I have gotten close to accepting another job, but with relocating, losing EDRP, and significantly lower salary (I have SSR now), it didn’t make sense. I would probably be miserable just from those changes alone even if the clinic environment was better. Once my service is up/my loans are paid, I am going to explore other healthcare systems.
VA Mental Health Provider Venting / Problem-solving / Peer Support Thread
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Aaaaaaaaaand...the death spiral begins. Pretty much the same here. I predict 'funding issues' as far as the eye can see, increased pressure on non-clinicians to ramp up efforts to appear to be doing useful work (trying to convince others that they are 'needed' and indispensable) and making life hell for the clinicians. We ain't seen nothin' yet.
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Exactly, it's gonna be pretty bad this next fiscal year at the least, especially as people continue to leave and backfills don't get backfilled (while more administrative actions are enacted to 'fill' this need).
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So I'm on a VISN committee, one of our leads told us that they anticipate that we will no longer be FTE neutral by tend of FY 25, which means we will be able to have funds to hire. I don't know how true that is though.
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On track with when we’re all transitioning to Cerner, right?
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This job is becoming undoable. The OIG just published a report where, among other things, they fault a social worker (who was, literally, just a few weeks into her job here) for not responding aggressively (in terms of safety planning, consulting with medication provider, and ‘lethal means safety counseling’) because a veteran with whom she did an intake scored in the ‘moderately depressed’ range on the PHQ-9 (completed electronically AFTER the appointment [I told them that doing this was a stupid idea]) and—hold your breath for this one—scored a ‘ONE’ (1) out of 3 on Item 9 (regarding thoughts of being better off dead (not necessarily suicidal) or hurting themselves in some way (extremely vague language in this item)), meaning ‘several days in past two weeks.’
https://lnks.gd/l/eyJhbGciOiJIUzI1N...i5QITVfWZ0bqrE/s/3179501511/br/249878396170-l
Do they realize how high the base rate of endorsement of Item 9 at a level of a ‘1’ (or more) is in the outpatient population? They are basically trying to establish a standard where we are supposed to go into high alert every time a patient even endorses that item at all, which would NOT represent standard of care/practice in the field.
It is so enlightening (and frightening) to read these OIG reports regarding ‘failures of the mental health system.’ They are bending over backwards to play ‘gotcha’ and tag the blame on providers who—in my estimation—were not at fault…at least in terms of departing from standards of care/practice in the field. No experienced provider would look at this situation and conclude that a CSRE was necessary because they endorsed a 1 on item 9 of the PHQ-9. Not to mention the fact that the VA/DoD’s own clinical practice guidelines regarding the assessment/management of suicidality endorses ‘weak for’ (or worse) evidence in favor of all of these things (lethal means safety counseling).
Regarding routinely ‘sending’ (electronically) clinical measures (PHQ-9/PCL-5) to veterans in between appointments (outside the context of a clinical encounter), I have ALWAYS expressed the opinion that this was a HORRIBLE idea to require us to do this (and actually, arguably, beneath standard of care/practice) and that it would come back to bite us in the ass…which it will…witness this OIG report.
These OIG reports appear to take the position that the expected/required level of performance of outpatient mental health providers with regard to preventing ANY suicide is perfection (not actual standard of care). The VA organization, by continuing to slather layer upon layer of policy/procedure/requirements on top of providers is just creating a monstrous system of expectations that is undoable and creating a system with more and more POINTS OF FAILURE opening themselves up to OIG criticism for failure to fully follow their own policies/procedures/mandates.
They also mis-quote the actual text (in a very misleading way) of PHQ-9 Item 9 to make the signficance of the endorsement appear more than it is.
