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

[Fan_of_Meehl]

They can see these metrics. The dashboard shows the number of unique patients seen. However, there is no metric for that in the standard performance plan, so no one looks at it.

...because if you looked at it...you might have to DO something about it...

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[Sanman]

...because if you looked at it...you might have to DO something about it...

That I think is a more of a national issue. I don't blame a section chief or supervisor that doesn't want to "go rogue" and enforce something no one else is doing. That said, then you need to have that policy in place when angry veterans call the white house hotline or congress for their unlimited therapy being cut off.

 

[PsyDr]

Treatment is based upon diagnosis. If you are treating malingering and/or financial problems as something else, you're going to be unsuccessful.

 

[cara susanna]

That Hill article made some good points, but I LOLed at their complaint that the SC system perpetuates the idea of the "broken veteran" and hurts recruitment

 

[Sanman]

Treatment is based upon diagnosis. If you are treating malingering and/or financial problems as something else, you're going to be unsuccessful.

That is part of the problem. The other issue is people who don't want to be told 'no' and politicians that do not want to give them that answer. The malingerers will stick around with minimal treatment if possible. I have colleagues that set up VVC groups just for these folks to get their "treatment" and no one shows up. The subset of folks that don't want evidence based treatment, but unlimited supportive counseling and crisis management when their attempts at avoidance or behavioral problems flair up that clog the system. I once had a veteran report me to congress (and the congressman called our program manager) because I refused to see him for outpatient psychotherapy in his home or allowed my team to provide home care until be addressed his substance abuse and physical violence issues via proper inpatient and SA treatment. Luckily I documented well.

 

[Shiori]

I have started taking the approach that it's not my problem to solve. I work to practice ethically, manage burnout, then appease the VA last. I have Veterans who are just active enough to stay on my schedule. They eventually trail off for their own reasons. In the meantime, I do what I can to engage them in treatment, discuss goals and the time limited nature of therapy, how therapy can be counterproductive and even harmful, etc. They still ultimately get to decide what they do because it's a system issue, not a me issue. I can huff and puff, but we have empowered the system to function the way it functions. I am trying to save my energy for winnable battles. I did print off the article! It looks interesting.

This is where the burnout question comes up. Having minimally engaged clients burns me out and I start leveraging other referrals like Whole Health or the LEC. Some still decide to stay, and I make a note of the discussion and their reasons for pushing for more therapy. There is no mechanism to keep them from just hopping to another provider or popping back up on my schedule within a few months (or days, honestly). Even if I had the burning desire, I don't have the tools to really fix it, so I don't try. Then I start pushing for spaced out appointments. I usually don't get as much pushback here. Spacing out appointments, groups, Whole Health, and the LEC have saved my sanity as I start looking at how to attack the issue from a higher level where it actually matters.

One other bonus is that the clinic is really great and we work as a team. We have a mental list of who does well with particular kinds of clients and we split them up the best we can based on these talents. I usually get PTSD cases where the Veteran isn't quite ready jump into trauma treatment yet, but are close. I don't have the pressures of PCT metrics, so we'll sometimes swap consults. It makes PCT happy and I get interesting cases. We're always looking for people if anyone wants to work here! We're chaotic, but fun.

 

[Fan_of_Meehl]

Treatment is based upon diagnosis. If you are treating malingering and/or financial problems as something else, you're going to be unsuccessful.
[/QUOTE]

I am becoming an expert on diagnosis and treatment of 'Service-Connection Deficit Disorder'

 

[Shiori]

I wonder if the length of time someone has been S/Ced matters. Many of my clients have had their S/C for years and know the ends and outs of the process. They also know very little of what we do in therapy matters all that much. I only have a few folks who are starting the process from scratch or have lingering anxiety about it.

 

[WisNeuro]

I wonder if the length of time someone has been S/Ced matters. Many of my clients have had their S/C for years and know the ends and outs of the process. They also know very little of what we do in therapy matters all that much. I only have a few folks who are starting the process from scratch or have lingering anxiety about it.

Maybe for some, but when I was still there, there are plenty of Vets who voiced concerns about losing their SC and needing to "keep proving" their disability.

 

[cara susanna]

I have started taking the approach that it's not my problem to solve. I work to practice ethically, manage burnout, then appease the VA last. I have Veterans who are just active enough to stay on my schedule. They eventually trail off for their own reasons. In the meantime, I do what I can to engage them in treatment, discuss goals and the time limited nature of therapy, how therapy can be counterproductive and even harmful, etc. They still ultimately get to decide what they do because it's a system issue, not a me issue. I can huff and puff, but we have empowered the system to function the way it functions. I am trying to save my energy for winnable battles. I did print off the article! It looks interesting.

