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

[Sanman]

‘Millions’ can enroll directly for VA health care starting in March

I imagine this should reduce burnout immensely.

---

Members don't see this ad.

 

[cara susanna]

‘Millions’ can enroll directly for VA health care starting in March

I imagine this should reduce burnout immensely.

Sarcasm, right?

Although not having to deal with eligibility stuff may be helpful for some staff. Wish they did this for MST-only eligibility...

 

[Sanman]

Sarcasm, right?

Although not having to deal with eligibility stuff may be helpful for some staff. Wish they did this for MST-only eligibility...

Absolutely. On the one hand, having folks in the VA that are not there for service connection/disability is a plus. On the other hand, an onslaught of new patients, access sprints, and hiring freeze seem like burnout waiting to happen.

 

[cara susanna]

Had another person decline PTSD treatment because of fear of losing SC. Gotta love this system...

 

[Shiori]

I think even if we don't formally implement the Indiana Model, I might do it mentally. I strive to keep my tier 3s to 5% or less of my caseload and consult when I'm having trouble getting them back on their feet. Having a system normalize what I'm informally practicing is validating.

 

[Sanman]

Had another person decline PTSD treatment because of fear of losing SC. Gotta love this system...

"Man, I can't afford to get better. I got boat payments to make."

 

[WisNeuro]

"Man, I can't afford to get better. I got boat payments to make."

I lost count of the times I heard a Vet mention going out and buying a new truck right after they got their SC backpay.

 

[Sanman]

I lost count of the times I heard a Vet mention going out and buying a new truck right after they got their SC backpay.

Some of the 100% sc vets I have seen have nicer stuff than I do.

1. It's insane how much some of them can collect with all the programs
2. That usually leads to a crisis down the road when they up for compensation review.

 

[WisNeuro]

Some of the 100% sc vets I have seen have nicer stuff than I do.

1. It's insane how much some of them can collect with all the programs
2. That usually leads to a crisis down the road when they up for compensation review.

I mean, it's like 4k/month tax free for the Vet alone, throw on some dependents and a spouse for A&A and that's an extra $500 month. Then get that spouse on caregiver support, boom. Work a full-time job, or go become a commercial pilot, like a lot of vets, and that's a pretty good chunk o change.

 

[cara susanna]

I've always wondered why people with 100% SC are allowed to work, unless they're individually unemployable. The VA approaches disability so differently than state SSDI (I wonder why that is, too)

 

[WisNeuro]

I've always wondered why people with 100% SC are allowed to work, unless they're individually unemployable. The VA approaches disability so differently than state SSDI (I wonder why that is, too)

Because Vets are a Golden Calf when it comes to legislative action. Our representatives would rather **** on people who cost far less of our tax dollars and actually need it, than reform the SC system, or actually go after those obviously scamming the system.

 

[cara susanna]

Doing my way overdue Ethics training... who doesn't get job offers while grocery shopping?

 

[cara susanna]

This is a new one, we got a report from testing in the community and they gave a diagnosis of "post-TBI ADHD"

 

[WisNeuro]

This is a new one, we got a report from testing in the community and they gave a diagnosis of "post-TBI ADHD"

We get that pretty often when reviewing records in IMEs.

 

[cara susanna]

We get that pretty often when reviewing records in IMEs.

Really? I find that sad. Any idea how that particular "diagnosis" came about?

 

[AcronymAllergy]

Really? I find that sad. Any idea how that particular "diagnosis" came about?

My guess: a gross misunderstanding of what ADHD is coupled with lack of awareness of how to properly code using the DSM. Was this from a psychologist, neuropsychologist, or "neuropsychologist?"

Edit to add that I would not uncommonly see this from VA providers as well, both MH and non-MH (e.g., primary care).

 

[cara susanna]

My guess: a gross misunderstanding of what ADHD is coupled with lack of awareness of how to properly code using the DSM. Was this from a psychologist, neuropsychologist, or "neuropsychologist?"

Edit to add that I would not uncommonly see this from VA providers as well, both MH and non-MH (e.g., primary care).