Relevant excerpt from the full report below:
Inadequate Suicide Risk Assessment and Lethal Means Safety Counseling During the PTSD evaluation on day 98, the patient reported “passive suicidal thoughts without any plan or intent approximately 2 to 3 weeks ago” and denied current suicidal ideation. The patient denied a history of suicide attempt, reported access to a firearm, and that the “firearm and ammo are stored in two separate locations.” The patient completed PTSD and depression rating scales that the social worker sent the patient through text and electronic mail. Approximately two hours after the PTSD evaluation, the social worker received the patient’s depression rating scale results.35 The depression rating scale indicated “moderately severe symptoms,” which included the patient had thoughts of being “better off dead” and self-harm several days during the prior two weeks. In an interview with the OIG, the social worker acknowledged not following up with the patient in response to the patient’s depression rating scale results. The social worker described not being concerned about the patient’s suicide risk based on a discussion with the patient regarding protective factors, including “future plans and goals and [the patient’s] support systems.” The social worker also reported the impression that the patient’s suicide risk was “minimal” based on the patient’s report of no prior suicide attempts or plan and because the extent of the patient’s suicidal ideation was “vague death wishes.” The social worker reported not considering completing a comprehensive suicide risk evaluation, which would have evaluated and 32 VA Suicide Risk Identification Strategy, “Frequently Asked Questions (FAQ),” updated January 5, 2023, and April 4, 2024; Deputy Under Secretary for Health for Operations and Management, “Suicide Risk Screening and Assessment Requirements,” memorandum to the Veterans Integrated Service Network (VISN) Directors, VISN Chief Medical Officers, VISN Mental Health Leads, May 23, 2018. 33 VA Suicide Risk Identification Strategy, “Frequently Asked Questions (FAQ)”; Deputy Under Secretary for Health for Operations and Management, “Suicide Risk Screening and Assessment Requirements,” memorandum. 34 “Safety Plan Reminder Dialogue Template: Instruction Guide,” VHA Office of Mental Health and Suicide Prevention, accessed February 7, 2024, dvagov.sharepoint.com/sites/VACOMentalHealth/Safety Planning SBR/Forms/AllItems.aspx?id=%2Fsites%2FVACOMentalHealth%2FSafety Planning SBR%2FSafety Planning%2FClinician Instructions and Quick Guides%2FSafety Plan Note Template User Guide%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2FSafety Planning SBR%2FSafety Planning%2FClinician Instructions and Quick Guides. (This site is not publicly accessible.) 35 The social worker reported typically sending mental health rating scales to patients through text and electronic mail within the two days prior to a scheduled appointment. The social worker did not recall when the depression and PTSD rating scales were sent to the patient. VA OIG 23-02393-250 | Page 13 | September 26, 2024 Mismanaged Mental Health Care for a Patient Who Died by Suicide and Review of Administrative Actions at the VA Tuscaloosa Healthcare System in Alabama documented the patient’s risk and protective factors and suicide risk level, based on the assumption that the patient would have had a negative C-SSRS result.36 The social worker told the OIG about not considering completing a safety plan or conducting further lethal means safety counseling with the patient due to a lack of knowledge about VHA safety plans and options, such as gunlocks, at the time.37 However, the OIG found that approximately one month prior to the patient’s PTSD evaluation, the social worker completed required suicide prevention and lethal means safety trainings, which reviewed safety planning and recommended discussion of firearm removal from a patient’s home and safe storage.38 In an interview with the OIG, the supervisory social worker reported being responsible for PTSD clinic operations at the facility and described an expectation for a social worker to discuss lethal means safety counseling for patients with access to a firearm, including giving the firearm to someone and offering a gun lock. The supervisory social worker reported providing the social worker with additional safety planning training after the patient’s death. Given the patient’s report of depression symptoms and firearm possession and responses on the depression rating scale indicating thoughts of death and self-harm, the OIG would have expected the social worker to pursue further evaluation, seek supervision, or consult with the patient’s prescriber, as later discussed. The OIG would have also expected the social worker to discuss additional lethal means safety measures with the patient to enhance firearms safety. The social worker’s failure to thoroughly evaluate the patient’s suicide risk and conduct adequate lethal means safety counseling may have contributed to the social worker’s underestimation of the patient’s suicide risk and the patient’s immediate access to the means to engage in suicidal behavior. Further, the social worker did not document the patient’s risk and protective factors and suicide risk level. Failure to document a patient’s risk and protective factors and suicide risk level in the EHR may result in lack of communication of important clinical information to other providers involved in the patient’s care.