This is where the burnout question comes up. Having minimally engaged clients burns me out and I start leveraging other referrals like Whole Health or the LEC. Some still decide to stay, and I make a note of the discussion and their reasons for pushing for more therapy. There is no mechanism to keep them from just hopping to another provider or popping back up on my schedule within a few months (or days, honestly). Even if I had the burning desire, I don't have the tools to really fix it, so I don't try. Then I start pushing for spaced out appointments. I usually don't get as much pushback here. Spacing out appointments, groups, Whole Health, and the LEC have saved my sanity as I start looking at how to attack the issue from a higher level where it actually matters.

One other bonus is that the clinic is really great and we work as a team. We have a mental list of who does well with particular kinds of clients and we split them up the best we can based on these talents. I usually get PTSD cases where the Veteran isn't quite ready jump into trauma treatment yet, but are close. I don't have the pressures of PCT metrics, so we'll sometimes swap consults. It makes PCT happy and I get interesting cases. We're always looking for people if anyone wants to work here! We're chaotic, but fun.

Your approach is similar to mine, and (this sounds dramatic but) I think that doing the best you can within the system, rather than trying to change or fight it, is really the only way to survive in this system.

 

[WisNeuro]

The Learned Helplessness Model of VHA Employment. I'm thinking of writing some studies on the topic, who wants in?

 

[Shiori]

I have been saving my energy for JC compliant intake battles. I am intrigued that MHS may one day have a Veteran-facing option to make filling out all the information we need less painful. In the meantime, using E-screening has also been on ongoing discussion. Leadership is listening to our requests and moving toward a solution.

 

[Sanman]

I have started taking the approach that it's not my problem to solve. I work to practice ethically, manage burnout, then appease the VA last. I have Veterans who are just active enough to stay on my schedule. They eventually trail off for their own reasons. In the meantime, I do what I can to engage them in treatment, discuss goals and the time limited nature of therapy, how therapy can be counterproductive and even harmful, etc. They still ultimately get to decide what they do because it's a system issue, not a me issue. I can huff and puff, but we have empowered the system to function the way it functions. I am trying to save my energy for winnable battles. I did print off the article! It looks interesting.

This is where the burnout question comes up. Having minimally engaged clients burns me out and I start leveraging other referrals like Whole Health or the LEC. Some still decide to stay, and I make a note of the discussion and their reasons for pushing for more therapy. There is no mechanism to keep them from just hopping to another provider or popping back up on my schedule within a few months (or days, honestly). Even if I had the burning desire, I don't have the tools to really fix it, so I don't try. Then I start pushing for spaced out appointments. I usually don't get as much pushback here. Spacing out appointments, groups, Whole Health, and the LEC have saved my sanity as I start looking at how to attack the issue from a higher level where it actually matters.

One other bonus is that the clinic is really great and we work as a team. We have a mental list of who does well with particular kinds of clients and we split them up the best we can based on these talents. I usually get PTSD cases where the Veteran isn't quite ready jump into trauma treatment yet, but are close. I don't have the pressures of PCT metrics, so we'll sometimes swap consults. It makes PCT happy and I get interesting cases. We're always looking for people if anyone wants to work here! We're chaotic, but fun.

That is a GS-15 and SES level problem and I am a lowly GS-13 just trying to get through the day and unable to make command decisions (this thread needed more government speak).

 

[Fan_of_Meehl]

Maybe for some, but when I was still there, there are plenty of Vets who voiced concerns about losing their SC and needing to "keep proving" their disability.

Ask veteran for goals for therapy or self-change, get recitation of re-experiencing symptoms

 

[Sanman]

Ask veteran for goals for therapy or self-change, get recitation of re-experiencing symptoms

Goals for therapy:

"I should have been one of those draft dodgers that hid in Canada, then I wouldn't have these problems"

Let me just get my Tardis out....

 

[Fan_of_Meehl]

Just finished reading an article on the poor efficacy of PTSD RRTP programs in VA in terms of PCL-5 reduction pre-post-4 mo. f/u.

It is entertaining to watch them ignore obvious variables (to front line clinicians) in the Discussion section write-up. They twisted themselves into knots trying to explain away the fact that veterans completing EBP oriented RRTPs fared no better than those who received no EBP component...and they all performed horribly. In the philosophy of science, it is understood that adherents of a particular position/theory will raise multiple post hoc"protective belts" of hypotheses to explain away empirical findings that seriously call into question their pet theory. It was happenin' here.

Does anyone else have the experience reading articles like this and thinking that the authors are ignoring elephants in the room? Should there be requirements that at least one article reviewer be a currently-practicing full-time VA clinician?

There was another study (I think it was with PTSD veterans going through PE/CPT who had been given the MMPI-2-RF) that found that veterans with significant elevations on the infrequency (F-r) and infrequency psychopathology (Fp-r) scales tended to actually attend more sessions while being rated by their protocol therapists as being significantly LESS engaged / compliant in session. My memory is a bit fuzzy, but I think that was one of the 'puzzling' findings.

