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

[AcronymAllergy]

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I wasn’t under the mental health service line, if that’s what you’re asking. I never did any peer review of notes when i was there. And I dont think anyone ever peer reviewed me either. I'm sure someone looked at my notes when prepping the performance eval and productivity report. But I never got any direct feedback from any kind of audit or anything.

That could've also had something to do with it, I suspect. Our facility classifies providers as medical staff based on their occupation (e.g., physician, psychologist, NP, etc.), regardless of what service they're in. All medical staff are required to undergo regular peer review, although the nature of that review is left up to each individual profession to determine (in conjunction with the director and chief of staff). Pretty much everyone here uses review of chart notes, as best I can tell.

 

[WisNeuro]

Yeah, I've heard of that version of peer review as well.

Reviewing notes/having notes reviewed is less work, but a case presentation could be a great way to actually actively demonstrate competence.

I agree, but maybe it's more pertinent to those of us who have lengthy documentation, but review of that documentation can be crucial. People can be able to competently present a case orally, but have some glaring issues in how they document that.

 

[AcronymAllergy]

I agree, but maybe it's more pertinent to those of us who have lengthy documentation, but review of that documentation can be crucial. People can be able to competently present a case orally, but have some glaring issues in how they document that.

Agreed. Even for therapy notes, documentation can be poor or too sparse.

Ideally, a system might include both types of review. But also ideally, they'd actually protect time in providers' schedules to perform those duties.

 

[cara susanna]

This was one of the (many) main reasons I left. The level of attention paid to specific aspects of the notes, the overburden of additional notes/templates/art projects mandatory for each - sometimes 20 minute! - patient destroyed any appeal for the actual work environment. Each patient was just a tedious check list of bureaucratic nonsense.

I was still in PCMHI when the CSRE guidelines were released and the complaints were all over the listserv. You couldn't actually implement interventions around someone's suicidality because the appt was spent on the assessment, not to mention other "checkmarks" that may be required like completing a safety plan. Actually, we even had some providers in OPMH with the longer appt times make that complaint.

They're making us do the Columbia screen with testing appts now, too, which especially annoys me.

 

[beginner2011]

I've begun seeing this in my system. It shows you which parts are copied/pasted, and there's a separate window that tells you where the information was copied from (e.g., MS Word, another chart, etc.). No clue if it's formally being monitored, for what, or by whom.

There are certain parts of notes that are required, but I wonder if your supervisor's list of required information is accurate. A good bit of it can also be templated so that minimal work on your part results in customizing the information to each individual patient. And you can also look into dictation software; even if you're a fast typist, it can save you time.

How does one go about getting an accurate list of required information?

Also, in folks estimation, is carry over assessment from previous notes frowned upon? I'm thinking particularly about the assessment section of a psychotherapy or case management note, which I often copy paste over and then revise with updates based on current session presentation/progress.

E.g., note 1 says, "Veteran demonstrates engagement with treatment and I believe he may benefit from ongoing group psychotherapy and care coordination provided by this writer to support expanding behavioral repertoire to include more adaptive coping skills and resolve ambivalence regarding making changes in health behaviors."

note 2 says, "Veteran continues to demonstrate engagement with care and based on veteran's presentation today he appears to have moved from contemplating health behavior change to taking action. I believe he may benefit from continued support from this writer focused on motivational enhancement and building coping skills through group psychotherapy participation to increase his self-efficacy and effectiveness."

 

[cara susanna]

How does one go about getting an accurate list of required information?

Also, in folks estimation, is carry over assessment from previous notes frowned upon? I'm thinking particularly about the assessment section of a psychotherapy or case management note, which I often copy paste over and then revise with updates based on current session presentation/progress.

E.g., note 1 says, "Veteran demonstrates engagement with treatment and I believe he may benefit from ongoing group psychotherapy and care coordination provided by this writer to support expanding behavioral repertoire to include more adaptive coping skills and resolve ambivalence regarding making changes in health behaviors."

note 2 says, "Veteran continues to demonstrate engagement with care and based on veteran's presentation today he appears to have moved from contemplating health behavior change to taking action. I believe he may benefit from continued support from this writer focused on motivational enhancement and building coping skills through group psychotherapy participation to increase his self-efficacy and effectiveness."