I THINK it was a psychologist, as in non-neuro. But it wasn't, like, someone from a sketchy program or training background either

 

[Sanman]

I THINK it was a psychologist, as in non-neuro. But it wasn't, like, someone from a sketchy program or training background either

I know plenty of sketchy practices from folks that came from decent programs. I know of at least one person that charges for neuropsych/psychoed evals (cash) and completed all of 8 batteries total in their doctoral training and with no prior interest in testing and who actually complained they has to learn the stuff. Amazing how views change when money is concerned.

 

[WisNeuro]

Really? I find that sad. Any idea how that particular "diagnosis" came about?

What AA said, with some arising from psychologists known to be plaintiff W-hores who will write anything a lawyer tells them to in a report.

 

[AcronymAllergy]

I THINK it was a psychologist, as in non-neuro. But it wasn't, like, someone from a sketchy program or training background either

Yeah, the misunderstanding of ADHD I've seen just in psychologists is staggering. I could maybe understand if the person wasn't great with diagnostic codes and (mistakenly) threw on ADHD to reflect an acquired attention impairment, but then made this very clear in their written impressions (e.g., "although a diagnosis of ADHD is listed, the patient does not have ADHD; rather, they have an acquired attentional impairment related to TBI"). But to say it's "post-TBI ADHD" is just asinine, IMO.

 

[aim-agm]

Yeah, the misunderstanding of ADHD I've seen just in psychologists is staggering. I could maybe understand if the person wasn't great with diagnostic codes and (mistakenly) threw on ADHD to reflect an acquired attention impairment, but then made this very clear in their written impressions (e.g., "although a diagnosis of ADHD is listed, the patient does not have ADHD; rather, they have an acquired attentional impairment related to TBI"). But to say it's "post-TBI ADHD" is just asinine, IMO.

The only way it would make sense if they had ADHD before the TBI and they are indicating additional acquired impairment or that the TBI complicates treatment of the ADHD in some way.
Although we are probably putting more thought into interpreting the diagnosis than the idiot put into making it.

 

[WisNeuro]

Out of the dozen or so times I've seen the "ADHD due to TBI" diagnosis, it was in cases with clear secondary gain factors present and zero PVT/SVT evaluation added into the assessment.

 

[Fan_of_Meehl]

Absolutely. On the one hand, having folks in the VA that are not there for service connection/disability is a plus. On the other hand, an onslaught of new patients, access sprints, and hiring freeze seem like burnout waiting to happen.

I'm already backed up about 3 months (not even joking) while the average 'age' (number of sessions) of almost all of my clients is extremely low. Literally couldn't get people in/out any faster. Doesn't matter.

 

[Fan_of_Meehl]

Had another person decline PTSD treatment because of fear of losing SC. Gotta love this system...

At least that client has an underlying grasp of the fundamental logic involved in making such a decision. I respect their candor. Clearly, they are not in the market for the service you are offering.

 

[Fan_of_Meehl]

Because Vets are a Golden Calf when it comes to legislative action. Our representatives would rather **** on people who cost far less of our tax dollars and actually need it, than reform the SC system, or actually go after those obviously scamming the system.

Interesting article from TheHill.com on guaranteed basic income for veterans:

Veteran Basic Income could be the solution the VA has been searching for

The old adage “delay, deny, wait til I die” appears to be many veterans’ experiences.

thehill.com

1) it would probably be at rates similar to SSDI disability (at or below subsistence), leading to rioting from those previously 70% - 100% S/C

2) demand for MH care would plummet to like 20% of what it is now (we'd need about 80% fewer psychologists)

3) burnout rates for the remaining psychologists would plummet

Edit: it' a crap article, I know, (e.g., author argues that the veteran disability system is 'adversarial' (it explicitly is not, VBA has a duty to help veterans develop their claims and there is an endless appeal process)); however, the article is notable in that it's an article for the general public arguing for guaranteed income for all veterans for life.

In general, government-subsidized mental illness is just SUCH a bad idea.

 

[butteredtoast27]

Anyone have experience with getting called for jury duty while working at VA? My supervisor had me submit special jury duty leave for the day I was called to report, but I'm worried about what might happen if I'm actually selected to serve for a longer period of time...