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Well, that is pretty horrifying. Did the staff member in question get in trouble, or is this an overall recommendation of how to improve the process?
"The social worker reported not considering completing a comprehensive suicide risk evaluation, which would have evaluated and 32 VA Suicide Risk Identification Strategy, "
As you all know, we don't have to complete the CSRE unless the CSSR-S is positive, and I agree that it sounds like it wouldn't have been with this patient (since they denied SI during the interview, which would have been a no to questions 1 and 2, or at least question 2 since question 1 corresponds with PHQ-9 item 9). But it sounds like this social worker didn't complete the CSSR-S, so that's probably the big concern they had (at least, I hope it is). Even if the patient literally completed one in Primary Care the other day, I give it at every single intake I do because that's the guidance I've been given.
I've started calling patients whenever they send me a positive PHQ-9 item 9 through BHL Touch, even if I have zero actual concerns, just as CYA thing. This just reinforces that further.
But also, like, six days later? That isn't exactly "imminent" risk, is it?
"The social worker reported not considering completing a comprehensive suicide risk evaluation, which would have evaluated and 32 VA Suicide Risk Identification Strategy, "
As you all know, we don't have to complete the CSRE unless the CSSR-S is positive, and I agree that it sounds like it wouldn't have been with this patient (since they denied SI during the interview, which would have been a no to questions 1 and 2, or at least question 2 since question 1 corresponds with PHQ-9 item 9). But it sounds like this social worker didn't complete the CSSR-S, so that's probably the big concern they had (at least, I hope it is). Even if the patient literally completed one in Primary Care the other day, I give it at every single intake I do because that's the guidance I've been given.
I've started calling patients whenever they send me a positive PHQ-9 item 9 through BHL Touch, even if I have zero actual concerns, just as CYA thing. This just reinforces that further.
But also, like, six days later? That isn't exactly "imminent" risk, is it?
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I hear ya on the CYA thing but...am I the only one who DESPISES PHQ-9 item 9?
Could an item be ANY more overly sensitive (and non-specific) as a 'measure' of suicidal ideation/risk???
Any thoughts of 'being better off dead" OR "hurting myself IN ANY WAY?" in the past two weeks in someone with clinical depression. Are we TRYING to train our patients to lie to us and minimize their symptoms to us by overreacting to such endorsements?
And, seriously, what IS is actual risk of completing suicide in the next month per patient, per endorsement of item 9 at a '1' or above? Like, probably 0.00000000002%???
The CYA thing can be a slippery slope, too. I've seen cases of urgent care physicians (probably illegally) involuntarily hospitalizing pts for endorsing even vague (no intent, plan, prep bx, or hx of attempts) 'thoughts of being better off dead or hurting themselves in some way.' Those vets will sure as hell think twice before asking for MH help in the future, calling the crisis line, or endorsing item 9. Their suicide risk just went up, longitudinally.
Are cardiologists expected to NEVER have patients who die of a heart attack?
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Oh, no, you're not the only one. I also am not the biggest fan of the C-SRRS, and neither are patients. They often really hate the binary questions when often it's way more complicated than a yes or a no.
I just read the full report and, yeah, I have a lot of thoughts... But, trying to be productive and not ruminative: I don't always do standard lethal means safety counseling, so this is a good reminder to me. I think I'll start giving that info routinely, even with patients who deny SI.
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I'll bet any amount of money that a full stem-to-stern chart review of this case would reveal a TON of clinical 'encounters' with all kinds of MH providers, but---
Probably not a single sentence, let alone a sophisticated paragraph, of a basic individualized COGNITIVE-BEHAVIORAL CASE FORMULATION pertinent to that veteran's depression/anxiety, frequently experienced negative automatic thoughts, intermediate/core beliefs, etc.