That's what I do. I don't like reinventing the wheel.

 

[AcronymAllergy]

How does one go about getting an accurate list of required information?

Also, in folks estimation, is carry over assessment from previous notes frowned upon? I'm thinking particularly about the assessment section of a psychotherapy or case management note, which I often copy paste over and then revise with updates based on current session presentation/progress.

E.g., note 1 says, "Veteran demonstrates engagement with treatment and I believe he may benefit from ongoing group psychotherapy and care coordination provided by this writer to support expanding behavioral repertoire to include more adaptive coping skills and resolve ambivalence regarding making changes in health behaviors."

note 2 says, "Veteran continues to demonstrate engagement with care and based on veteran's presentation today he appears to have moved from contemplating health behavior change to taking action. I believe he may benefit from continued support from this writer focused on motivational enhancement and building coping skills through group psychotherapy participation to increase his self-efficacy and effectiveness."

Good question. Probably a combination of reviewing JCAHO and CMS/CPT code requirements along with VA (local and national) policies.

I don't think carrying over information from prior notes is or should be frowned upon, assuming it's still relevant and/or is clearly labeled as such (e.g., a list of material covered in, or testing results from prior sessions). It would just need occasional pruning so it doesn't become unwieldy.

 

[thebalmofhurtminds]

Good question. Probably a combination of reviewing JCAHO and CMS/CPT code requirements along with VA (local and national) policies.

I don't think carrying over information from prior notes is or should be frowned upon, assuming it's still relevant and/or is clearly labeled as such (e.g., a list of material covered in, or testing results from prior sessions). It would just need occasional pruning so it doesn't become unwieldy.

We actually had this as a huge issue at one of the VAs I trained at. They refused to share the list of required information on the local level, but continued to ding people for not having the required information in their notes. Certainly made meetings fun.

 

[Fan_of_Meehl]

We actually had this as a huge issue at one of the VAs I trained at. They refused to share the list of required information on the local level, but continued to ding people for not having the required information in their notes. Certainly made meetings fun.

I always wanted to challenge someone to 'process map' the whole job of being an outpatient psychotherapist at VA or--hell--just a single outpatient session and associated documentation. It would be a Manhattan project type undertaking. For fun and illustrative purposes I once process mapped (comprehensive flow chart with decision points) the mere process of dealing with a no-show as a therapist including begging the MSA to do their parts and all the associated followup and documentation. It looked like Euclid vomited on the entire page with all kinds of circles, lines, and interconnected loops.

 

[beginner2011]

I always wanted to challenge someone to 'process map' the whole job of being an outpatient psychotherapist at VA or--hell--just a single outpatient session and associated documentation. It would be a Manhattan project type undertaking. For fun and illustrative purposes I once process mapped (comprehensive flow chart with decision points) the mere process of dealing with a no-show as a therapist including begging the MSA to do their parts and all the associated followup and documentation. It looked like Euclid vomited on the entire page with all kinds of circles, lines, and interconnected loops.

Do you still have the process map? I would love to see it.

 

[Fan_of_Meehl]

Na

Do you still have the process map? I would love to see it.

Nah...it was hand-written but it was hilarious and demonstrated the complexity of dealing with a no-show in the VA system where, in private practice, the support staff take care of a no-show all on their own without even needing to involve the provider.

 

[IWillSurvive]

I was still in PCMHI when the CSRE guidelines were released and the complaints were all over the listserv. You couldn't actually implement interventions around someone's suicidality because the appt was spent on the assessment, not to mention other "checkmarks" that may be required like completing a safety plan. Actually, we even had some providers in OPMH with the longer appt times make that complaint.

They're making us do the Columbia screen with testing appts now, too, which especially annoys me.

Not to one-up you here, but at one point, we were being told to give the Columbia in EVERY session...which would include groups. Will we ever get to do therapy again?

 

[AbnormalPsych]

Not to one-up you here, but at one point, we were being told to give the Columbia in EVERY session...which would include groups. Will we ever get to do therapy again?

This is happening at my non-VA place. It is done by computer/tablet/robot overlords, but we still have to review it. Some patients come to groups multiple days per week. Some...multiple groups per day. And then individual. And then med management apts.... it is a bit.... much.