Does that finding surprise any VA practitioners out there?

Edit: additional info from the study: so, when analyzing pre-post and 4 mo follow up outcome in PTSD sxs, they didn't focus on the whole sample but, rather, split the sample into three categories/groups for analysis: (1) Mild/Rebound, (2) Moderate/Rebound, (3) Severe/Stable.

What is 'rebound' in context of a tx outcome study, you may ask? It's not tx failure/inefficacy, you see, nonono...it's (euphemistically labeled) 'rebound.' Meaning, though there may have been some pre-post PCL-5 scores at the end of an expensive, intensive, evidence-based episode of residential tx, the average pt 'rebounded' (is that a new term for 'relapsed?') back to their pre-tx levels of symptomatology.

And the 'Severe/Stable' group? Well, back in the olden times, we may have used such terms as 'non-responders' or even spoken of the intervention as inefficacious for this subgroup (some utter troglodytes may have even dared to speak of 'treatment failure').

"Stable." I'd love to see some data of that group's MMPI-2-RF or SIMS testing results. By the way, this 'Severe/Stable' group made up the majority of participants in the study (51.8% of non-EBP and 58.5% of the EBP treatment group). The top researchers appear to be looking in vain everywhere for the elephant in the room but are failing to check the middle of the room.

Looking at the outcome data in the study itself, it is plainly clear that these expensive, intensive residential courses of treatment simply didn't work. Yet, due to the connotative sorcery of carefully chosen words/labels, the sample was split into two groups of "Rebounders" and one severely impaired group that was "Stable" in their pathology pre-tx, post-tx, and at 4 month follow up.

If the 'evidence-based' tx components hadn't been courses of well-beloved protocols like CPT/PE but, rather, some form of controversial (to the academicians) 'non-evidence-based treatment' do you think that the authors would have characterized the patients in the study as 'Stable' or 'Rebounders' or do you think the authors would be more critical of the presumed efficacy of the treatment approaches for the population under study in the face of clearly contradictory findings? Well, I suppose that some treatment approaches are truly 'more equal' than others in the face of empirically-confirmed failure to work.

"Treatments That Work."

Give me a break.

The emperor is buck naked, dude.

 

[cara susanna]

Just finished reading an article on the poor efficacy of PTSD RRTP programs in VA in terms of PCL-5 reduction pre-post-4 mo. f/u.

It is entertaining to watch them ignore obvious variables (to front line clinicians) in the Discussion section write-up. They twisted themselves into knots trying to explain away the fact that veterans completing EBP oriented RRTPs fared no better than those who received no EBP component...and they all performed horribly. In the philosophy of science, it is understood that adherents of a particular position/theory will raise multiple post hoc"protective belts" of hypotheses to explain away empirical findings that seriously call into question their pet theory. It was happenin' here.

Does anyone else have the experience reading articles like this and thinking that the authors are ignoring elephants in the room? Should there be requirements that at least one article reviewer be a currently-practicing full-time VA clinician?

There was another study (I think it was with PTSD veterans going through PE/CPT who had been given the MMPI-2-RF) that found that veterans with significant elevations on the infrequency (F-r) and infrequency psychopathology (Fp-r) scales tended to actually attend more sessions while being rated by their protocol therapists as being significantly LESS engaged / compliant in session. My memory is a bit fuzzy, but I think that was one of the 'puzzling' findings.

Does that finding surprise any VA practitioners out there?

Edit: additional info from the study: so, when analyzing pre-post and 4 mo follow up outcome in PTSD sxs, they didn't focus on the whole sample but, rather, split the sample into three categories/groups for analysis: (1) Mild/Rebound, (2) Moderate/Rebound, (3) Severe/Stable.

What is 'rebound' in context of a tx outcome study, you may ask? It's not tx failure/inefficacy, you see, nonono...it's (euphemistically labeled) 'rebound.' Meaning, though there may have been some pre-post PCL-5 scores at the end of an expensive, intensive, evidence-based episode of residential tx, the average pt 'rebounded' (is that a new term for 'relapsed?') back to their pre-tx levels of symptomatology.

And the 'Severe/Stable' group? Well, back in the olden times, we may have used such terms as 'non-responders' or even spoken of the intervention as inefficacious for this subgroup (some utter troglodytes may have even dared to speak of 'treatment failure').

"Stable." I'd love to see some data of that group's MMPI-2-RF or SIMS testing results. By the way, this 'Severe/Stable' group made up the majority of participants in the study (51.8% of non-EBP and 58.5% of the EBP treatment group). The top researchers appear to be looking in vain everywhere for the elephant in the room but are failing to check the middle of the room.