Also, probably not a single, individualized ACTIVE CBT intervention...even something so simple as an individualized coping card for how to respond to discouraged thinking, a basic chain analysis of environmental/cognitive/emotional/behavioral antecedents to hopeless/pessimistic thinking and behavioral isolation.
Nope. With all the likely 10s of thousands of $$$s of professional 'care' focused on stuff like the PHQ-9, the CSSRS, the CSRE, the policies, the procedures, the fact that a gun was owned, the enire Liturgy and Canon of the Holy Church of Suicide Prevention (all of which enjoys no/scant ('weak for,' at best) support from the empirical literature (see the VA/DoD expert consensus guidelines for suicide prevention)) as well as a team of lawyers to mis-quote Item 9 in order to 'prosecute' the poor social worker in the name of 'ending the scourge of veteran suicide'...
Not a single actual clinically useful/meaningful psychological intervention targeting important processes (negative triad of depression, behavioral inactivation, cognitive restructuring, etc) was (likely) delivered to that patient. Something that any well-trained psych intern could complete and document in <30 mins with the patient.
We're focused on (and paying for) the wrong things.
With respect to what we're getting in terms of ACTUAL suicide prevention from the very expensive and time consuming things that we are doing with the superficial label/name of "suicide prevention" I'm reminded of the immortal words of Fogorn Leghorn who said:
"Boy! I say...BOY!!! I see a whole lotta choppin'...but not a lotta wood flyin'!"
No wonder that, despite all the millions of $s and increased staffing of [labeled] "suicide prevention" staff, veteran suicide rates aren't going down over time.
But...money's tight, ya'll. We can't afford to hire any more of them there expensive healthcare providers who actually see patients---especially not them fancypants clinical psychologists and, even if we do hire them, we can't leave them any time to focus on actual, individualized, cognitive-behavioral interventions (unless they have an acronym and prescripted agendas for every session).
VA to remain ‘very discerning’ on health care hiring, calls on Congress to address $12B shortfall in December
The VA expects to grow its health care workforce to approximately 404,000 total employees next year, if Congress approves supplemental funding.
federalnewsnetwork.com
The truth on the ground is the VA has plenty of money in its budget. It's just wasted on the wrong things.
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Sanman
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I made the bolded comment in another thread recently.
Agreed on the passive death wish issue. For me, I treat folks with cancer, Parkinson's, ALS, and a host of other terminal diseases. They all think about death and a relief from suffering, they are sick after all. We had this issue come up recently where suicide prevention wanted an involuntary commitment on a veteran with a vague plan and no apparent access to the stated means (drugs he is not prescribed and did not know how to acquire, just heard about in the news). Somehow a welfare check by the police was not considered enough action despite a scheduled home visit the next morning.
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A few years back I had a social worker program manager ask me what I thought about the folks recently (at that time) making pledges about us engaging in the 'Zero Veteran Suicide' initiative. Basically, proposing that we would 'fail' if we failed to 'eliminate' suicide as an outcome for veteran mental health patients.
I replied, "It tells me that those people who say those sorts of things aren't really serious about addressing the problem of veteran suicide...I don't take them (those people) seriously." I stand by that statement.
If I had made the comment publicly, or in writing, I would have been metaphorically 'drawn-and-quartered' for such a sacreligious viewpoint
Tell me how we DON'T have a Church of Suicide Prevention (complete with OIG Inquisitors).
Again, the VA/DoD's own 'evidence-based' lit review and guidelines document SCANT support for all of the 'thou shalt's' in policy/procedure. But we're 'evidence-based in our approach to suicide prevention? Right? BS. It's religious-level hysteria and emotionally-driven irrational persecution of scapegoats.
Every tragedy doesn't require a 'villain' to blame for its occurrence.
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Sanman
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I just don't agree with the stance generally aside from the obvious idea that there will never be zero of any cause of mortality. I had a supervisor that treated AIDS patients in the 1980s-90s before there were treatments. We used to discuss the false idea that there was "no reason" for suicide when confronted with a person facing a terminal disease with a painful ending. We both agreed there are good reasons...
