (with a straight face), 'Well...if you're too good at your job (meaning too efficient in getting people in/out of my caseload), then you're going to have openings in your schedule to schedule new patients into.' So...the schema, 'the provider is to blame' (and its corollary, 'no admin staff is ever responsible or to blame') is so powerful that the problem is cast as...'Your too good at doing what you do.' I mean, forget doing your job as 'leader' and holding the other clinician(s) accountable for getting people in and out of their caseloads at a reasonable rate, this guy being too productive is causing all the issues.

 

[aim-agm]

I literally was told in a meeting the other day that 'the problem' is that I am too good at my job. I was complaining about getting 300% - 400% of what another provider is receiving in 'new cases' (via consults/intakes, transfers from other providers ('within-team' consults), all the returning cases from two providers who recently left, etc..

The program manager looked me dead in the eye with that smug, supervisory arrogance and said (with a straight face), 'Well...if you're too good at your job (meaning too efficient in getting people in/out of my caseload), then you're going to have openings in your schedule to schedule new patients into.' So...the schema, 'the provider is to blame' (and its corollary, 'no admin staff is ever responsible or to blame') is so powerful that the problem is cast as...'Your too good at doing what you do.' I mean, forget doing your job as 'leader' and holding the other clinician(s) accountable for getting people in and out of their caseloads at a reasonable rate, this guy being too productive is causing all the issues.

If the reward for good work is more work, then people are going to stop working...

I've noticed that when there is at least some expectation (or fantasy) that going the extra mile today will make tomorrow easier its a lot easier to be motivated and endure the workload, but otherwise it can get wearisome.

Also, your system is rewarding clinicians for doing a bad job, because a follow-up is always easier than an intake. So the clinician is incentivized to not help the veteran to get better (workload), and the veteran is incentivized to stay sick (service connection)...at least everyone is on the same page.

 

[aim-agm]

Does anyone have good resources or recommendations for psychotherapy with patients that have narcissistic personality traits (w/o full disorder)?
I've gone from ~0% of my therapy patients in training having narcissistic features to ~100% of my current patients having them, typically either contributing to or causing depression.

I've been pretty successful at getting them to acknowledge the character issues and agree that they need to be worked on, but I don't think I'm having much effect. I've also found that my typical therapy approach is markedly less effective with them.

 

[Sanman]

If the reward for good work is more work, then people are going to stop working...

I've noticed that when there is at least some expectation (or fantasy) that going the extra mile today will make tomorrow easier its a lot easier to be motivated and endure the workload, but otherwise it can get wearisome.

Also, your system is rewarding clinicians for doing a bad job, because a follow-up is always easier than an intake. So the clinician is incentivized to not help the veteran to get better (workload), and the veteran is incentivized to stay sick (service connection)...at least everyone is on the same page.

It is actually worse than that because many folks that pay nothing for services (plenty of 100%sc PTSD folks) and cannot be discharged love to soak up your time whether you want them to or not and refuse to engage in real treatment. No different than folks that are non-compliant with meds and specialist visits and then blame the PCP because they are still sick.

 

[cara susanna]

I literally was told in a meeting the other day that 'the problem' is that I am too good at my job. I was complaining about getting 300% - 400% of what another provider is receiving in 'new cases' (via consults/intakes, transfers from other providers ('within-team' consults), all the returning cases from two providers who recently left, etc..

The program manager looked me dead in the eye with that smug, supervisory arrogance and said (with a straight face), 'Well...if you're too good at your job (meaning too efficient in getting people in/out of my caseload), then you're going to have openings in your schedule to schedule new patients into.' So...the schema, 'the provider is to blame' (and its corollary, 'no admin staff is ever responsible or to blame') is so powerful that the problem is cast as...'Your too good at doing what you do.' I mean, forget doing your job as 'leader' and holding the other clinician(s) accountable for getting people in and out of their caseloads at a reasonable rate, this guy being too productive is causing all the issues.

That's why our clinic just assigns equally by provider, regardless of access. We used to have that system and it was very problematic.

 

[summerbabe]

That's why our clinic just assigns equally by provider, regardless of access. We used to have that system and it was very problematic.

I agree, this is the best method for our system.

We will all have some unequal ebbs & flows, like periods where we are discharging a lot and periods where everybody is showing up & wanting weekly treatment but this methods equals things out much more equitably in the long run.

 

[deleted1038433]

That's why our clinic just assigns equally by provider, regardless of access. We used to have that system and it was very problematic.

Where do you work and are they hiring? Lol

 

[deleted1038433]

I agree, this is the best method for our system.