I don't really consider myself a therapist anymore, but more of a triage and crisis provider, a receptionist, and someone who does psychotherapy sometimes.

Still happier than I was at VA.

 

[Fan_of_Meehl]

This is happening at my non-VA place. It is done by computer/tablet/robot overlords, but we still have to review it. Some patients come to groups multiple days per week. Some...multiple groups per day. And then individual. And then med management apts.... it is a bit.... much.

I don't really consider myself a therapist anymore, but more of a triage and crisis provider, a receptionist, and someone who does psychotherapy sometimes.

Still happier than I was at VA.

One wonders what will ultimately be the upper bounds of the current 'measurement fetish' that is running rampant and driven primarily by overly-concrete control-freak admin types. I'd rate my personal dissatisfaction with the system as a 12.396 out of 10.000.

 

[Sanman]

One wonders what will ultimately be the upper bounds of the current 'measurement fetish' that is running rampant and driven primarily by overly-concrete control-freak admin types. I'd rate my personal dissatisfaction with the system as a 12.396 out of 10.000.

So, have you formulated your escape plan?

 

[Fan_of_Meehl]

So, have you formulated your escape plan?

There is no escape...unless I wanted to leave MH entirely. I'm just waiting for the inevitable pushback (or pendulum swing) back to relative sanity within the field.

 

[WisNeuro]

Escape from the VA is like escaping from a black hole, once you've reached the event horizon (X amount of years before achieving pension) you are forever in its gravitational pull until retirement. You get out early, or not at all.

 

[Sanman]

Escape from the VA is like escaping from a black hole, once you've reached the event horizon (X amount of years before achieving pension) you are forever in its gravitational pull until retirement. You get out early, or not at all.

It really depends on how early you are talking. For me, the decision would have to be by the 10 year mark or Mid-forties in age. Beyond that point, I would hang in there until MRA.

 

[cara susanna]

I obviously can't speak for our patients, but if I were CONSTANTLY asked about my suicidal thoughts (like every single appt) I would start to be like, umm, are you worried about me or something? Do you know something that I don't?

At some point it might become not only counter-therapeutic and cumbersome, but perhaps even harmful.

I also have patients with chronic SI and if you asked me to do a Columbia with them every single session we'd never get anything done. Not to mention reinforcing the SI...

 

[Sanman]

I obviously can't speak for our patients, but if I were CONSTANTLY asked about my suicidal thoughts (like every single appt) I would start to be like, umm, are you worried about me or something? Do you know something that I don't?

At some point it might become not only counter-therapeutic and cumbersome, but perhaps even harmful.

Or providers may just stop asking and fill the form out with a negative screening. At some point, I am sure this will happen on a widespread basis.

 

[sloh]

There is no escape...unless I wanted to leave MH entirely. I'm just waiting for the inevitable pushback (or pendulum swing) back to relative sanity within the field.

Can you elaborate why you would have to leave MH entirely?

 

[Fan_of_Meehl]

Can you elaborate why you would have to leave MH entirely?

Yeah...I was commenting more on the 'measurement fetish' aspect and the general phenomenon of diminishing respect for exercised clinical judgment (within the standard of care and respecting the empirical literature) and over-emphasis on brute force concrete authoritarian mandates such as having to do a Columbia at every session. It may be a bit worse at VA but it appears to be a trend in full swing in all of mental health (sadly).

 

[AcronymAllergy]

Yeah...I was commenting more on the 'measurement fetish' aspect and the general phenomenon of diminishing respect for exercised clinical judgment (within the standard of care and respecting the empirical literature) and over-emphasis on brute force concrete authoritarian mandates such as having to do a Columbia at every session. It may be a bit worse at VA but it appears to be a trend in full swing in all of mental health (sadly).

I used to joke back in graduate school about "WAIS therapy" with testing patients. This is the non-comedic, real-world equivalent.

 

[Fan_of_Meehl]

I used to joke back in graduate school about "WAIS therapy" with testing patients. This is the non-comedic, real-world equivalent.

Heck, at least the WAIS is a norm-referenced measurement of performance. The current climate of taking all self-report symptom checklists at face value in MH is disturbing. When I was in training, we were taught that self-report is *one* source of assessment data, not *the* source of assessment data.

