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

[Shiori]

I took on 6 hours of administrative stuff. My workload is the same, but I can do something different with my brain. The role still ends up being really clinical, but I get a bit more autonomy with the veterans I see.

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[Behaviorismiscool]

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.

I'm interested in educating the mental health service line. The largest number of bad referrals come from psychiatry and same day access social workers within mental health and both have expressed that they would like a referral guide and resource document to give to veterans. Ideally these things would help guide the referral process and allow veterans to understand what they're signing up for and what lower level of care resources are if now is not a good time for psychotherapy (e.g., whole health, recreational therapy, chaplain services). I educate my smaller team, and they have really improved quality and reduced frequency of their referrals.

I hear you about transferring to a specialty clinic or low-key CBOC. That won't be possible at my VA hospital. I'm geographically bound, and I would like to help make my VA a place general mental health clinic psychologists can thrive. I think I may need to move on to remote VA options soon because change isn't happening here. Anyone with a good team and culture hiring? I don't care if there is drama as long as my colleagues work hard and are competent at what they do. I am a good fit for general mental health or a PTSD clinic.

 

[Fan_of_Meehl]

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.

Real talk. 100%

 

[AcronymAllergy]

I'm interested in educating the mental health service line. The largest number of bad referrals come from psychiatry and same day access social workers within mental health and both have expressed that they would like a referral guide and resource document to give to veterans. Ideally these things would help guide the referral process and allow veterans to understand what they're signing up for and what lower level of care resources are if now is not a good time for psychotherapy (e.g., whole health, recreational therapy, chaplain services). I educate my smaller team, and they have really improved quality and reduced frequency of their referrals.

I hear you about transferring to a specialty clinic or low-key CBOC. That won't be possible at my VA hospital. I'm geographically bound, and I would like to help make my VA a place general mental health clinic psychologists can thrive. I think I may need to move on to remote VA options soon because change isn't happening here. Anyone with a good team and culture hiring? I don't care if there is drama as long as my colleagues work hard and are competent at what they do. I am a good fit for general mental health or a PTSD clinic.

You might have already tried this, but maybe go ahead and create a brief referral guide, then send it to your supervisor and say, "hey, I was going to send this along to medical media/whoever else for approval and wanted to get your okay before doing so."

 

[Behaviorismiscool]

If they aren't motivated or making progress, I stop doing psychotherapy with them and provide termination counseling. I think we have freedom to choose to terminate psychotherapy quickly as is clinically indicated in many cases. It is tricky because there is a lack of mid-level leadership guidance and support to do this effectively, and patients can call back in at any point and get back on my schedule. Many patients do respond well to the limit setting, particularly when the referring provider has shaped expectations and they provide written consent with me during treatment planning for the therapy process. Some patients do become verbally abusive and disruptive at any therapy limit setting, but those are the outliers. It is more common to have patients who have been conditioned to be so highly dependent that they resist termination even when they are clearly unmotivated to make changes or we have reached maximum therapeutic benefit for this round of therapy. When this becomes a high portion of my caseload, as is the case now, it is a daily slog. I believe it is still my responsibility to conclude treatment in these cases; the termination process just takes some extra sessions. The function of taking more sessions to send them on their way is sometimes scaffolding, sometimes self-serving to reduce patient complaints. It is a lot of pressure on the individual provider to keep doing the right thing when it may be "easier" to let these patients whine indefinitely since there are no negative consequences for other therapists who do longterm supportive counseling.

 

[Behaviorismiscool]

You might have already tried this, but maybe go ahead and create a brief referral guide, then send it to your supervisor and say, "hey, I was going to send this along to medical media/whoever else for approval and wanted to get your okay before doing so."

I did. Mid level leadership said they're already working on this and any written materials for wide distribution will need approval at higher levels and that I should stop working on it. They've supposedly been working on something like this for at least the last 5 years. I made some public irreverent jokes about the clinic being stuck in contemplation with some preparation and no plan for moving to action soon. I noted that I would not see the clinic for individual therapy if it were a patient. No idea if they appreciate the humor or what they are about to lose with all I do for productivity and team morale. My sense is no, and they would rather have more ineffective therapists than work to keep the ones they have that are good.