We will all have some unequal ebbs & flows, like periods where we are discharging a lot and periods where everybody is showing up & wanting weekly treatment but this methods equals things out much more equitably in the long run.

Where are these VA locations? 😳

 

[Fan_of_Meehl]

That's why our clinic just assigns equally by provider, regardless of access. We used to have that system and it was very problematic.

Jesus, I wish our place would operate like that. I'd be in heaven.

 

[summerbabe]

Where are these VA locations? 😳

Looking at current remote jobs on USAJobs, I would not recommend Denver or Austin.

I have some first hand experiences with both. The main problem there is the absolute crazy overall population growth in both areas over the past decade that greatly outpace strategic growth plans for serving veteran in these areas. Plus Colorado Springs is technically a CBOC for the Denver system but it’s literally one of the towns with the most growth in the past decade. So providers & admin burn out quickly and move on.

There's also a job at the Iron Mountain VA. I don't know a thing about them but it sounds rural with a likely stable population which might ease some of the biggest systems related pressures that contribute to craziness.

 

[Sanman]

Looking at current remote jobs on USAJobs, I would not recommend Denver or Austin.

I have some first hand experiences with both. The main problem there is the absolute crazy overall population growth in both areas over the past decade that greatly outpace strategic growth plans for serving veteran in these areas. Plus Colorado Springs is technically a CBOC for the Denver system but it’s literally one of the towns with the most growth in the past decade. So providers & admin burn out quickly and move on.

There's also a job at the Iron Mountain VA. I don't know a thing about them but it sounds rural with a likely stable population which might ease some of the biggest systems related pressures that contribute to craziness.

Absolutely, one of the reasons I like my rural populations is that demand for services is usually more stable. The hard part is when some services close up. We had a few retirements/folks quitting recently and that has put pressure on my system locally as recruiting for those positions can be harder.

 

[summerbabe]

Absolutely, one of the reasons I like my rural populations is that demand for services is usually more stable. The hard part is when some services close up. We had a few retirements/folks quitting recently and that has put pressure on my system locally as recruiting for those positions can be harder.

100%

I even saw some fully virtual RRTP jobs for Tomah WI (or somewhere like that) a while back, which I'm sure is hugely challenging & annoying logistically for a residential program but I'm guessing it was better than not being able to recruit locally based staff and falling behind on CARF standards by not providing appropriate care.

 

[Sanman]

I literally was told in a meeting the other day that 'the problem' is that I am too good at my job. I was complaining about getting 300% - 400% of what another provider is receiving in 'new cases' (via consults/intakes, transfers from other providers ('within-team' consults), all the returning cases from two providers who recently left, etc..

The program manager looked me dead in the eye with that smug, supervisory arrogance and said (with a straight face), 'Well...if you're too good at your job (meaning too efficient in getting people in/out of my caseload), then you're going to have openings in your schedule to schedule new patients into.' So...the schema, 'the provider is to blame' (and its corollary, 'no admin staff is ever responsible or to blame') is so powerful that the problem is cast as...'Your too good at doing what you do.' I mean, forget doing your job as 'leader' and holding the other clinician(s) accountable for getting people in and out of their caseloads at a reasonable rate, this guy being too productive is causing all the issues.

This is the part of the job where radical acceptance and managing what you are allowed to do comes in. My job is to literally show up at 8am and leave at 4:30pm. If this is how the system chooses to manage referrals, it is time to slow down a bit. This is not your private practice. A few buffer sessions with good clients and take your time with termination. Keep a few supportive therapy cases on your caseload (Monday mornings and Friday afternoons are my preference). Leave time for the inevitable paperwork and extra tasks the system will not build time for properly.

I understand that you are much more of an idealist than I am (or seem so) and probably won't take this advice, but it never hurts to hear it.

 

[cara susanna]

I can say that Tomah has recurrent staff turnover in the RRTP, and I doubt it's a coincidence. Iron Mountain's position is for their fledgling PCT and I think it would be a great job for someone who wants 100% virtual. I was tempted to apply, myself!

Also, my clinic is always hiring. We are constantly understaffed (but we're in a CBOC in a non-metro area so not exactly a ton of resources).

 

[Fan_of_Meehl]

This is the part of the job where radical acceptance and managing what you are allowed to do comes in. My job is to literally show up at 8am and leave at 4:30pm. If this is how the system chooses to manage referrals, it is time to slow down a bit. This is not your private practice. A few buffer sessions with good clients and take your time with termination. Keep a few supportive therapy cases on your caseload (Monday mornings and Friday afternoons are my preference). Leave time for the inevitable paperwork and extra tasks the system will not build time for properly.