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Agreed. But, sadly, engaging in any examination of the topic of 'veteran suicide' using a level of reasoning or sophistication above the level of one's brainstem is often considered heretical and/or evidence that you don't "truly care" about veteran welfare. It is truly fanatical and ridiculous.
I'm not a HUGE fan of the burgeoning use of AI / machine learning / deep learning paradigms in mental health treatment (e.g., to predict suicide attempts) but--I have to say--there's no way that an empirically-derived prediction algorithm would freak out about the case described (with these particular data as model 'inputs') in this OIG report. It may be a direction we need to go in as an antidote to this type of fundamentalist hysteria.
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Sanman
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Nope, government only wants them to die if someone else is shooting at them (usually in a foreign country). Sanctity of life is only for veteran suicides and abortions.
I'm curious as to who in OIG runs these things. Is there a licensed provider reviewing the case? Was it just a ding for not doing the C-SSRS? I didn't read the full report.
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The mis-quoting (intentional or not) of the text of PHQ-9 Item 9 in the report section where they attack the social worker strongly suggests to me that the report was written/supervised by folks who do not have day-to-day experience utilizing that instrument with actual patients.
And the 'did she fail to do the C-SSRS' is an interesting question.
I mean, if she asked the questions on the C-SSRS in the context of a flowing clinical interview and obtained sufficient info that would rule out a 'positive CSSRS screen' by, for example, ascertaining that the patient merely endorsed thoughts of 'not being here anymore' but denied specific thoughts/plans/intent of self-harm actions and a history negative for self-directed harm or suicide attempts...did she really 'fail' to do the proper screening? Or did she fail to concretely enter the data in the format that the Church prescribes as part of its Liturgy?
Of course I tend to read the C-SSRS questions verbatim, in order, as yes/no questions and use the official note template because I know how hot the Fires of Perdition burn for Sinners...but...is there a point at which we've gone too far with our concreteness of thought here (speaking of the holy rollers in suicide prevention, quality improvement, and OIG)? Are we bending over backwards to 'find evidence' of 'substandard care/screening' due to not following the (non-evidence-based) Rituals to the letter?
I think we need to be more aware of the misleading (Sophistic?) language than can creep in and shape opinions (e.g., regarding the adequacy/inadequacy of our clinical work) when we (or our policies) refer to something like the C-SSRS as an "empirically-validated suicide prevention tool/procedure/instrument." In truth, it's merely a handful of yes/no questions covering (admittedly) key info required to complete an initial/basic screening of suicide risk. That's it. It's hardly an advanced, overly-technical or overly-sophisticated medical procedure/instrument like an MRI or an MMPI-2-RF. It's a few yes/no questions.
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This is why I'm happy I work mostly with older adults and can use the GDS. Item 9 is far too sensitive.
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I have very, very strong thoughts about zero suicide initiatives and MH being the gatekeepers of suicide in general. I get a bit Thomas Szasz-y on this topic, in fact.
Again, 6 days! That is so much time for things to change. How are we expected to predict the future? We can't predict suicidal behavior. We can predict ideation, but not behavior, and most people don't go from ideation to behavior.
Again, 6 days! That is so much time for things to change. How are we expected to predict the future? We can't predict suicidal behavior. We can predict ideation, but not behavior, and most people don't go from ideation to behavior.
Sanman
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My question is whether there is any actual fallout from this other than someone's opinion on a piece of paper and the eventual systemic freak out and overreaction?
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Exactly. If the facts of the case had been that the veteran had a recent, high-lethality suicide attempt (attempted hanging) two weeks ago, endorsed lack of confidence that he could avoid carrying out a plan to shoot himself in between outpatient appointments, and commented that he planned to go home and drink himself into a coma...and the therapist had failed to take this seriously...I'd say, blame the therapist for failing to act responsibly.
It's not our job to prevent all possible negative outcomes in all patients we see. That's simply not possible. We DON'T have that degree of control or power. We are not God.