 

[Fan_of_Meehl]

If they aren't motivated or making progress, I stop doing psychotherapy with them and provide termination counseling. I think we have freedom to choose to terminate psychotherapy quickly as is clinically indicated in many cases. It is tricky because there is a lack of mid-level leadership guidance and support to do this effectively, and patients can call back in at any point and get back on my schedule. Many patients do respond well to the limit setting, particularly when the referring provider has shaped expectations and they provide written consent with me during treatment planning for the therapy process. Some patients do become verbally abusive and disruptive at any therapy limit setting, but those are the outliers. It is more common to have patients who have been conditioned to be so highly dependent that they resist termination even when they are clearly unmotivated to make changes or we have reached maximum therapeutic benefit for this round of therapy. When this becomes a high portion of my caseload, as is the case now, it is a daily slog. I believe it is still my responsibility to conclude treatment in these cases; the termination process just takes some extra sessions. The function of taking more sessions to send them on their way is sometimes scaffolding, sometimes self-serving to reduce patient complaints. It is a lot of pressure on the individual provider to keep doing the right thing when it may be "easier" to let these patients whine indefinitely since there are no negative consequences for other therapists who do longterm supportive counseling.

I have had similar experiences. I applaud your approach.

Regarding clients who get upset with limit-setting and an 'on task' approach in therapy...well...I just consider this a self-correcting issue, with time. As long as I 'stick to my guns,' as it were, and make sure therapy isn't a reinforcing environment for them, they tend to drop out.

I have found it possible to implement my own standards for psychotherapy engagement in my OWN clinical work but I am extremely skeptical about being able to influence this SYSTEM to improve in that regard.

The good news is that if you implement a disciplined approach to outpatient psychotherapy practice at VA you can eliminate (in the long run) a lot of disengaged, Axis II clientele from your caseload. The bad news is, since you're so efficient at keeping your caseloads cleared out of "dead weight," managers will just see fit to give you 3x - 5x the rate of new cases as everyone else so you have to do more work and will eventually be backed up for months on end.

Oh well...we may not be able to choose not to suffer but we can pick our brand of suffering.

 

[Harry3990]

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.

Anyone have tips on how to determine from the outside (or interview) whether a CBOC is “quiet” and/or has a decent PCP?

 

[Fan_of_Meehl]

Anyone have tips on how to determine from the outside (or interview) whether a CBOC is “quiet” and/or has a decent PCP?

Ask them how 'backed up' they are (i.e., for intakes or therapy slots). Ask them about caseload size (and see the deer-in-the-headlights gaze and crickets in the background). Ask how many intake slots there are per week. Ask about 'inflow' vs. 'outflow' of patients in people's psychotherapy clinic, e.g., on average, how many new cases is a provider expected to take into his psychotherapy caseload per week or month and be able to handle. Ask them how long the planned or actual 'courses' of psychotherapy are in the clinic. Ask them if they schedule people for monthly (or less frequent) 'psychotherapy' appointments. Ask them about their philosophy of psychotherapy treatment including structure/effort, whether they do 'supportive' therapy (and how they differentiate 'supportive therapy' from mental health case management).

I have had the following two experiences in the past week that--juxtaposed against one another--make carnival music start playing in my head:

(a) I interviewed for a GS-14 'program manager' position in PCMHI and there were several questions about how much experience do I have managing a complex budget for a department (that made me feel inadequate/inexperienced in this area)
(b) I sat in an impromptu discussion/meeting with my boss (over a PCT clinic) where we have two full-time psychologist vacancies and--when she said 'it looks like we aren't going to be able to fill those vacancies...we're not doing any new hires right now, just moving around existing staff' and she said she is having to write up a justification for actually needing to fill those psychologist positions...
When I mentioned that I'd be glad to write out a brief analysis using basic logic and 4th grade arithmetic to 'prove' that we 'need' to replace those two full-time psychologist positions based on number/rate of intakes, the average course of therapy (e.g., 12+ weekly sessions), number of weekly intake slots, etc., she got this disgusted eye-rolling look on her face and flat out said that the people who would be reading this written justification (the 'big wigs in mental health' locally) wouldn't want to be bothered with math or logical arguments. I said, oh...so appeals to emotion, then? I suppose I could do that too.