Looking at the outcome data in the study itself, it is plainly clear that these expensive, intensive residential courses of treatment simply didn't work. Yet, due to the connotative sorcery of carefully chosen words/labels, the sample was split into two groups of "Rebounders" and one severely impaired group that was "Stable" in their pathology pre-tx, post-tx, and at 4 month follow up.

If the 'evidence-based' tx components hadn't been courses of well-beloved protocols like CPT/PE but, rather, some form of controversial (to the academicians) 'non-evidence-based treatment' do you think that the authors would have characterized the patients in the study as 'Stable' or 'Rebounders' or do you think the authors would be more critical of the presumed efficacy of the treatment approaches for the population under study in the face of clearly contradictory findings? Well, I suppose that some treatment approaches are truly 'more equal' than others in the face of empirically-confirmed failure to work.

"Treatments That Work."

Give me a break.

The emperor is buck naked, dude.

IIRC we are generally finding that PTSD EBPs may be less effective in group format vs. individual. Residential also is less effective, likely because it doesn't generalize.

 

[WisNeuro]

IIRC we are generally finding that PTSD EBPs may be less effective in group format vs. individual. Residential also is less effective, likely because it doesn't generalize.

Is that because the facilitators have to constantly try to defuse the inevitable "who's trauma is worse" pissing contests? I absolutely hated doing PTSD groups. I would gladly do 5 straight PE sessions than 1 group any day.

 

[Fan_of_Meehl]

Is that because the facilitators have to constantly try to defuse the inevitable "who's trauma is worse" pissing contests? I absolutely hated doing PTSD groups. I would gladly do 5 straight PE sessions than 1 group any day.

Five years ago I started quoting (to colleagues and superiors) the abundant literature (even VA/DoD's own guidelines) that group psychotherapies were crap interventions with PTSD veterans. Yesterday, director of PCT in a private convo context said to me that, "group therapy isn't effective, even group EBP tx." I'm so proud we've come around to that realization, lol. Ben Franklin had some good advice about soft-pedaling ideas so that others can eventually come around to considering these their original ideas. Then they'll be 'good' ideas.

What tends to happen is that the majority who choose or are sent to group tx have poor attitudes and are poorly engaged and then the group will just reinforce the stance of non-engagement and then sabotage or infuriate the veteran in the group who would otherwise be motivated to participate in CPT.

Traditionally, admins love groups because they falsely believe that they are the solution to the access crisis.

 

[WisNeuro]

Five years ago I started quoting (to colleagues and superiors) the abundant literature (even VA/DoD's own guidelines) that group psychotherapies were crap interventions with PTSD veterans. Yesterday, director of PCT in a private convo context said to me that, "group therpy isn't effective, even group EBP tx." I'm so proud we've come around to that realization, lol.

What tends to happen is that the majority who choose or are sent to group tx have poor attitudes and are poorly engaged and then the group will just reinforce the stance of non-engagement and then sabotage or infuriate the veteran in the group who would otherwise be motivated to participate in CPT.

Traditionally, admins love groups because they falsely believe that they are the solution to the access crisis.

Yeah, I'd be curious to see the numbers when there is no secondary gain attached to members in a group, and they are selected for motivation for change. I still think it would lag behind individual therapy effectiveness, but probably be somewhat effective.

 

[cara susanna]

Is that because the facilitators have to constantly try to defuse the inevitable "who's trauma is worse" pissing contests? I absolutely hated doing PTSD groups. I would gladly do 5 straight PE sessions than 1 group any day.

I personally think it's because there's just less individualized attention. Also, from my experience EVERY CPT group has one patient who's like "wait, but! What about this!" and throws a wrench in your lovely cognitive restructuring.

Also, yes, group referrals aren't always vetted as well and they may not actually be in board with the treatment. Will never forget when I did a CPT session 1 in a group that had been organized by another therapist (my co-facilitator who was not formally trained in CPT). Pretty much everyone hated me and fought me because no one had actually talked to them about what CPT actually is and what it involves, I assume the discussion was just like "oh, PTSD group? Sure!'. My response was like, you don't have to be here, lol. Eventually the group dwindled down to two people, although those two people did phenomenally might I add.

 

[Fan_of_Meehl]

IIRC we are generally finding that PTSD EBPs may be less effective in group format vs. individual. Residential also is less effective, likely because it doesn't generalize.

I sometimes think that RRTPs function (for many) as training academies for climbing the service-connection ladder.