 

[AcronymAllergy]

Heck, at least the WAIS is a norm-referenced measurement of performance. The current climate of taking all self-report symptom checklists at face value in MH is disturbing. When I was in training, we were taught that self-report is *one* source of assessment data, not *the* source of assessment data.

Hmm, I see. Would you please complete this Likert-based survey so that I can quantify your complex and nuanced thoughts on the matter, condense them to a handful of numerical values, and quickly present them to leadership in a fancy spreadsheet?

 

[Fan_of_Meehl]

Hmm, I see. Would you please complete this Likert-based survey so that I can quantify your complex and nuanced thoughts on the matter, condense them to a handful of numerical values, and quickly present them to leadership in a fancy spreadsheet?

Veteran: "My memory is AWFUL...just ask my wife. I can't remember anything anymore."

Also Veteran : *aces objective neuropsych measures of memory and executive functioning*

Nearly. Every. Single. Time.

 

[WisNeuro]

Veteran: "My memory is AWFUL...just ask my wife. I can't remember anything anymore."

Also Veteran : *aces objective neuropsych measures of memory and executive functioning*

Nearly. Every. Single. Time.

You have a MUCH higher PVT passing rate than I ever did in the VA then.

 

[PsyDr]

Veteran: "My memory is AWFUL...just ask my wife. I can't remember anything anymore."

Also Veteran : *aces objective neuropsych measures of memory and executive functioning*

Nearly. Every. Single. Time.

Have you met their wives? Maybe they are onto something.

 

[thebalmofhurtminds]

Have you met their wives? Maybe they are onto something.

Idk man, most of my veteran's wives seemed like they had the short end of that deal.

 

[cara susanna]

VA psychologists: how many of you do cognitive testing outside of neuropsych? Like I'm talking WAIS and stuff

 

[Sanman]

VA psychologists: how many of you do cognitive testing outside of neuropsych? Like I'm talking WAIS and stuff

Mostly RBANS and brief screeners unless I am supervising a student. No full batteries or anything.

 

[Fan_of_Meehl]

Can you elaborate why you would have to leave MH entirely?

I don't think The Mandalorian would like mental health administrators or the VA much. I appreciate the flamethrower more than I should.


"This is the way."

Men must find their path in life...very underappreciated in modern psychology/psychiatry.

 

[AcronymAllergy]

VA psychologists: how many of you do cognitive testing outside of neuropsych? Like I'm talking WAIS and stuff

Speaking on behalf of other psychologists in my system, I'd say there's a small handful who will do the occasional RBANS. Definitely the minority. There are perhaps a few more who do personality testing, and then a small set who do the law enforcement evals.

 

[cara susanna]

Can you imagine being MHS champion? What a thankless role.

 

[Fan_of_Meehl]

Can you imagine being MHS champion? What a thankless role.

No...I couldn't. I try not to let my ire against that ridiculous 'tool' appear directed at them in any way, it's not their fault that they are being used by MH admin to diffuse responsibility with resp ct to competent, flexible, and ongoing real clinical supervision on cases, standards of care, the empirical literature or best practices. Somehow (God knows how) there existed competent, effective clinical therapeutic services before MH Suite was ever 'implemented.'

 

[Sanman]

No...I couldn't. I try not to let my ire against that ridiculous 'tool' appear directed at them in any way, it's not their fault that they are being used by MH admin to diffuse responsibility with resp ct to competent, flexible, and ongoing real clinical supervision on cases, standards of care, the empirical literature or best practices. Somehow (God knows how) there existed competent, effective clinical therapeutic services before MH Suite was ever 'implemented.'

I do feel bad for them. Is it wrong that despite sitting through an entire MHS 5.0 presentation, I still have no idea how to use it? I'm not sure that it matters as I have never used it for my patients anyway and no one has explained how I would. I will wait for someone to yell at me about it...I may be retired by then anyway.

 

[AcronymAllergy]

I do feel bad for them. Is it wrong that despite sitting through an entire MHS 5.0 presentation, I still have no idea how to use it? I'm not sure that it matters as I have never used it for my patients anyway and no one has explained how I would. I will wait for someone to yell at me about it...I may be retired by then anyway.

I've seen multiple presentations on it (although not 5.0 specifically, I don't think). I still have little to no idea what MHS is.