It was just wild to me that while I was in the GS-14 position interview being grilled by people about what experience I had (or in this case didn't have) managing 'complex budgetary blah blah blah'...the bigwigs interviewing me are those same people in the organization who apparently can't or won't attend to basic logic and 4th grade arithmetic (addition, subtraction, division, multiplication, and maybe percentages).

 

[Sanman]

Ask them how 'backed up' they are (i.e., for intakes or therapy slots). Ask them about caseload size (and see the deer-in-the-headlights gaze and crickets in the background). Ask how many intake slots there are per week. Ask about 'inflow' vs. 'outflow' of patients in people's psychotherapy clinic, e.g., on average, how many new cases is a provider expected to take into his psychotherapy caseload per week or month and be able to handle. Ask them how long the planned or actual 'courses' of psychotherapy are in the clinic. Ask them if they schedule people for monthly (or less frequent) 'psychotherapy' appointments. Ask them about their philosophy of psychotherapy treatment including structure/effort, whether they do 'supportive' therapy (and how they differentiate 'supportive therapy' from mental health case management).

I have had the following two experiences in the past week that--juxtaposed against one another--make carnival music start playing in my head:

(a) I interviewed for a GS-14 'program manager' position in PCMHI and there were several questions about how much experience do I have managing a complex budget for a department
(b) I sat in an impromptu discussion/meeting with my boss (over a PCT clinic) where we have two full-time psychologist vacancies and--when she said 'it looks like we aren't going to be able to fill those vacancies...we're not doing any new hires right now, just moving around existing staff' and she said she is having to write up a justification for actually needing to fill those psychologist positions...
When I mentioned that I'd be glad to write out a brief analysis using basic logic and 4th grade arithmetic to 'prove' that we 'need' to replace those two full-time psychologist positions based on number/rate of intakes, the average course of therapy (e.g., 12+ weekly sessions), number of weekly intake slots, etc., she got this disgusted eye-rolling look on her face and flat out said that the people who would be reading this written justification (the 'big wigs in mental health' locally) wouldn't want to be bothered with math or logical arguments. I said, oh...so appeals to emotion, then? I suppose I could do that too.

It was just wild to me that while I was in the GS-14 position interview being grilled by people about what experience I had (or in this case didn't have) managing 'complex budgetary blah blah blah'...the bigwigs interviewing me are those same people in the organization who apparently can't or won't attend to basic logic and 4th grade arithmetic (addition, subtraction, division, multiplication, and maybe percentages).

Because they won't care until their pet metric is hurt. Let consults go past 30 days on the regular, then it may affect their job.

 

[Fan_of_Meehl]

Because they won't care until their pet metric is hurt. Let consults go past 30 days on the regular, then it may affect their job.

 

[texanpsychdoc]

I was considering trying to get contracted with the VA to do C&P evals - would this be worth it? I have no desire to go through those 3rd party agencies that contract you to do them. I've declined several offers to do those with those companies.

 

[WisNeuro]

I was considering trying to get contracted with the VA to do C&P evals - would this be worth it? I have no desire to go through those 3rd party agencies that contract you to do them. I've declined several offers to do those with those companies.

Depends on how much they are paying for the time. I haven't seen any offers that come close to being worth it for me.

 

[AcronymAllergy]

I was considering trying to get contracted with the VA to do C&P evals - would this be worth it? I have no desire to go through those 3rd party agencies that contract you to do them. I've declined several offers to do those with those companies.

Agreed that it probably depends on the rate they offer and how much work you think will be involved. I know someone who does this (efficiently) and enjoys it. I believe the benefit is that they're paid as a part-time W-2 employee, so VA covers payroll taxes, among other potential tax uses.