And, I swear, if I have one more veteran presenting all of a sudden with one of the following PTE's after an extensive MH contact history where these events were never mentioned, I may start getting suspicious:

(1) We were in boot camp training to throw grenades, one got loose and my sgt (or my buddy) leapt onto the grenade and exploded right in front of me

(2) I was on a ship (Navy vet) and a woman sailor was raped, her lips/nose/ears were bitten off and she was thrown overboard

Not saying that these don't or didn't happen...it just seems like some pretty bizarre PTE scenarios are tending to resemble one another and all of a sudden are being reported by people in their 50s/60s who are just about to retire (but have never been reported before).

 

[Fan_of_Meehl]

I personally think it's because there's just less individualized attention. Also, from my experience EVERY CPT group has one patient who's like "wait, but! What about this!" and throws a wrench in your lovely cognitive restructuring.

Also, yes, group referrals aren't always vetted as well and they may not actually be in board with the treatment. Will never forget when I did a CPT session 1 in a group that had been organized by another therapist (my co-facilitator who was not formally trained in CPT). Pretty much everyone hated me and fought me because no one had actually talked to them about what CPT actually is and what it involves, I assume the discussion was just like "oh, PTSD group? Sure!'. My response was like, you don't have to be here, lol. Eventually the group dwindled down to two people, although those two people did phenomenally might I add.

Ah...yes...the ole Hot Potato Red Rover 'dumping' maneuver. 'This vet would be an EXCELLENT candidate for your group,' lol.

It's amazing how universal the actual VA provider experience is (as opposed to the Kool-Aid version of how it's supposed to be).

We should start our own journal, 'VA Psychology: Real Talk Edition' or something. Would be invaluable for interns and new hires to normalize their shock.

 

[cara susanna]

I sometimes think that RRTPs function (for many) as training academies for climbing the service-connection ladder.

And, I swear, if I have one more veteran presenting all of a sudden with one of the following PTE's after an extensive MH contact history where these events were never mentioned, I may start getting suspicious:

(1) We were in boot camp training to throw grenades, one got loose and my sgt (or my buddy) leapt onto the grenade and exploded right in front of me

(2) I was on a ship (Navy vet) and a woman sailor was raped, her lips/nose/ears were bitten off and she was thrown overboard

Not saying that these don't or didn't happen...it just seems like some pretty bizarre PTE scenarios are tending to resemble one another and all of a sudden are being reported by people in their 50s/60s who are just about to retire (but have never been reported before).

Well, it used to be that you were automatically bumped to 100% while in an RRTP, but I think that is no longer true.

 

[AcronymAllergy]

At least the group(s) are offering an actual treatment. We had a long-running (i.e., decades) weekly group that really wasn't anything other than a social hour. When the person who ran it left for another position (some kind of champion, of course), clinic leadership tried to cancel the group so the resources could be better utilized elsewhere. There were numerous congressional complaints and they were required to re-instate the group. Good times.

 

[cara susanna]

Oh, we have one of those too! I think every VA does, lol.

Actually, we have two: one for PTSD and one for SMI.

 

[Fan_of_Meehl]

At least the group(s) are offering an actual treatment. We had a long-running (i.e., decades) weekly group that really wasn't anything other than a social hour. When the person who ran it left for another position (some kind of champion, of course), clinic leadership tried to cancel the group so the resources could be better utilized elsewhere. There were numerous congressional complaints and they were required to re-instate the group. Good times.

I inherited one such group in a PCT. Still have it. At first, I tried MI and some active CBT interventions to absolutely no avail. The group is composed of mostly Vietnam era vets who are 100% dedicated to their 100% PTSD status. I have repeatedly encouraged them to allow me to put in an RTC to see me in my individual clinic to review their tx history/options and/or see them individually for ideas of interventions that may help improve their QOL or reduce their PTSD symptoms. Zero percent have taken me up on the offer. They immediately break eye contact and change the subject. I use the elephant in the room's trunk for a footrest and I go on getting paid to participate in the charade. I do think they get something from the social support and cameraderie of the group, but it really should be a peer support group, officially.

 

[Shiori]

We have had zero success encouraging the group participants to run their own groups in the community even though they're mostly just socializing. We have also had to stop most of our psychoeducation groups due to poor attendance.

 

[cara susanna]

Anyone else at a CBOC with very few people present on Fridays (due to AWS and AL), leaving you SOL when someone presents for same-day access? This is the second Friday in a row that I've had to take a walk-in and I'm kinda cranky about it.

 

[AcronymAllergy]

I inherited one such group in a PCT. Still have it. At first, I tried MI and some active CBT interventions to absolutely no avail. The group is composed of mostly Vietnam era vets who are 100% dedicated to their 100% PTSD status. I have repeatedly encouraged them to allow me to put in an RTC to see me in my individual clinic to review their tx history/options and/or see them individually for ideas of interventions that may help improve their QOL or reduce their PTSD symptoms. Zero percent have taken me up on the offer. They immediately break eye contact and change the subject. I use the elephant in the room's trunk for a footrest and I go on getting paid to participate in the charade. I do think they get something from the social support and cameraderie of the group, but it really should be a peer support group, officially.