 

[Fan_of_Meehl]

If you want to get out of serving for a longer period of time, familiarize yourself with the principle of 'jury nullification' and express to the court that you believe in the right of the jury to judge the law itself as well as the facts of the case. You'll be out of consideration in no time.

 

[psycho1391]

I'm worried about what might happen if I'm actually selected to serve for a longer period of time...

You can continue to use the jury leave option. One of my colleague was out for ~2 weeks. Its NBD.

 

[Sanman]

If you want to get out of serving for a longer period of time, familiarize yourself with the principle of 'jury nullification' and express to the court that you believe in the right of the jury to judge the law itself as well as the facts of the case. You'll be out of consideration in no time.

Or just seem intelligent and well reasoned. Honestly, the one time I was picked for a jury is was faster than not being picked. Cases often settle at the stage of jury selection and I was out of there maybe 45 min after selection.

 

[AcronymAllergy]

Anyone have experience with getting called for jury duty while working at VA? My supervisor had me submit special jury duty leave for the day I was called to report, but I'm worried about what might happen if I'm actually selected to serve for a longer period of time...

I was called a couple times but never selected. Missed just a day each time, I think. Told my boss beforehand and it was a very easy process for getting the time excused.

A co-worker or two were also called at different times, with one actually getting on a jury for like a week. She also didn't have problems getting the time covered. The biggest headache is just dealing with all the rescheduled patients, which for me in neuropsych meant overbooking because my next available was 6+ months out. Might not be as rough with therapy patients.

 

[Fan_of_Meehl]

Because Vets are a Golden Calf when it comes to legislative action. Our representatives would rather **** on people who cost far less of our tax dollars and actually need it, than reform the SC system, or actually go after those obviously scamming the system.

Interesting article on proposed VA funding

Budget deal includes VA funding hike, firearm ownership protections

The appropriations measure is expected to be approved by Congress later this week.

www.militarytimes.com

Total VA funding proposed at 'more than' 328 billion.

Total for mental health = 16.2 billion.

Rounding off, VA will spend <5% of its funds on mental health (16/328 = 0.048).

So...is suicide prevention still the 'top clinical priority' with MH clinics backlogged as far as the eye can see?

 

[WisNeuro]

Interesting article on proposed VA funding

Budget deal includes VA funding hike, firearm ownership protections

The appropriations measure is expected to be approved by Congress later this week.

www.militarytimes.com

Total VA funding proposed at 'more than' 328 billion.

Total for mental health = 16.2 billion.

Rounding off, VA will spend <5% of its funds on mental health (16/328 = 0.048).

So...is suicide prevention still the 'top clinical priority' with MH clinics backlogged as far as the eye can see?

The top clinical priority is making sure that SC figures continue to go through the roof, apparently.

 

[PsyDr]

Oh look: the VA says they do not have to comply with federal laws that were created because a veteran shot and killed the president with a mail ordered rifle.

Same organization that lied about the number of suicides.

Misinformation | 22 Veteran Suicides a Day

In the work I do to support service members, Veterans, and their families (SMVF), I see misinformation daily.

www.prainc.com

 

[WisNeuro]

Oh look: the VA says they do not have to comply with federal laws that were created because a veteran shot and killed the president with a mail ordered rifle.

Same organization that lied about the number of suicides.

Misinformation | 22 Veteran Suicides a Day

In the work I do to support service members, Veterans, and their families (SMVF), I see misinformation daily.

www.prainc.com

I mean, why would we want to enforce deadly weapon laws in a population at a much greater chance of perpetrating violence than pretty much any other demo?

 

[aim-agm]

I like how the email that went out this morning about the PACT Act acknowledges the "significant work that has happened...leading up to this expansion" but not the work that will occur as a result of the expansion.

I also didn't know that the expansion had previously been planned for phase-in over the course of almost a decade. This makes the plan of phase-in over the course of an instant much more reasonable in contrast.

/s

 

[PsyDr]

I mean, why would we want to enforce deadly weapon laws in a population at a much greater chance of perpetrating violence than pretty much any other demo?

Worked out great for such veterans as: Jeffery Dahmer, Charles Ng, David Berkowz, Gary Ridgeway, Dennis Rader, Israel Keys, Timothy McVeigh, etc.