 

[Sanman]

I was considering trying to get contracted with the VA to do C&P evals - would this be worth it? I have no desire to go through those 3rd party agencies that contract you to do them. I've declined several offers to do those with those companies.

Not sure you can be contracted with the VA directly as an independent provider. The VA contracts with around five companies (which are the third party contractors) and they all underpay. If you know of a different way, I am certainly curious to hear about it.

 

[cara susanna]

Teams is down nationwide and I am one of the affected users. It is AWFUL. I didn't realize how dependent I was on it

 

[Sanman]

Teams is down nationwide and I am one of the affected users. It is AWFUL. I didn't realize how dependent I was on it

Can't be everywhere because mine is working just fine and I just got a Teams message.

 

[cara susanna]

Can't be everywhere because mine is working just fine and I just got a Teams message.

It's not everyone, but it is a national issue. I think it's related to the new Teams.

 

[Sanman]

It's not everyone, but it is a national issue. I think it's related to the new Teams.

This is why I stay away from new things. Teams Classic works just fine.

 

[WisNeuro]

This is why I stay away from new things. Teams Classic works just fine.

 

[Shiori]

Yeah, Classic is the only thing working for me. I'll give them time to figure it out.

 

[Harry3990]

What is the deal with part-time VA positions? Considering putting in an application for one in my area at a CBOC. Do they still typically include partial benefits? Can anyone speak to whether part-time is worth considering?

 

[WisNeuro]

What is the deal with part-time VA positions? Considering putting in an application for one in my area at a CBOC. Do they still typically include partial benefits? Can anyone speak to whether part-time is worth considering?

I think it depends on how part-time. I thought you had to be at least .6FTE for bennies.

 

[WisNeuro]

Just had my first clinical no show in like a year. Just though you VA peeps would like to know.

 

[Sanman]

Just had my first clinical no show in like a year. Just though you VA peeps would like to know.

I mean, you're fee for service, I'm salaried....that sounds like a nightmare to me . Let me know when they are all no shows and you still get paid. Now that is a business model!

EDIT: I believe that is the Planet Fitness business model actually.

 

[WisNeuro]

I mean, you're fee for service, I'm salaried....that sounds like a nightmare to me . Let me know when they are all no shows and you still get paid. Now that is a business model!

EDIT: I believe that is the Planet Fitness business model actually.

Meh, I consider clinical evals my sort of pro bono work anyway. And yeah, Planet Fitness is a genius business strategy, market to the people least likely to actually show up to your club, and set your monthly membership level at a level just low enough that they'll never be motivated to spend the 15-20 minutes to cancel it.

 

[Sanman]

Meh, I consider clinical evals my sort of pro bono work anyway. And yeah, Planet Fitness is a genius business strategy, market to the people least likely to actually show up to your club, and set your monthly membership level at a level just low enough that they'll never be motivated to spend the 15-20 minutes to cancel it.

But the fact they could go and that keeps them there. I am as guilty as all the rest, my gym habit dwindled to nothing with the pandemic and the addition of a tiny human.

 

[DonutFox]

What is the deal with part-time VA positions? Considering putting in an application for one in my area at a CBOC. Do they still typically include partial benefits? Can anyone speak to whether part-time is worth considering?

I’m currently .5 FTE and I get all of the same benefits, just cut in half. I also have a small private practice. It’s a nice balance. Definitely worth considering.

 

[cara susanna]

Have any of you ever had a patient who just is incredibly spotty and inconsistent with therapy, to the point where you feel like, even if things have changed and they're ready to be consistent, you are no longer able to be effective with them because you are just SO tired?

 

[Sanman]

Have any of you ever had a patient who just is incredibly spotty and inconsistent with therapy, to the point where you feel like, even if things have changed and they're ready to be consistent, you are no longer able to be effective with them because you are just SO tired?

You just described all my 'regular' patients. There are ebbs and flows. I imagine that is how a lot their providers feel, which is why they often encounter resistance when getting care. That said, maybe it means you are working too hard with them?

 

[cara susanna]

You just described all my 'regular' patients. There are ebbs and flows. I imagine that is how a lot their providers feel, which is why they often encounter resistance when getting care. That said, maybe it means you are working too hard with them?

