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

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Sanman said:
How exactly does this work?
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Provider A enters consult for a specific therapy/protocol (e.g., CBT for Nightmares [CBT-N]) and also immediately writes the treatment plan in MH suite stipulating that Provider B will be doing CBT-N with the patient over X period of time. Even though Provider B hasn't even had the chance to meet with the patient yet to discuss other treatment options with far more empirical support for their efficacy (like CPT).

We have a 'rule' (maybe everyone has it) that the tx plan in MH Suite must be completed by session 3. That rule along with the observation that the MH Suite software allowed him to do it was cited as justification for Provider A's actions.
 
Fan_of_Meehl said:
Provider A enters consult for a specific therapy/protocol (e.g., CBT for Nightmares [CBT-N]) and also immediately writes the treatment plan in MH suite stipulating that Provider B will be doing CBT-N with the patient over X period of time. Even though Provider B hasn't even had the chance to meet with the patient yet to discuss other treatment options with far more empirical support for their efficacy (like CPT).

We have a 'rule' (maybe everyone has it) that the tx plan in MH Suite must be completed by session 3. That rule along with the observation that the MH Suite software allowed him to do it was cited as justification for Provider A's actions.
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Ahh, I don't use MH suite. Also, I am not the greatest at following rules.
 
AcronymAllergy said:
Yep, we were also strongly encouraged not to complete ESA letters, and were directly told not to complete DBQs (probably because some providers had been filling them out).
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I’m late to the party on this conversation, but… I just recently completed one. I didn’t have any issues with it for this particular person (I had discharged them a month or more prior) but I’m curious, who would fill it out if not the treating provider? I don’t have the directive on hand but clearly I missed the part where it says treating provider shouldn’t fill it out. Does that mean not to complete it only if you’re actively seeing them *now*?

I get asked about social security disability forms more often and my supervisor’s hard line has been under no circumstances should be complete them, since it’s asking us to make medical determinations outside the confines of our roles as psychotherapy providers. It’s saved me from having to deal with patient reactions to my real answer, which is that except in extreme cases, I don’t think someone is permanently disabled because of (whatever diagnosis) for the rest of their life. I’ve yet to come across someone in my current role I believe was severely disabled such that they couldn’t work at all.

In other news, I was recently smacked upside the head with some fierce burnout that felt like it came out of nowhere. I’ve been extremely happy with my current role and I can’t get articulate where this came from. But I have been on the prowl for and have applied to a few jobs that are mental health related but more in the program development/public health realm. Advocacy has always been my passion and while I love clinical work, I am getting tired of the repetition of addressing the same problems on an individual basis a million times over. A couple of my patients have told me I look tired lol.
 
ccpsych16 said:
I’m late to the party on this conversation, but… I just recently completed one. I didn’t have any issues with it for this particular person (I had discharged them a month or more prior) but I’m curious, who would fill it out if not the treating provider? I don’t have the directive on hand but clearly I missed the part where it says treating provider shouldn’t fill it out. Does that mean not to complete it only if you’re actively seeing them *now*?

I get asked about social security disability forms more often and my supervisor’s hard line has been under no circumstances should be complete them, since it’s asking us to make medical determinations outside the confines of our roles as psychotherapy providers. It’s saved me from having to deal with patient reactions to my real answer, which is that except in extreme cases, I don’t think someone is permanently disabled because of (whatever diagnosis) for the rest of their life. I’ve yet to come across someone in my current role I believe was severely disabled such that they couldn’t work at all.

In other news, I was recently smacked upside the head with some fierce burnout that felt like it came out of nowhere. I’ve been extremely happy with my current role and I can’t get articulate where this came from. But I have been on the prowl for and have applied to a few jobs that are mental health related but more in the program development/public health realm. Advocacy has always been my passion and while I love clinical work, I am getting tired of the repetition of addressing the same problems on an individual basis a million times over. A couple of my patients have told me I look tired lol.
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Is this RE: ESA letters or DBQs?

Either way, both are quasi-forensic (or straight up forensic) documents. Completing them as a clinician is a potentially risky situation. And as you've said regarding SS disability, both have the potential to significantly damage the treating relationship with no real upside for you.
 