I understand that you are much more of an idealist than I am (or seem so) and probably won't take this advice, but it never hurts to hear it.

All fair points, chief.

 

[summerbabe]

Looking at current remote jobs on USAJobs, I would not recommend Denver or Austin.

I have some first hand experiences with both. The main problem there is the absolute crazy overall population growth in both areas over the past decade that greatly outpace strategic growth plans for serving veteran in these areas. Plus Colorado Springs is technically a CBOC for the Denver system but it’s literally one of the towns with the most growth in the past decade. So providers & admin burn out quickly and move on.

There's also a job at the Iron Mountain VA. I don't know a thing about them but it sounds rural with a likely stable population which might ease some of the biggest systems related pressures that contribute to craziness.

To add on:

The Colorado Springs population went from 280,000ish in 1990 to 484,000 in 2021. The current metro population is estimated at 755,000. So whatever planning, such as deciding to not build an emergency room when the current clinic was designed & built, almost certainly did not account for this growth.

Now, whether that was an error of omission or we genuinely could not predict it, the reality is that all of the spacing, staffing, and services were designed with data in mind that absolutely do not reflect the current reality of needed care.

So if a new administrator takes a job and has the best of intentions, they will quickly be overwhelmed with meeting different and usually impossible, rigidly defined VA system demands such as timely access to care (even if staffing is lagging multiple times behind what is needed because metrics and SoPs don't care). And if somebody comes into that job actively trying to play the metric game & get promoted, their providers will suffer even more.

Austin has a same problem. The Austin/Round Rock/Georgetown metro area is home now to 2.4 million people now. Their new facility was commissioned in 2010, is 270,000 sq foot and the campus is 35 acres. But it doesn't have an emergency room! Veterans wanting this care need to be bused 1.5 hours (assuming no traffic lol) north to Temple TX or go into the community.

I don't know the factors that went into this decision but I'm looking at some historical data that suggests Austin has been growing steadily at 4% since the 80s (and 3% prior). So if choices like this were being made at the highest levels, it doesn't bode well for providers who will be responsible for providing front-line care.

So if you're in a place with impossible demographic demands, it's probably only going to get worse & not better and you should consider exiting the system all together or looking at virtual jobs in systems that will give you a fighting chance to be able to do what Sanman recommended a couple of posts ago.

 

[WisNeuro]

To add on:

The Colorado Springs population went from 280,000ish in 1990 to 484,000 in 2021. The current metro population is estimated at 755,000. So whatever planning, such as deciding to not build an emergency room when the current clinic was designed & built, almost certainly did not account for this growth.

Now, whether that was an error of omission or we genuinely could not predict it, the reality is that all of the spacing, staffing, and services were designed with data in mind that absolutely do not reflect the current reality of needed care.

So if a new administrator takes a job and has the best of intentions, they will quickly be overwhelmed with meeting different and usually impossible, rigidly defined VA system demands such as timely access to care (even if staffing is lagging multiple times behind what is needed because metrics and SoPs don't care). And if somebody comes into that job actively trying to play the metric game & get promoted, their providers will suffer even more.

Austin has a same problem. The Austin/Round Rock/Georgetown metro area is home now to 2.4 million people now. Their new facility was commissioned in 2010, is 270,000 sq foot and the campus is 35 acres. But it doesn't have an emergency room! Veterans wanting this care need to be bused 1.5 hours (assuming no traffic lol) north to Temple TX or go into the community.

I don't know the factors that went into this decision but I'm looking at some historical data that suggests Austin has been growing steadily at 4% since the 80s (and 3% prior). So if choices like this were being made at the highest levels, it doesn't bode well for providers who will be responsible for providing front-line care.

So if you're in a place with impossible demographic demands, it's probably only going to get worse & not better and you should consider exiting the system all together or looking at virtual jobs in systems that will give you a fighting chance to be able to do what Sanman recommended a couple of posts ago.

Most importantly for the latter, a person would have to intentionally choose to live in TX. Just...eww.

 

[Fan_of_Meehl]

To add on:

The Colorado Springs population went from 280,000ish in 1990 to 484,000 in 2021. The current metro population is estimated at 755,000. So whatever planning, such as deciding to not build an emergency room when the current clinic was designed & built, almost certainly did not account for this growth.

Now, whether that was an error of omission or we genuinely could not predict it, the reality is that all of the spacing, staffing, and services were designed with data in mind that absolutely do not reflect the current reality of needed care.