We can only practice responsibly within the boundaries of standards of care and standards of practice.
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Yeah, local leadership is gonna freak out and require all clinicians to complete a full CSRE, safety plan, home gun safe inspection, and revised mental health suite tx plan every time a veteran circles a '1' on the PHQ-9 Item 9.
What does
The fatal (heh) problem with PHQ-9 item 9 is that it doesn't even screen correctly for criteria 9 of MDD: "Recurrent thoughts of death (not just fear of dying); recurrent suicidal ideation without a specific plan; a specific suicide plan; or a suicide attempt." Ya it asks about SI, but not about sense of forshortened future, morbid preoccupation, etc..
Also, a score in the "moderate depression" (10-14) range on PHQ9 is incompatible with MDD, that would require a score of at least 15 (at a bare, idealized minimum).
I think the PHQ9 is excellent...as a didactic tool to teach students about terrible screeners and related topics.
The fatal (heh) problem with PHQ-9 item 9 is that it doesn't even screen correctly for criteria 9 of MDD: "Recurrent thoughts of death (not just fear of dying); recurrent suicidal ideation without a specific plan; a specific suicide plan; or a suicide attempt." Ya it asks about SI, but not about sense of forshortened future, morbid preoccupation, etc..
Also, a score in the "moderate depression" (10-14) range on PHQ9 is incompatible with MDD, that would require a score of at least 15 (at a bare, idealized minimum).
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The PHQ-9 also has a LOOOT of potential overlap with physical health conditions that could cause fatigue, poor sleep, etc
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It's not ideal. A good clinical interview beats it by a mile. I will use it as a baseline to help veterans track progress but it's not worth a lot to me otherwise.
One mentor described it as a measure of general distress.
I saw a study comparing PHQ-9 before and after starting residency...without even attempting to account for what going from working 0 hours/week to 80 hours/week will directly do to sleep, energy, engagement in non-work activities, etc. independent of any psychiatric effects.
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Fun fact I learned this is exactly why it’s often used in settings where federal and state funds reimbursement are involved.
Apparently if items 1 or 2 are a score of 2 or 3 and the total score is 10 or higher the facility or agency may hit criteria that allows them access to more money.
I do a lot of current work in settings where private equity firms own medical facilities and train their bean counter staff and managers who have zero understanding of these measures to ensure a certain percentage rate of 10 or higher scores. Because money.
As for the PHQ-9 itself , item 9 is muddled IMO as thoughts of not wanting to be around anymore should be a separate question from active thoughts of self harm or suicide. We know this and we know when we need to further assess statements made and risk assess further. You know, what do you mean or can you tell me a bit more about that feeling, and go from there. But non clinicians don’t understand it, if they mean well and think there’s risk they just automatically assume any score over 0 on item 9 means the worst then come find us in a panic. If I had a dollar for every time a physician or nurse came running up as if the place was burning down because they heard a patient say something , well I’d have a lot of dollars. Seriously though in those cases it’s nice they care: rather be cautious. If they’re just bean counters or data analyzing statistics for the place that’s a whole different issue.
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This is why I balk at psychologists that give it as a sole mood measure in a presurgial evaluation.
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Folks are out there risking it all:
https://www.cnn.com/2024/09/30/politics/veterans-affairs-jd-vance-tim-walz/index.html
https://www.cnn.com/2024/09/30/politics/veterans-affairs-jd-vance-tim-walz/index.html
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Like -WHY- would someone think that is ok????
Part of me wonders if a news outlet offered employees money to creep?
but still
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Jeez, no excuse for this. This particular no-no was drilled into employees ad nauseam in the VA when I was there. Fireable offense and reportable to a licensing board.
butteredtoast27
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Just further proof that repeated TMS trainings on the same topics don't improve the quality of care 😒 Seriously though, how dumb were these people to assume they wouldn't get caught? Not to mention the appalling lack of ethics..
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TMS has only taught me that, if you sell patient social security numbers, you just get a fine and minimal prison time. Haha.
