WAIT. You guys are at one intake per week in the VA these days!? I'm at one intake per day in a non-VA hospital system. Specialty clinic. Access is the name of the game.
Yes. 100%. If we just could do our jobs, patients would get better and use the ED less, use other medical services less, be healthier overall. But.. who is looking at those long term metrics other than academics? Not the government bean quarterly and annual counters. But I guarantee the $ would be in our favor.
I have noticed since 2020 patients are less looking for therapy and to just show up and some one to fix them. Like going to the dentist for a cleaning, or cavity fill if serious **** happening. Its... bizarre. My non-VA system is also giving out time off work letters and disability stuff like candy. I was talking to a colleague about this recently, and it is like the issues with VA the past decade are now prevalent in some aspects of other systems. Not VA related, but I also think that companies like BetterHelp and Cerebral will kill psychology by promoting dumb practices. There will be consequences to society long term. I'm sad for the field.
As 'therapy' bleeds into everyday culture more (at least, it feels like it has in my lifetime with the decreasing stigma and apparently increased mainstream interest), it also becomes 'washed out.' What I mean is that there is a loss of subtlety and sophistication and a general diffusion (disappearance?) of meaning of the terms and concepts that--although they may have had a precise, technical, professional meaning before--they have now become 'buzzwords' mindlessly chanted/mouthed everywhere (and in every circumstance) by the masses and the public relations 'admin' types who hold all the power but--at the end of the day--zero responsibility in our increasingly-fragmented and decreasingly-effective mental healthcare systems.
'Trauma' is a good example as a term/concept (and this was extensively explored in another thread).
'(Psycho)Therapy' is another. In the current VA MH system, I see very few (a small handful) of providers actually delivering effective courses of active psychotherapy with patients. Continuity of care is nearly non-existent. The current 'game' appears to be one of getting 'skilled' at shuffling patients
from your service/caseload
to another person's service/caseload (through entering consults, 'tagging' people on notes, etc.)...I call it the 'Red Rover' ('red rover, red rover, send Mr. Smith right over..') maneuver and it is irritating.
Most MH providers now consider themselves narrow 'specialists' (only providing a 'slice' of intervention focused on a single (or few) very circumscribed targets/disorders/special issues) rather than generalists and, therefore, there are very few therapists who actually treat the 'whole person' in any kind of integrated or comprehensive manner. I think we need to train the vast majority (80%+) of VA mental health therapists as providers who at least have basic competencies to treat the most frequent MH problems our patients present with...for example, I'd argue that if you do MH in VA, even if you are a 'specialist' in a certain area (e.g., MST, Pain, PCMHI, Neuropsych, SUDs, whatever), you should be able to competently work up, diagnose, and treat the following:
- PTSD
- Depression
- Anxiety
- SUDS
- 'anger' issues
These are the frequently encountered presenting issues that everyone keeps 'passing around' to other providers until they eventually land in the caseload of someone who doesn't 'pass them on' to someone else. I'm one such provider (the 'buck' stops with me...I can't even turn down consults (not that I generally would want to, but still). When I get someone sent to me, I'm not thinking, 'hmm...how can I send them somewhere else?'
There needs to be much less passing people around among providers and more continuity of care.
Unfortunately, with the proliferation of different 'layers' of MH care, fractionating into 'PCMHI,' vs. 'BHIP,' vs. 'Specialty' levels of care, we're creating a lot of
churn in mental health care, but very little actual meaningful
intervention. Moving to a 'BHIP heavy' model is a mistake (at least to the extent that I understand the philosophy underlying BHIP). The BHIP lead at my facility appears to be acting like the 'thalamus' of the nervous system (basically, a
relay station through which MH patients travel, but don't stay for therapy/intervention). They're talking about expanding the BHIP psychologist positions from
one to
five at my facility. Great...four more relay stations. But how many 'destinations' do we have? Like, providers to actually commit to a course of psychotherapy treatment with all those patients. Unfortunately, in our braindead system, providers merely 'touching' a case (by doing an 'assessment/intake' and then passing them along to another provider to do
their assessment/intake...who, in turn, passes them to a third provider to.........you get the idea) are getting 'credit' for 'doing a lot of work' or 'seeing a lot of patients' because everyone is about eyeballing some 'easy metric' and fraudulently presenting 'stats' as something that they are not. But that comes from the general traits of cowardice and laziness in the upper levels of management.
I may completely misunderstand the BHIP model (or maybe it is being incorrectly implemented here), but we don't need more of that. We need to go back to the majority of MH providers being able and willing to provide courses of therapy to the majority of veterans with the high-frequency (PTSD, dep/anx, SUDS, etc.) problems. Sending someone to someone else (when
you have the ability to offer them a course of effective treatment) needs to become a rarity rather than a routine practice.
Edit: I need to clarify that I don't actually disagree fundamentally with the
philosophy of the BHIP model, but the problem is the
reality of the VA system and the
implementation (or lack thereof) of that philosophy. Basically, what I see happening (and it is already happening) is that people are seeing the BHIP position (at least at my facility) as a perfect political stepping stone to climb the promotion ladder (high visibility position, the next new 'hot' thing) which involves very little actual (messy and labor intensive) clinical intervention. You get to be 'the decider' with the BHIP 'badge' having been deputized to make the decisions regarding where vets need to be sent. There is a lot of power in that position in the corrupt system that we have and I see it already being abused and the potential for worse abuse is pretty amazing. They become de facto supervisors (through their roles of being 'deciders' about where (and how many) patients get sent to whom, and why) and will be able to exert a tremendous amount of influence with 'leadership' and get to reward their political allies and punish their political enemies.
I've seen this system fail over the years due to favoritism and disparate treatment. The good providers get overloaded with far more than their share of cases, get burnt out, and then leave/retire/move on. The cycle just repeats itself. We would be far better off--in my opinion--with a much simpler system. How about just trying to give every provider approximately the same number/frequency of intakes of MH cases over the course of a year and then--at the end of the year--meet with their supervisor to review how they did with those cases? How many are still on your caseload? Why or why not? You know, (gasp), REAL clinical supervision. What interventions/models are you using? Are you still dealing with too many 'hangers on' in your caseload? What support/suggestions can your clinical supervisor provide you to help you with that?
But to do that, we'd have to operate more like a
healthcare system rather than a
public relations firm.