Exactly, and I agree. It's just something they should be organizing out in the community rather than coming into a hospital/clinic for, or that should at least (as you've said) be categorized correctly.

 

[Fan_of_Meehl]

Exactly, and I agree. It's just something they should be organizing out in the community rather than coming into a hospital/clinic for, or that should at least (as you've said) be categorized correctly.

This is somewhat unrelated but I need some input from psychologists whom I actually respect.

One of the patients an intern is seeing (sent to us by another psychologist in our system) apparently 'has a diagnosis' of 'pseudobulbar affect.' Person is also diagnosed with borderline personality disorder, other specified trauma- and stressor related disorder. The psychologist is making a big deal out of the apparent diagnosis (but the only thing I could find in the chart was a reference in a psychologist report that she 'has' it...I could find no history of neurology consults, it wasn't on the Problem List, I didn't see any diagnoses of neurodegenerative diseases like Parkinsons, multiple sclerosis, history of stroke, etc.

I have done a bit of a lit review so far and am finding some really goofy stuff. Like a study where people sent out questionnaires to OEF/OIF mTBI veterans (a seven item Likert scale asking about--from what I can tell--mood dysregulation symptoms) finding something ridiculous like a 70+ percent positive screen for this neurological issue...I mean...huh?

I'm asking the knowledgeable folks on the board (especially the competent neuropsychologists) what do you know about 'pseudobulbar affect' as a 'diagnosis.' Isn't it more of a feature (and is it controversial in terms of definitive 'diagnosis') of neurodegenerative illnesses (which CAN be confirmed)? I feel like people may be trying to slap a pseudoneurological label of 'pseudobulbar affect' on this veteran who has borderline personality disorder and unstable/labile affect.

Oh yeah...the psychologist who sent her to us (and who is making a big fuss about her 'having' 'pseudobulbar affect') gave her a copy of 'The Body Keeps the Score' to read for her 'trauma.'

 

[AcronymAllergy]

This is somewhat unrelated but I need some input from psychologists whom I actually respect.

One of the patients an intern is seeing (sent to us by another psychologist in our system) apparently 'has a diagnosis' of 'pseudobulbar affect.' Person is also diagnosed with borderline personality disorder, other specified trauma- and stressor related disorder. The psychologist is making a big deal out of the apparent diagnosis (but the only thing I could find in the chart was a reference in a psychologist report that she 'has' it...I could find no history of neurology consults, it wasn't on the Problem List, I didn't see any diagnoses of neurodegenerative diseases like Parkinsons, multiple sclerosis, history of stroke, etc.

I have done a bit of a lit review so far and am finding some really goofy stuff. Like a study where people sent out questionnaires to OEF/OIF mTBI veterans (a seven item Likert scale asking about--from what I can tell--mood dysregulation symptoms) finding something ridiculous like a 70+ percent positive screen for this neurological issue...I mean...huh?

I'm asking the knowledgeable folks on the board (especially the competent neuropsychologists) what do you know about 'pseudobulbar affect' as a 'diagnosis.' Isn't it more of a feature (and is it controversial in terms of definitive 'diagnosis') of neurodegenerative illnesses (which CAN be confirmed)? I feel like people may be trying to slap a pseudoneurological label of 'pseudobulbar affect' on this veteran who has borderline personality disorder and unstable/labile affect.

Oh yeah...the psychologist who sent her to us (and who is making a big fuss about her 'having' 'pseudobulbar affect') gave her a copy of 'The Body Keeps the Score' to read for her 'trauma.'

In my experience: I don't know that I ever saw pseudobulbar affect used/described appropriately, especially in MH contexts, once all the pharma commercials about it started coming out. It essentially became a "nice" way of saying emotionally dysregulated.

There are definitely pockets of psychologists who can be especially bad about attaching unwarranted significance to questionable medical diagnoses. Happened all the time with (m)TBI.

 

[Fan_of_Meehl]

In my experience: I don't know that I ever saw pseudobulbar affect used/described appropriately, especially in MH contexts, once all the pharma commercials about it started coming out. It essentially became a "nice" way of saying emotionally dysregulated.

There are definitely pockets of psychologists who can be especially bad about attaching unwarranted significance to questionable medical diagnoses. Happened all the time with (m)TBI.

I haven't watched regular/cable TV in many years. Had no idea about the commercials. I think I may be in for a comical treat on YouTube this weekend.

 

[AcronymAllergy]

In my experience: I don't know that I ever saw pseudobulbar affect used/described appropriately, especially in MH contexts, once all the pharma commercials about it started coming out. It essentially became a "nice" way of saying emotionally dysregulated.