 

[cara susanna]

UBI makes more sense than SC for veterans, but it would feel so unfair that they get UBI and no one else does

 

[WisNeuro]

UBI makes more sense than SC for veterans, but it would feel so unfair that they get UBI and no one else does

I mean, they get so many things that no else does, why not this?

 

[Sanman]

UBI makes more sense than SC for veterans, but it would feel so unfair that they get UBI and no one else does

I mean, they get so many things that no else does, why not this?

1. UBI for veterans is not UBI because it is not universal. It is just and entitlement, like welfare. Which so many veterans hate (while living off VA service connection). I think it will never fly politically for that reason. No one can argue with helping an injured veteran, but welfare for veterans?

2. Something like that would just lead to a bunch of folks that join the military and drop something heavy on their foot.

 

[Fan_of_Meehl]

1. UBI for veterans is not UBI because it is not universal. It is just and entitlement, like welfare. Which so many veterans hate (while living off VA service connection). I think it will never fly politically for that reason. No one can argue with helping an injured veteran, but welfare for veterans?

2. Something like that would just lead to a bunch of folks that join the military and drop something heavy on their foot.

Things are about to get a lot worse. I think they're finally getting ready to revise the service-connection 'ladder' for MH conditions (0, 10, 30, 50, 70, 100%) in ways that represent an improvement in validity but are going to lead to way more veterans legitimately qualifying for 100%.

This will lead to the vast majority of veterans making appointments with MH clinics to get 're-evaluated' in order to up their percentages to 100%. If you examine the actual current criteria for 100% s/c disability for a mental health condition (including PTSD), only the most hard-core psychotic and/or demented/delirious patients would actually meet 100% criteria if they were properly applied.

The revision involves a 100% designation that is a lot more rational/valid for, say, PTSD but is something that a lot of veterans would qualify for (even if they currently would qualify for 50-70%). Along with the toxic exposure/ PACT Act push recently, we're about to be deluged with new cases in the PTSD (and general mental health) clinics over the next couple of years. I'm already backed up about 3 months at this point. I guess we'll start paying out the nose by sending everyone to the community for care soon.

I've already seen YouTube videos of 'professional' disabled veterans announcing how important it is for veterans to do the above once the criteria are updated.

And there was a recent congressional hearing (one of the Veteran's commitees) where they were touting a bill that will allow veterans to collect military retirement + service connection benefits (added together). To date, I think they could do one or the other (laws prevented 'double-dipping'). But if this bill is passed, they could get (a) full military retirement + (b) 100% service connection benefits + (c) income from working full-time job + (whatever else..caregiver support, aid and attendance, SSDI (some do)). I mean...I don't really care but when some of the people from the younger generation have both spouses working and are barely able to make ends meet and they have friends who are veterans who are pulling in 200K+ (as a self-described '100% disabled veteran') from all those sources of income...interesting times ahead. My guess is that they will have over-reached at this point and the elephant in the room that has been invisible will suddenly be getting a lot of attention. Then comes the backlash and then all of the veterans who are legitimately disabled from PTSD will have a much harder time of it.

 

[AcronymAllergy]

Things are about to get a lot worse. I think they're finally getting ready to revise the service-connection 'ladder' for MH conditions (0, 10, 30, 50, 70, 100%) in ways that represent an improvement in validity but are going to lead to way more veterans legitimately qualifying for 100%.

This will lead to the vast majority of veterans making appointments with MH clinics to get 're-evaluated' in order to up their percentages to 100%. If you examine the actual current criteria for 100% s/c disability for a mental health condition (including PTSD), only the most hard-core psychotic and/or demented/delirious patients would actually meet 100% criteria if they were properly applied.

The revision involves a 100% designation that is a lot more rational/valid for, say, PTSD but is something that a lot of veterans would qualify for (even if they currently would qualify for 50-70%). Along with the toxic exposure/ PACT Act push recently, we're about to be deluged with new cases in the PTSD (and general mental health) clinics over the next couple of years. I'm already backed up about 3 months at this point. I guess we'll start paying out the nose by sending everyone to the community for care soon.

I've already seen YouTube videos of 'professional' disabled veterans announcing how important it is for veterans to do the above once the criteria are updated.