I don't feel like I'm working too hard (although I recognize that can often be the source of this). It's just this constant: they attend 1-2 sessions, drop off, ask for therapy again via their psychiatrist (not even calling me), attend 1-2 sessions, drop off, request therapy again... rinse and repeat

 

[Harry3990]

I’m currently .5 FTE and I get all of the same benefits, just cut in half. I do private practice for the rest of my time since there’s not a non-compete. It’s a nice balance. Definitely worth considering.

Do you know, is pay determined similarly? .5 FTE at GS-13 step 1 would get half of typical GS-13 step 1 pay as well?

 

[Sanman]

I don't feel like I'm working too hard (although I recognize that can often be the source of this). It's just this constant: they attend 1-2 sessions, drop off, ask for therapy again via their psychiatrist (not even calling me), attend 1-2 sessions, drop off, request therapy again... rinse and repeat

We should just call this the VA shuffle. It's kind like the hokey pokey, you dip your right foot in then you take you right foot out and run away for a little while.

 

[DonutFox]

Do you know, is pay determined similarly? .5 FTE at GS-13 step 1 would get half of typical GS-13 step 1 pay as well?

Yep! My hourly rate is the same, but I only get paid for 20 hours.

 

[coffee&CBT]

Yep! My hourly rate is the same, but I only get paid for 20 hours.

Can you share about how you got the .5? Was it a posted .5 position or did you ask to step down from full-time?

 

[Fan_of_Meehl]

Teams is down nationwide and I am one of the affected users. It is AWFUL. I didn't realize how dependent I was on it

Just wait until 2030 and MS Cerebra-Teams (embedded chip) uses its AI algorithm to give you real time feedback regarding 'optimizing your efficiency' as a 'valued provider' because it detected you staring off into space for more than 20 seconds without being 'on task.' Get back to work or the discomfort slider on your internal avatar will be readjusted from a value of 0 to 5 out of 100. Have a nice day, citizen.

To hell with Teams. Call me a troglodyte, a Luddite, whatever but bring back 1990 any day and its paper charts and telephones as peak technology.

 

[Fan_of_Meehl]

We should just call this the VA shuffle. It's kind like the hokey pokey, you dip your right foot in then you take you right foot out and run away for a little while.

Absolutely. 60 - 80% of my sessions are focused on significant lack of engagement as the target of therapy, explicitly attempting to psychoeducate and engage with the patient in problem-solving overt barriers to engagement such as:
- lack of attendance (no shows, cancellations)
- coming late or leaving early in sessions
- not completing measures or between-session worksheets / assignments
- the fact that therapy is focused on SELF-change and not complaining about the state of the world/VA/society, not an endless recitation of (labels for) traumatic events and re-experiencing symptoms (nightmares, memories, 'flashbacks'), not an audition for service-connection or higher percentages thereto
- not a forum for re-litigating service-connection percentages, aid and attendance or 'caregiver' denial letters, or an opportunity to get a 'prescription' for a service dog or medical marijuana

Generously, approximately 40% of my caseload represents veteran mental health patients who have legitimate / authentic mental health diagnoses (including actual PTSD) and only about half of these (20% of entire caseload/ appointments) are in any significant manner 'engaged' in the active psychotherapy process. Not so generously, you could easily cut those percentages in half--depending on the week--to result in about 10% of my sessions actually engaged in high-level specialty psychotherapy services with willing participants.

And now they are (nationally, I believe) rolling out an additional template required in notes for all PTSD patients we're having sessions with prompting us to type in (I do this, naturally, anyway at the end of an episode of care, but now they're hand over hand prompting us with the new template, I suppose) the scores for pre-post PCL-5 or PHQ-9 readings. Which implies, at some point, they are going to crunch/publish the numbers on how many veterans just keep coming back for monthly (or less often) 'psychotherapy' appointments for decades on end with PCL-5 scores being elevated (and flat over time, or increasing steadily over time (I see this a lot)) as a result of decades of 'psychotherapy.'