There are definitely pockets of psychologists who can be especially bad about attaching unwarranted significance to questionable medical diagnoses. Happened all the time with (m)TBI.

Yeah, I haven't seen any recently, but they were pretty widespread a few years ago.

 

[Fan_of_Meehl]

In my experience: I don't know that I ever saw pseudobulbar affect used/described appropriately, especially in MH contexts, once all the pharma commercials about it started coming out. It essentially became a "nice" way of saying emotionally dysregulated.

There are definitely pockets of psychologists who can be especially bad about attaching unwarranted significance to questionable medical diagnoses. Happened all the time with (m)TBI.

Got this from the web:

A positive screening for PBA was determined by a Center for Neurologic Study-Lability (CNS-LS) score of 13 or greater and/or a report of sudden laughing and/or crying episodes. The CNS-LS is a seven-item self-report rating scale that measures perceived frequency and control over laughing and/or crying episodes.

Hunted down this 'instrument.' These are the items:

Using the scale below, please write the number that describes the degree to which each item
applies to you DURING THE PAST WEEK. Write only 1 number for each item.

1 - Applies never
2 - Applies rarely
3 - Applies occasionally
4 - Applies frequently
5 - Applies most of the time

1. There are times when I feel fine one minute, and then I’ll become tearful
the next over something small or for no reason at all.
2. Others have told me that I seem to become amused very easily or
that I seem to become amused about things that really aren’t funny.
3. I find myself crying very easily.
4. I find that even when I try to control my laughter, I am often unable to do so.
5. There are times when I won’t be thinking of anything happy or funny at all,
but then I’ll suddenly be overcome by funny or happy thoughts.
6. I find that even when I try to control my crying, I am often unable to do so.
7. I find that I am easily overcome by laughter

I mean...

Really???

If I slung this out to all the patients in the PCT clinic along with the PHQ-9s and PCL-5's I think that about 95% of them would 'screen positive' for this neurological condition

 

[Fan_of_Meehl]

Yeah, I haven't seen any recently, but they were pretty widespread a few years ago.

My sense is that this condition is obviously a legit feature of some neurodegenerative disorders (and is no laughing matter) and very debilitating. I would imagine that it is very distinctive (delimited affective outbursts totally unrelated to underlying mood state or provoking stimuli).

I would also imagine that it is (mis)'diagnosed' by a lot of psychiatric patients (on themselves) and on behalf of a lot of psychiatric patients whenever they display significant mood lability in a clinical context because...you know, 'The Body Keeps The Score.'

I'd imagine that if you ever saw it as a medical student on psychiatric or neurological grand rounds it would be pretty distinctive as a phenomenon.

But people 'diagnosing' pseudobulbar affect when they see emotional lability is like people 'diagnosing' cogwheel rigidity in their patients who raise their hand abruptly to ask a question.

 

[AcronymAllergy]

My sense is that this condition is obviously a legit feature of some neurodegenerative disorders (and is no laughing matter) and very debilitating. I would imagine that it is very distinctive (delimited affective outbursts totally unrelated to underlying mood state or provoking stimuli).

I would also imagine that it is (mis)'diagnosed' by a lot of psychiatric patients (on themselves) and on behalf of a lot of psychiatric patients whenever they display significant mood lability in a clinical context because...you know, 'The Body Keeps The Score.'

I'd imagine that if you ever saw it as a medical student on psychiatric or neurological grand rounds it would be pretty distinctive as a phenomenon.

But people 'diagnosing' pseudobulbar affect when they see emotional lability is like people 'diagnosing' cogwheel rigidity in their patients who raise their hand abruptly to ask a question.

I've certainly seen it in a subset of neurological patients (e.g., with Parkinson's, ALS). The MH "variant" that I saw was not the same. That questionnaire seems a bit...iffy.

 

[Fan_of_Meehl]

I've certainly seen it in a subset of neurological patients (e.g., with Parkinson's, ALS). The MH "variant" that I saw was not the same. That questionnaire seems a bit...iffy.

I think the specificity of that questionnaire goes WAY up when used in a population of patients who DON'T have diagnosed mood disorders and who DO have confirmed neuropathology (multiple sclerosis, Parkinsons, post-stroke, etc.).

 

[Sanman]

I have come across cases of PBA in patients with moderate to severe dementia and one CVA case. Even in some of the dementia cases the dx was iffy due to diminished communication in the patient. IMO, affective disorders should be a rule out for PBA, not a complementary dx. Folks with PTSD can obviously have inappropriate reactions that are related to their mental health concerns rather than neurological deficits. Seems like a bad dx.