So if a new administrator takes a job and has the best of intentions, they will quickly be overwhelmed with meeting different and usually impossible, rigidly defined VA system demands such as timely access to care (even if staffing is lagging multiple times behind what is needed because metrics and SoPs don't care). And if somebody comes into that job actively trying to play the metric game & get promoted, their providers will suffer even more.

Austin has a same problem. The Austin/Round Rock/Georgetown metro area is home now to 2.4 million people now. Their new facility was commissioned in 2010, is 270,000 sq foot and the campus is 35 acres. But it doesn't have an emergency room! Veterans wanting this care need to be bused 1.5 hours (assuming no traffic lol) north to Temple TX or go into the community.

I don't know the factors that went into this decision but I'm looking at some historical data that suggests Austin has been growing steadily at 4% since the 80s (and 3% prior). So if choices like this were being made at the highest levels, it doesn't bode well for providers who will be responsible for providing front-line care.

So if you're in a place with impossible demographic demands, it's probably only going to get worse & not better and you should consider exiting the system all together or looking at virtual jobs in systems that will give you a fighting chance to be able to do what Sanman recommended a couple of posts ago.

The main problem with VA outpatient psychotherapy is that the strategies are designed to treat a problem that doesn't even exist. We don't have (really) access issues. We have issues with implementation of boundaries on clients who are not really there for therapy. For purely political reasons, most therapists and administrators are scared to death about being honest with veterans, even if you can do it skillfully and professionally, about the fact that therapy is work and if they don't want to do the work then we can explore other options.

 

[Grenth]

The main problem with VA outpatient psychotherapy is that the strategies are designed to treat a problem that doesn't even exist. We don't have (really) access issues. We have issues with implementation of boundaries on clients who are not really there for therapy. For purely political reasons, most therapists and administrators are scared to death about being honest with veterans, even if you can do it skillfully and professionally, about the fact that therapy is work and if they don't want to do the work then we can explore other options.

This makes me think about when I received a notice that I had been reported to the patient advocate by a patient who saw me for 6 sessions in outpatient and was irritated when I discharged him. This is a Vietnam veteran who literally wanted to come in weekly and read me chapters of his autobiography about the war. Diagnostically he is mildly depressed but his reason for coming in is because he's lonely. He's actually a lovely person but he is not interested in therapy. I recommended he use peer support, the Vet Center, our supportive therapy groups, but nope individual therapy or bust. He saw his last VA psychologist (much beloved by him, referenced at each appointment) for 15 years. And one before that for 4 years.

Apparently I must see him eternally or else since I touched him last (unless he has no contact with anyone in outpatient for 25 months which never happens) with no options except to kick him to a different outpatient provider. So now I schedule him monthly for a check in chat and try to enjoy the "break" rather than fume about how stupid and broken this system is. But it's hard when I'm getting dinged for not doing all my daily reminders and other busy work that I can't do while I'm hearing once again for 30 minutes about how stupid Secretary McNamara was for ordering a troop surge.

 

[cara susanna]

Our MHICM isn't taking new referrals because they're too full. 1) must be nice to be able to just not take more people when you're full 2) what are we supposed to do with these high acuity patients??

 

[Fan_of_Meehl]

This makes me think about when I received a notice that I had been reported to the patient advocate by a patient who saw me for 6 sessions in outpatient and was irritated when I discharged him. This is a Vietnam veteran who literally wanted to come in weekly and read me chapters of his autobiography about the war. Diagnostically he is mildly depressed but his reason for coming in is because he's lonely. He's actually a lovely person but he is not interested in therapy. I recommended he use peer support, the Vet Center, our supportive therapy groups, but nope individual therapy or bust. He saw his last VA psychologist (much beloved by him, referenced at each appointment) for 15 years. And one before that for 4 years.

Apparently I must see him eternally or else since I touched him last (unless he has no contact with anyone in outpatient for 25 months which never happens) with no options except to kick him to a different outpatient provider. So now I schedule him monthly for a check in chat and try to enjoy the "break" rather than fume about how stupid and broken this system is. But it's hard when I'm getting dinged for not doing all my daily reminders and other busy work that I can't do while I'm hearing once again for 30 minutes about how stupid Secretary McNamara was for ordering a troop surge.

Truth is the handmaiden of love.

I have a real hard time with mental health professionals who do not appear to understand that, since self-deception is the root of all psychopathology, lying to veterans/patients (even if you are doing so to (in your mind) be an 'advocate' for them or 'help' them) is not a virtuous act.

The best thing I can do for my clients as their therapist is not to lie to them. I may be wrong (and I am imperfect), but I will NOT intentionally tell them something that I do not believe to be true.