 

[Sanman]

I've seen multiple presentations on it (although not 5.0 specifically, I don't think). I still have little to no idea what MHS is.

From what I gather, it is the VA's attempt to provide comprehensive patient centered care taking multiple (outpatient, inpatient, etc) provider treatment plans and combining them into one huge incomprehensible document so that JCAHO is happy and we cannot do anything useful with whatever extra time we happen to have.

 

[cara susanna]

I've used it quite a bit and the presentation we sat through was immensely confusing and just had too much information. The providers who have no MHS experience were very overwhelmed.

 

[Fan_of_Meehl]

I've used it quite a bit and the presentation we sat through was immensely confusing and just had too much information. The providers who have no MHS experience were very overwhelmed.

That's one of my biggest gripes with it. Instead of simplifying case formulation and TX planning in a helpful way, it's overly focused on breaking things up into multiple fragmented TX targets (generally surface level topographical things like specific sx and dxs) and then proceeds to require you to break things down unnecessarily into a nested tree structure involving 'problem, goal, objective, intervention' and demands 'point predictions' involving target dates when sx's will be objectively and formally 'resolved' down to a specific measurable level.. It's overly mechanistic, confusing, and a miraculously tangled monstrosity of nested linear left-brain hyper-analytical hyperthreaded horsecrap that does nothing but sap clinician time/energy and over-complicate TX planning, care coordination, and collaboration efforts. And it's double charting as well.

And I have NEVER heard ONE provider say ONE good thing about having to use it. EVER.

 

[AbnormalPsych]

 

[cara susanna]

That's one of my biggest gripes with it. Instead of simplifying case formulation and TX planning in a helpful way, it's overly focused on breaking things up into multiple fragmented TX targets (generally surface level topographical things like specific sx and dxs) and then proceeds to require you to break things down unnecessarily into a nested tree structure involving 'problem, goal, objective, intervention' and demands 'point predictions' involving target dates when sx's will be objectively and formally 'resolved' down to a specific measurable level.. It's overly mechanistic, confusing, and a miraculously tangled monstrosity of nested linear left-brain hyper-analytical hyperthreaded horsecrap that does nothing but sap clinician time/energy and over-complicate TX planning, care coordination, and collaboration efforts. And it's double charting as well.

And I have NEVER heard ONE provider say ONE good thing about having to use it. EVER.

You summarized the issues SO WELL. Preach. I haven't heard any good things, either. Even the supervisors are basically like "sorry, but we can't do anything about this requirement" when providers pose concerns to them.

 

[Fan_of_Meehl]

You summarized the issues SO WELL. Preach. I haven't heard any good things, either. Even the supervisors are basically like "sorry, but we can't do anything about this requirement" when providers pose concerns to them.

I've brought up a couple of points regarding MH Suite in meetings and got nothing but, "Yeah, but we gotta do it" several times:

1) you cannot point me to ANY resources in the professional literature (books, journal articles, training program curricula) where this new approach (using MHS) has been referenced, explicated, discussed, or critiqued. Nothing. Nada. You also, when asked, cannot provide any examples of how you would use the program to address anything but the most narrow of clinical targets (e.g., smoking cessation or weight loss). Try a veteran with comorbid PTSD, MDD, SUDS, personality disorder who is in pre-contemplation with respect to behavior change, suspicious of meds but with significant suicidal ideation. The MHS champion gave us as the example of a treatment target 'veteran will pay their rent on time each month.'

2) the MHS stuff, especially the problem, goal, objective, intervention, specific target date, specific drop in %age self-report or symptoms paradigm is NOT how expert CBT practitioners even practice. Read their books, train with them and you'll see.

Edit: oh yeah, I just had to share this one: the other example of a treatment goal provided in official MHS training was this: 'veteran will name thee high-risk situations associated with risk of relapse' with a target date for completion something like three months hence. I **** you not. Anyone with a modicum of common sense realizes that such a treatment goal can and should be accomplished, at most, in a single session (likely the same session in which the goal is devised, making it pointless to even list as a goal) and, actually, with a semi-competent therapist and reasonably willing client, would require between 2 and 15 minutes of actual therapy time to accomplish.