 

[Fan_of_Meehl]

You know it's bad when a patient with a PTSD diagnosis is tempted to replace, 'that was my PTSD acting up' with 'that was my pseudobulbar affect acting up' as an explanation/excuse for an emotional outburst. And I'm talking about a patient whose chart review reveals ABSOLUTELY NO confirmed/diagnosed neurological illness or even a single note from a neurologist or even a community consult for neurology. To 'diagnose' 'pseudobulbar affect' in a patient without neurological illness but with a long history of serious emotional dysregulation and affective disorders just seems inappropriate. I would imagine that there is some mention of history of concussion somewhere (the ole mTBI 'diagnosis' (really an historical event)) in the chart (it's very common at VA) and that is what they are speculating is the cause of so-called 'pseudobulbar affect.'

 

[Sanman]

You know it's bad when a patient with a PTSD diagnosis is tempted to replace, 'that was my PTSD acting up' with 'that was my pseudobulbar affect acting up' as an explanation/excuse for an emotional outburst. Again, I'm talking about a patient whose chart review reveals ABSOLUTELY NO confirmed/diagnosed neurological illness or even a single note from a neurologist or even a community consult for neurology.

But now they can take Nuedexta and the Nuedexta pharma rep can continue to buy lunch for everyone (I think it was Chick-fil-a last time they fed me, they need to up their game).

 

[aim-agm]

You know it's bad when a patient with a PTSD diagnosis is tempted to replace, 'that was my PTSD acting up' with 'that was my pseudobulbar affect acting up' as an explanation/excuse for an emotional outburst. And I'm talking about a patient whose chart review reveals ABSOLUTELY NO confirmed/diagnosed neurological illness or even a single note from a neurologist or even a community consult for neurology. To 'diagnose' 'pseudobulbar affect' in a patient without neurological illness but with a long history of serious emotional dysregulation and affective disorders just seems inappropriate.

Worse, diagnosing a condition that is typically a product of a significant neurological condition, typically a neurodegenerative one, and then not attempting/referring to work up the underlying cause is a serious departure from the standard of care.

 

[Sanman]

Did anyone else read the announcement of:

The Task Force to Reduce Clinical Team Inefficiencies

This made me lol so hard. They are going to need more than a task force for that.

 

[Fan_of_Meehl]

Did anyone else read the announcement of:

The Task Force to Reduce Clinical Team Inefficiencies

This made me lol so hard. They are going to need more than a task force for that.

Exactly. The fundamental problem is cultural within the organization and it is deep rooted to such a degree that only a crisis brought on by something like a 70%+ cut in funding or a complete dismantling would ever hope to address the rot.

They have done everything possible to disassociate AUTHORITY from RESPONSIBILITY within the organization. The positive (self-reinforcing) feedback loops are locked in too tightly. Everyone in power is reading from the same sheet of music and mouthing the same hymns/phrases/slogans 24/7/365. I personally am witnessing so-called 'directives' that people in authority sit in meetings one minute and preach about how we *must* implement them and those same people, literally minutes or hours later within the same shift who have the AUTHORITY to implement them choose not to. They are always talking out of both sides of their mouths, just like the organization itself. They really should send MBA students to VA externship/rotations to find out exactly what NOT to do in terms of implementing an effective leadership culture in an organization.

Another committee, 'clinical team,' or bureaucratic circle-jerk session isn't going to do squat.

 

[psycho1391]

Did anyone else read the announcement of:

The Task Force to Reduce Clinical Team Inefficiencies

I barely made it through the ReBoot email that came moments before.

 

[cara susanna]

I barely made it through the ReBoot email that came moments before.

I'm thinking of the Meatloaf song: "I would do anything to reduce employee burnout, but I won't do that"

("that" of course being giving us more admin time, reducing focus on metrics, etc etc)

 

[Sanman]

I'm thinking of the Meatloaf song: "I would do anything to reduce employee burnout, but I won't do that"

("that" of course being giving us more admin time, reducing focus on metrics, etc etc)

They are also sending this out in the middle of a budget crisis and position freezes. Which is not their fault, but short staffing is short staffing.

 

[psycho1391]

I'm thinking of the Meatloaf song: "I would do anything to reduce employee burnout, but I won't do that"

("that" of course being giving us more admin time, reducing focus on metrics, etc etc)

There was a lot of "what can the burnout employee do?" and not systematic changes for sure.

 

[cara susanna]

Oh yeah, VA burnout reduction efforts are basically like "use your lunch hour to attend a yoga session." My favorite thing is how it's all mental health focused and stuff that pretty much every mental health employee would already know so, thanks guys. It's like when our facility set up a lounge to reduce employee stress during COVID and mandated that it be staffed by mental health employees (what about our stress?)

Our facility recently sent out a survey about employee wellness events (unless it was national, idk) and my coworker WENT OFF on them.

 

[JustNoticing]

our hospital recently announced they are closing the staff gym permanently while continuing to fund six figure whole health staff to send us email reminders to exercise and lead a balanced lifestyle.