As backdrop to all of this, I have seen a steady decline in numbers of psychotherapist positions (especially generalists or people who actually carry real caseloads and are not some boutique 'specialty' provider who doesn't have to see people long-term or complete MH Suite treatment plans--they just 'specialize' on disorders of the left pinky fingernail or some such...not the whole veteran) and we are under a de facto hiring freeze where we are being told that vital positions (full-time staff positions in the PTSD specialty clinic) will not be backfilled. We've lost 2 out of 4 full-time positions in the past year in PCT (so, 50% clinician capacity) and I am now backed up 3 months and rising.

But we have 'too many' clinicians.

Interesting times ahead.

 

[Fan_of_Meehl]

Agreed that it probably depends on the rate they offer and how much work you think will be involved. I know someone who does this (efficiently) and enjoys it. I believe the benefit is that they're paid as a part-time W-2 employee, so VA covers payroll taxes, among other potential tax uses.

You can do it quite 'efficiently' by doing a 5 min chart review, a 20-30 min interview, and spending 1 minute scoring and entering a PCL-5.

I see that done all the time.

 

[AcronymAllergy]

You can do it quite 'efficiently' by doing a 5 min chart review, a 20-30 min interview, and spending 1 minute scoring and entering a PCL-5.

I see that done all the time.

The PCL-5 tells no lies, obviously. I mean, it's got numbers!

 

[Fan_of_Meehl]

The PCL-5 tells no lies, obviously. I mean, it's got numbers!

Had an intake yesterday. Veteran with questionable Criterion A's, dx of PTSD, etc.

Was seen a couple of years ago by VA psychologist who recently retired (couldn't take the crap any longer). Actually a decent/good clinician. Imagine that.

Well, Dr. X had seen this patient years ago for psych eval. Was dubious of PTSD dx. Had it as a rule-out for a couple of sessions. Administerd PAI. NIM (overreporting scale) through the roof. Write up of results? 'Testing was invalid. May need to try again at a later time' (lol).

One or two sessions later, veteran takes a PCL-5. 80 out of 80 (another lol from me). Psychologist basically says, 'oh well, 80 out of 80 on PCL means they probably have PTSD' and diagnoses PTSD.

Edit: this was not actually a bad clinician. This was a good clinician worn down, overloaded, and burned out by a bad system. They knew (or at least assumed) that it would be futile to try to not diagnose PTSD in a veteran who clearly wanted the dx and would probably raise hades is they didn't get it.

If the higher ups in mental health administration can't be bothered with elementary arithmetic (on other matters) what is the probability that they'll be able to follow an explanation regarding proper interpretation of validity scale elevations and hesitance to diagnose/confirm a diagnosis like PTSD (which is complex and of specific etiology) which is based almost entirely on self-report?

 

[Sanman]

Had an intake yesterday. Veteran with questionable Criterion A's, dx of PTSD, etc.

Was seen a couple of years ago by VA psychologist who recently retired (couldn't take the crap any longer). Actually a decent/good clinician. Imagine that.

Well, Dr. X had seen this patient years ago for psych eval. Was dubious of PTSD dx. Had it as a rule-out for a couple of sessions. Administerd PAI. NIM (overreporting scale) through the roof. Write up of results? 'Testing was invalid. May need to try again at a later time' (lol).

One or two sessions later, veteran takes a PCL-5. 80 out of 80 (another lol from me). Psychologist basically says, 'oh well, 80 out of 80 on PCL means they probably have PTSD' and diagnoses PTSD.

Edit: this was not actually a bad clinician. This was a good clinician worn down, overloaded, and burned out by a bad system. They knew (or at least assumed) that it would be futile to try to not diagnose PTSD in a veteran who clearly wanted the dx and would probably raise hades is they didn't get it.

If the higher ups in mental health administration can't be bothered with elementary arithmetic (on other matters) what is the probability that they'll be able to follow an explanation regarding proper interpretation of validity scale elevations and hesitance to diagnose/confirm a diagnosis like PTSD (which is complex and of specific etiology) which is based almost entirely on self-report?