So,
Problem: excessive alcohol use
Goal: decrease alcohol use and reduce risk of relapse
Objective: be able to name three situations which are high risk for relapse
Intervention: individual psychotherapy to help veteran identify high risk situations
Responsible person: Ignor H. Amos Ph.D.
Target date: (specific date three months from now)

Obviously, it would take more time to do treatment planning/documentation around this objective than to just accomplish the objective same session...the epitome of clinical inefficiency.

 

[beginner2011]

That's one of my biggest gripes with it. Instead of simplifying case formulation and TX planning in a helpful way, it's overly focused on breaking things up into multiple fragmented TX targets (generally surface level topographical things like specific sx and dxs) and then proceeds to require you to break things down unnecessarily into a nested tree structure involving 'problem, goal, objective, intervention' and demands 'point predictions' involving target dates when sx's will be objectively and formally 'resolved' down to a specific measurable level.. It's overly mechanistic, confusing, and a miraculously tangled monstrosity of nested linear left-brain hyper-analytical hyperthreaded horsecrap that does nothing but sap clinician time/energy and over-complicate TX planning, care coordination, and collaboration efforts. And it's double charting as well.

And I have NEVER heard ONE provider say ONE good thing about having to use it. EVER.

This approach to patient care is a big contributor to my own decision not to pursue VA employment. There are so many benefits to VA as a staff member, but I just can't imagine myself wading through this level of bureaucratic intrusion on clinical practice for a 30+ year career and being happy. Wish I could.

If I want my heart to hurt a little bit I take a moment to imagine what could be accomplished by the excellent MHS providers at VA if there were no top-down mandates and clinics/teams could freely generate their own policies and procedures to achieve the functional goal of MHS (which I'd describe as to reduce prevalence and severity of mental health problems and improve functioning among their panel of veterans).

 

[cara susanna]

Yes! The biggest problem with the VA is that practice is politically or administratively driven, not clinically driven.

Also, Fan of Meehl, that's a hilarious example. I always put more clinically relevant goals like "reduce avoidance" and never have gotten flack from administration. Guess we'll see though.

 

[WisNeuro]

This is all very unfortunate. I still firmly believe, and the evidence would suggest also, that in general the care in the VA is far better than what most similarly situated people outside of the VA can even dream of. But, that comes at the expense of the clinicians who usually have to go above and beyond to deliver that care. Just wonder where the burnout line is, where the demands on clinicians lead to reduced care efficacy or a critical mass of providers leaving the system.

 

[Fan_of_Meehl]

Yes! The biggest problem with the VA is that practice is politically or administratively driven, not clinically driven.

Also, Fan of Meehl, that's a hilarious example. I always put more clinically relevant goals like "reduce avoidance" and never have gotten flack from administration. Guess we'll see though.

Reduce avoidance is a very valid and very streamlined approach to treating PTSD and any anxiety disorder. I like having the flexibility to work collaboratively with clients to decide on (and tweak) the specific parameters of working toward that goal. The problem with MHS is that it presumes you can work out all the details of how every clinical intervention and HW assignment will go for the next 3 to 6 months and that just ain't how therapy works, especially with VA populations.

 

[Sanman]

Reduce avoidance is a very valid and very streamlined approach to treating PTSD and any anxiety disorder. I like having the flexibility to work collaboratively with clients to decide on (and tweak) the specific parameters of working toward that goal. The problem with MHS is that it presumes you can work out all the details of how every clinical intervention and HW assignment will go for the next 3 to 6 months and that just ain't how therapy works, especially with VA populations.

What is the treatment plan for veteran continually avoids psychotherapy sessions when given concrete goals that he needs to meet and then reschedules for a few weeks later attempting to avoid discussion of said goals. However, I can't discharge him because he remains on our primary care team, so he or his wife will just call me in crisis a few weeks later anyway if not followed regularly.

 

[WisNeuro]

What is the treatment plan for veteran continually avoids psychotherapy sessions when given concrete goals that he needs to meet and then reschedules for a few weeks later attempting to avoid discussion of said goals. However, I can't discharge him because he remains on our primary care team, so he or his wife will just call me in crisis a few weeks later anyway if not followed regularly.

'
He obviously just needs an increase in SC.

 

[Sanman]

'
He obviously just needs an increase in SC.

Already 100% SC