And there was a recent congressional hearing (one of the Veteran's commitees) where they were touting a bill that will allow veterans to collect military retirement + service connection benefits (added together). To date, I think they could do one or the other (laws prevented 'double-dipping'). But if this bill is passed, they could get (a) full military retirement + (b) 100% service connection benefits + (c) income from working full-time job + (whatever else..caregiver support, aid and attendance, SSDI (some do)). I mean...I don't really care but when some of the people from the younger generation have both spouses working and are barely able to make ends meet and they have friends who are veterans who are pulling in 200K+ (as a self-described '100% disabled veteran') from all those sources of income...interesting times ahead. My guess is that they will have over-reached at this point and the elephant in the room that has been invisible will suddenly be getting a lot of attention. Then comes the backlash and then all of the veterans who are legitimately disabled from PTSD will have a much harder time of it.

Military recruitment has been down recently. Maybe this is a measured expense to encourage more people to sign up.

 

[Behaviorismiscool]

Tough few weeks in VA with my mid-level leadership being ineffective and incompetent. Is the best strategy to keep my head down or to find a different VA to work at?

How have you guys made it work for you when your supervisor moved up to get away from patient care and can't/won't make even small changes to the clinic?

 

[WisNeuro]

Tough few weeks in VA with my mid-level leadership being ineffective and incompetent. Is the best strategy to keep my head down or to find a different VA to work at?

How have you guys made it work for you when your supervisor moved up to get away from patient care and can't/won't make even small changes to the clinic?

Grass isn't always greener, incompetent leadership seems to be a feature, not a bug in the VA.

 

[Sanman]

Tough few weeks in VA with my mid-level leadership being ineffective and incompetent. Is the best strategy to keep my head down or to find a different VA to work at?

How have you guys made it work for you when your supervisor moved up to get away from patient care and can't/won't make even small changes to the clinic?

Depends on your supervisor and how much they know. I make small changes without ever informing my supervisor unless they ask about it. It helps that I work in a specialty area and most leadership have little to no idea what I do. Easier to beg forgiveness than ask permission.

 

[Sanman]

Grass isn't always greener, incompetent leadership seems to be a feature, not a bug in the VA.

The problem is that the smartest leaders also realize that doing the job more than about three years is pointless.

 

[AcronymAllergy]

Tough few weeks in VA with my mid-level leadership being ineffective and incompetent. Is the best strategy to keep my head down or to find a different VA to work at?

How have you guys made it work for you when your supervisor moved up to get away from patient care and can't/won't make even small changes to the clinic?

Generally speaking, given the turnover in leadership that's pretty common at VA, I found that keeping my head down for more inconsequential/aggravating administrative-type issues was best for my sanity. And like Sanman, I at times made necessary changes in my specialty practice area without informing leadership.

What types of changes is it you're wanting/needing done with the clinic?

 

[Fan_of_Meehl]

Generally speaking, given the turnover in leadership that's pretty common at VA, I found that keeping my head down for more inconsequential/aggravating administrative-type issues was best for my sanity. And like Sanman, I at times made necessary changes in my specialty practice area without informing leadership.

What types of changes is it you're wanting/needing done with the clinic?

I learned pretty early on that asking leadership for help/advice always made me end up in a worse position that if I hadn't even informed them of anything in the first place.

Sad, but true at VA.

 

[Behaviorismiscool]

Generally speaking, given the turnover in leadership that's pretty common at VA, I found that keeping my head down for more inconsequential/aggravating administrative-type issues was best for my sanity. And like Sanman, I at times made necessary changes in my specialty practice area without informing leadership.

What types of changes is it you're wanting/needing done with the clinic?

Main change that would help is educating referring providers and veterans about what we do in general mental health clinic. Lots of referrals sent to us even though they are looking for ongoing vent sessions. And some colleagues in psychiatry and social work who'd like us to do various ineffective things, like lifelong support sessions or critical incident stress debriefing even when I explain the lack of evidence base and that that isn't the role of a psychologist in an outpatient mental health clinic. I know we can't stop all bad referrals by a long shot, but it seems like shaping patient expectations better before they get into a room with me would help a ton. I've offered to put together a referral guide and resource book. I've shown my leadership examples of such tools from other VAs. I've also suggested a service line wide email blast about what we do and referral processes (as has happened with some of our specialty clinics). I've told them about consent forms for evidence-based, time-limited episodes of care. No movement toward doing anything differently for at least the past 5 or so years. I can do things the way I like as an individual provider but that doesn't change the sheer volume of unnecessary referrals that create a backlog in my case load and prevent me from providing a decent standard of care.