Even, 'you have PTSD and need more money.'

That being said, everything has to be viewed through the perspective of my role as a therapist with an individual veteran. My main responsibility is to try to help them, psychologically. I am not a 'hard-ass' initially when it comes to PTSD diagnosis or implementation of rigid boundaries in psychotherapy. Everything is done in service to the mission of helping them as an individual. They may--in truth--have antisocial personality disorder, be severely alcoholic and personality disordered, and absolutely convinced that they 'have PTSD.' Fine. For now, we'll try CPT. But, if it doesn't work, then let's regroup and re-assess. I just can't be okay with lying to people, no matter how dedicated to that the VA, as an organization, fundamentally is.

 

[Fan_of_Meehl]

This makes me think about when I received a notice that I had been reported to the patient advocate by a patient who saw me for 6 sessions in outpatient and was irritated when I discharged him. This is a Vietnam veteran who literally wanted to come in weekly and read me chapters of his autobiography about the war. Diagnostically he is mildly depressed but his reason for coming in is because he's lonely. He's actually a lovely person but he is not interested in therapy. I recommended he use peer support, the Vet Center, our supportive therapy groups, but nope individual therapy or bust. He saw his last VA psychologist (much beloved by him, referenced at each appointment) for 15 years. And one before that for 4 years.

Apparently I must see him eternally or else since I touched him last (unless he has no contact with anyone in outpatient for 25 months which never happens) with no options except to kick him to a different outpatient provider. So now I schedule him monthly for a check in chat and try to enjoy the "break" rather than fume about how stupid and broken this system is. But it's hard when I'm getting dinged for not doing all my daily reminders and other busy work that I can't do while I'm hearing once again for 30 minutes about how stupid Secretary McNamara was for ordering a troop surge.

I really like Marsha Linehan's strategy of 'throwing people off guard' by not responding how they expect us to (according to their schemas and learning history). I think 'irreverence' is an aspect of it. (Some of the other folks who follow this forum will know the name). It is basically saying, 'I'm not cool with playing this game. I want to interact with you authentically.' Or something to that effect.

 

[Fan_of_Meehl]

This makes me think about when I received a notice that I had been reported to the patient advocate by a patient who saw me for 6 sessions in outpatient and was irritated when I discharged him. This is a Vietnam veteran who literally wanted to come in weekly and read me chapters of his autobiography about the war. Diagnostically he is mildly depressed but his reason for coming in is because he's lonely. He's actually a lovely person but he is not interested in therapy. I recommended he use peer support, the Vet Center, our supportive therapy groups, but nope individual therapy or bust. He saw his last VA psychologist (much beloved by him, referenced at each appointment) for 15 years. And one before that for 4 years.

Apparently I must see him eternally or else since I touched him last (unless he has no contact with anyone in outpatient for 25 months which never happens) with no options except to kick him to a different outpatient provider. So now I schedule him monthly for a check in chat and try to enjoy the "break" rather than fume about how stupid and broken this system is. But it's hard when I'm getting dinged for not doing all my daily reminders and other busy work that I can't do while I'm hearing once again for 30 minutes about how stupid Secretary McNamara was for ordering a troop surge.

He does, truly, sound like he is lonely. Now we just have to figure out what to do about that 🙂.

 

[Fan_of_Meehl]

Our MHICM isn't taking new referrals because they're too full. 1) must be nice to be able to just not take more people when you're full 2) what are we supposed to do with these high acuity patients??

We have two full-time psychologist vacancies in my area (PCT). I have told them that I will work 80 hours per week seeing extra patients and doing extra work if they will pay me, lol. They look at me as if I had just proposed that they hand over the keys to the bank to me. But they are 'saving' the salaries of two, full-time, GS-13 psychologists for the past couple of months (and for the foreseeable future, given the inaction of HR).

I already 'handle' 4x the number of cases per unit time (per month, for example) for 'free.' But they are not willing to pay for 'overtime' to handle the extra workload.

 

[Sanman]

Our MHICM isn't taking new referrals because they're too full. 1) must be nice to be able to just not take more people when you're full 2) what are we supposed to do with these high acuity patients??

Recently, the answer over here seems to be shove them into HBPC? All I am getting is suicidal folks and non-compliant bipolar folks off their meds. Who needs a whole team when there is one guy driving around the middle of nowhere.

 

[Sanman]

He does, truly, sound like he is lonely. Now we just have to figure out what to do about that 🙂.

Find a nice older female vet for him? Maybe one with a hearing aid that turns off?