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Does anyone else confuse JLV and MHV all of the time? The acronyms are too similar!
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PIV and HIV are way too close for my liking.
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It is reasonable to discuss and describe best practices when providing virtual treatment.
It is unreasonable to offend our eyes/ears and the English language with that neologism.
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Do any of you ever attend case consultation and just find it's sooooo much naval gazing without any actual practical use? Wait, isn't that what Meehl wrote about it in his article?
Sanman
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Case consultation in formal settings is largely pointless as the presentation and feedback is so filtered as to be useless. Informal case consultation with colleagues who are friends and prize honesty? That is wonderful.
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It's "Why I Don't Attend Case Conferences."
(You guys actually get into groups and discuss cases? Our jailers would never allow that...to much 'lost productivity')
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Sanman
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Even more reason not to attend.
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It's required for my position.
Sanman
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Writing like this is why I love Meehl (and things have only gotten MUCH worse since his time):
"In one respect the clinical case conference is no different from other academic group phenomena such as committee meetings, in that many intelligent, educated, sane, rational persons seem to undergo a kind of intellectual deterioration when they gather around a table in one room. The cognitive degradation and feckless vocalization characteristic of committees are too well known to require comment. Somehow the group situation brings out the worst in many people, and results in an intellectual functioning that is at the lowest common denominator, which in clinical psychology and psychiatry is likely to be pretty low."
Anyone have recs for therapy for functional neurological disorder? We’ve gotten several consults for this lately (sometimes it’s seizures, sometimes it’s other bizarre abnormal movements or symptoms) and they tend to reference CBT, but none of us at the clinic have ever treated this in therapy before. I have one resource but it focuses on non epileptic seizures.
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I'm no longer at the VA so I can't find the exact consult name, but there is a specialty clinic based out of California that focuses on treatment of functional neurologic disorder and conversion disorder, especially for psychogenic seizures. They see veterans nationwide by telehealth if your clients are open to referral, or the clinical team might be able to share some resources.
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Oxford University Press 'Treatments That Work' series has a client workbook and therapist manual:
- Taking Control of Your Seizures (workbook)
- Treating Non-epileptic Seizures (Therapist Guide)
At least it's an 'evidence-based' comprehensive and structured approach to case formulation and treatment.
However, off the record, in my experience, these patients tend to have treatment-interfering factors like:
-Resistance to psychological/behavioral explanations for their sxs
-Attendance/engagement issues
-Axis II comorbidities including a tendency to 'split' MH vs. general medical providers
This sort of treatment likely requires specialty settings where clinician (and organizational) sophistication, intercommunication, and collaboration is high. If I recall correctly, an important part of the protocol involves close collaboration between MH providers and the epileptologist/neurologist in tapering/titrating anticonvulsant med regimens. That aspect had always given me pause with respect to attempting to implement this particular protocol in a VA setting.
Plus, they have to do the work.
The Oxford U. Press materials could prove useful to review in prep to do a good old fashioned CBT case formulation and intervention, though.
oliversacks4thewin
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This is fascinating to hear that it is also permeating in the VA. I work at an AMC affiliated children's hospital, and we have seen a significant increase in FNSD presentations as well. I echo the use of the Treatments That Work manuals. I will also mention that there is some decent resources housed in the FNDhope.org website that while limited for providers, can be a helpful site to direct patients and families to to help reduce some of the interfering barriers that Fan_of_Meehl appropriately acknowledged.
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Hi everyone - rather than creating an entirely new thread I wanted to ask in here. I'm having difficulty finding specific covid vaccine requirements for the VA sites I'm applying to for internship. For example, I'm not sure if they have a time limit since you were last vaccinated or if they require boosters etc. I am trying to get all my medical stuff covered while my deductible is met (haha) so I'm preparing in advance for everything!
If you have any idea where I can find this info or how it works please let me know. Feel free to privately message if you don't want to spam this thread. Thanks a bunch!
If you have any idea where I can find this info or how it works please let me know. Feel free to privately message if you don't want to spam this thread. Thanks a bunch!