I don't know that it'd be that much different anywhere else. Perhaps I should let the freak flag fly and put up a memento mori poster or skull in the office, but phrase it more nicely with all of these unmotivated patients. (Please try doing something differently, one thing even, because you will die one day. Pretty please with sprinkles on top?)

 

[Fan_of_Meehl]

Main change that would help is educating referring providers and veterans about what we do in general mental health clinic. Lots of referrals sent to us even though they are looking for ongoing vent sessions. And some colleagues in psychiatry and social work who'd like us to do various ineffective things, like lifelong support sessions or critical incident stress debriefing even when I explain the lack of evidence base and that that isn't the role of a psychologist in an outpatient mental health clinic. I know we can't stop all bad referrals by a long shot, but it seems like shaping patient expectations better before they get into a room with me would help a ton. I've offered to put together a referral guide and resource book. I've shown my leadership examples of such tools from other VAs. I've also suggested a service line wide email blast about what we do and referral processes (as has happened with some of our specialty clinics). I've told them about consent forms for evidence-based, time-limited episodes of care. No movement toward doing anything differently for at least the past 5 or so years. I can do things the way I like as an individual provider but that doesn't change the sheer volume of unnecessary referrals that create a backlog in my case load and prevent me from providing a decent standard of care.

I don't know that it'd be that much different anywhere else. Perhaps I should let the freak flag fly and put up a memento mori poster or skull in the office, but phrase it more nicely with all of these unmotivated patients. (Please try doing something differently, one thing even, because you will die one day. Pretty please with sprinkles on top?)

On a bad week, 80% of my sessions are spent with me pretending to believe veterans who are covertly auditioning for a MH service-connection (or increase in service-connection) while pretending to be there for active psychotherapy. There are days when the back-and-forth between us is amusing, even entertaining--but most of the time it is just an absolute slog.

 

[Sanman]

Main change that would help is educating referring providers and veterans about what we do in general mental health clinic. Lots of referrals sent to us even though they are looking for ongoing vent sessions. And some colleagues in psychiatry and social work who'd like us to do various ineffective things, like lifelong support sessions or critical incident stress debriefing even when I explain the lack of evidence base and that that isn't the role of a psychologist in an outpatient mental health clinic. I know we can't stop all bad referrals by a long shot, but it seems like shaping patient expectations better before they get into a room with me would help a ton. I've offered to put together a referral guide and resource book. I've shown my leadership examples of such tools from other VAs. I've also suggested a service line wide email blast about what we do and referral processes (as has happened with some of our specialty clinics). I've told them about consent forms for evidence-based, time-limited episodes of care. No movement toward doing anything differently for at least the past 5 or so years. I can do things the way I like as an individual provider but that doesn't change the sheer volume of unnecessary referrals that create a backlog in my case load and prevent me from providing a decent standard of care.

I don't know that it'd be that much different anywhere else. Perhaps I should let the freak flag fly and put up a memento mori poster or skull in the office, but phrase it more nicely with all of these unmotivated patients. (Please try doing something differently, one thing even, because you will die one day. Pretty please with sprinkles on top?)

That's a big ask that is unlikely to change the referrals you get and mess with office politics. The truth of the matter is the system continues to reinforce bad referrals, lately with badly implemented 'smart' goals. Veteran is sad, phq-2/9 is positive, etc. and the intervention is psychotherapy consult. Physician's job is done and the problem is yours. Education may change some of that, but not likely and you risk pissing off other depts who will just complain to your dept chief.

Unlikely to find a VA that has a good general mental health clinic. There is a reason those jobs are difficult to staff and keep staffed. Most folks find a different position within the VA that allows for more job satification or leave altogether. Your best shot is specialty clinic or find a quiet cboc with a good pcp and take that.