I can't really blame them. I had a case like this recently. No one could figure out the psychosis piece and someone considered dementia as a dx. Chart review shows the psychosis turned up right before a successful comp and pen after years of nothing but depression, financial problems, and failed comp and pens for PTSD. Psychosis has never gotten better or worse since then despite multiple medications. Not my fight.

 

[aim-agm]

If the higher ups in mental health administration can't be bothered with elementary arithmetic (on other matters) what is the probability that they'll be able to follow an explanation regarding proper interpretation of validity scale elevations and hesitance to diagnose/confirm a diagnosis like PTSD (which is complex and of specific etiology) which is based almost entirely on self-report?

"You know how y'all are obsessed with metrics and don't just rely on our self-report for how productive we are? This is like that, but actually reasonable."

 

[Fan_of_Meehl]

I can't really blame them. I had a case like this recently. No one could figure out the psychosis piece and someone considered dementia as a dx. Chart review shows the psychosis turned up right before a successful comp and pen after years of nothing but depression, financial problems, and failed comp and pens for PTSD. Psychosis has never gotten better or worse since then despite multiple medications. Not my fight.

I can't blame them (or anyone else) either. But VA mental health (esp. S/C for MH) is a house of cards right now...at some point, a mere breath of reality and shift in public sentiment / narrative and the whole thing is going to collapse.

 

[Sanman]

I can't blame them (or anyone else) either. But VA mental health (esp. S/C for MH) is a house of cards right now...at some point, a mere breath of reality and shift in public sentiment / narrative and the whole thing is going to collapse.

Absolutely, but when the government move comp and pen to the lowest bidder that is what you get. Then you get folks that insist they have PTSD because the comp and pen said so despite years of clinicians telling them no. There is a reason that these evals pay nothing and a lot of forensic work pay tons. Middle management maybe stupid, but the highest levels are not. People know exactly what they will get. They okay this stuff anyway. Money for votes.

 

[Fan_of_Meehl]

Absolutely, but when the government move comp and pen to the lowest bidder that is what you get. Then you get folks that insist they have PTSD because the comp and pen said so despite years of clinicians telling them no. There is a reason that these evals pay nothing and a lot of forensic work pay tons. Middle management maybe stupid, but the highest levels are not. People know exactly what they will get. They okay this stuff anyway. Money for votes.

The problem comes when enough regular citizens get wind of multiple people in their peer group with 100% (schedular) disability ratings who are working full-time demanding jobs and start scratching their heads about it.

And then Google the actual criteria for 100% disability ratings for mental health and compare it to objective reality.

 

[Sanman]

The problem comes when enough regular citizens get wind of multiple people in their peer group with 100% (schedular) disability ratings who are working full-time demanding jobs and start scratching their heads about it.

And then Google the actual criteria for 100% disability ratings for mental health and compare it to objective reality.

Someone will get thrown under the bus eventually. First some veterans, like those FAA pilots then maybe it will be another VA "scandal" if some reporter gets bored and digs into it. That said, look at PACT Act money being thrown at them for any random symptom.

 

[Sanman]

https://www.cnn.com/2024/03/06/health/robert-card-brain-study/index.html

This is a can of worms...

 

[cara susanna]

There have been a few articles lately that stress not to use the PCL-5 to diagnose PTSD. Research suggests that people overreport on the PCL compared to the CAPS-5 (big shocker there).

 

[Fan_of_Meehl]

There have been a few articles lately that stress not to use the PCL-5 to diagnose PTSD. Research suggests that people overreport on the PCL compared to the CAPS-5 (big shocker there).

Yup. And there is also an article pretty much confirming what clinicians have suspected/observed for years, namely, that veterans who score extremely high on the PCL-5 also tend to fail symptom validity tets.

Shura, R.D. Rowland, J.A., Miskey, H.M. et al. (2023). Symptom validity indices in the posttraumatic stress disorder checklist for DSM-5. Journal of Traumatic Stress, 36: 919-931.

 

[psy.d. 2021]

The CAPS unfortunately is pretty unwieldy in practice in my opinion in a BHIP ..they say it takes 45-60 min....maybe I'm missing something