AcronymAllergy said:
Is this RE: ESA letters or DBQs?

Either way, both are quasi-forensic (or straight up forensic) documents. Completing them as a clinician is a potentially risky situation. And as you've said regarding SS disability, both have the potential to significantly damage the treating relationship with no real upside for you.
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Sorry, DBQs. I thought we had a VA policy against letters for ESAs/service dogs. At least that’s what our supervisor tells us and I’m fine with that. I don’t believe I’m equipped to evaluate for service animals, and I’ve told patients I don’t believe in ESAs. They’re untrained and all pets give us emotional support. I get asked to write letters to apartment complexes to give an exception to the no pet policy. Nope.
 
ccpsych16 said:
Sorry, DBQs. I thought we had a VA policy against letters for ESAs/service dogs. At least that’s what our supervisor tells us and I’m fine with that. I don’t believe I’m equipped to evaluate for service animals, and I’ve told patients I don’t believe in ESAs. They’re untrained and all pets give us emotional support. I get asked to write letters to apartment complexes to give an exception to the no pet policy. Nope.
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I would definitely not complete DBQs. That is something VBA will do, plus they can refer to your notes if needed.
 
GOD I hate this expectation that people call into the clinic and should get an immediate response, like the MSAs are held hostage until a provider can take the call. Like someone calling and saying they need to speak to someone at noon. Do any of you call a clinic and expect an immediate response over the lunch hour?

If it's THAT urgent, call the VCL.
 
cara susanna said:
GOD I hate this expectation that people call into the clinic and should get an immediate response, like the MSAs are held hostage until a provider can take the call. Like someone calling and saying they need to speak to someone at noon. Do any of you call a clinic and expect an immediate response over the lunch hour?

If it's THAT urgent, call the VCL.
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Part of that is training the MSA as well. The answer from the MSA should be that providers are not available at this time and message has been forwarded, the VCL is available for more emergent situations.
 
Sanman said:
Part of that is training the MSA as well. The answer from the MSA should be that providers are not available at this time and message has been forwarded, the VCL is available for more emergent situations.
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MSAs have told us that they aren't allowed to triage that, so they have to speak to MH
 
psy.d. 2021 said:
It's baffling. MSAs at my clinic seem to exist to cause more pushback and their managers seem to want to create more work to justify their own positions
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This seems to be a pretty universal experience. Good MSAs are a huge boon; unfortunately, there are many more...less good MSAs out there who are very happy to do the bare minimum. And MSA leadership, in my experience, have been some of the most stubborn, unreasonable, non-team-oriented folks in VA.
 
cara susanna said:
Apparently a bunch of politicians are working to require Stellate Ganglion Block be offered by all VAs as a first line treatment for PTSD AND require the VA/DOD CPG be updated to reflect this.

All Info - H.R.3023 - 118th Congress (2023-2024): Treatment and Relief through Emerging and Accessible Therapy for PTSD Act | Congress.gov | Library of Congress
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Because politicians totally know better than psychologists, psychiatrists, and other mental health experts in terms of what treatments are evidence-based and necessary. This is how we end up with hyperbaric oxygen for mTBI.
 
cara susanna said:
Apparently a bunch of politicians are working to require Stellate Ganglion Block be offered by all VAs as a first line treatment for PTSD AND require the VA/DOD CPG be updated to reflect this.

All Info - H.R.3023 - 118th Congress (2023-2024): Treatment and Relief through Emerging and Accessible Therapy for PTSD Act | Congress.gov | Library of Congress
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Can somebody give me a quick rundown on SGB? It's a term that I've heard over the years but never did any digging into.
 
summerbabe said:
Can somebody give me a quick rundown on SGB? It's a term that I've heard over the years but never did any digging into.
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I looked at the lit about 4-5 years ago, and it was disappointing at best. After some case series, SGB did no better than placebo in some RCTs. Not sure if there have been tweaks or other extensive work since then.
 
WisNeuro said:
I looked at the lit about 4-5 years ago, and it was disappointing at best. After some case series, SGB did no better than placebo in some RCTs. Not sure if there have been tweaks or other extensive work since then.
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"Even if it does work, why do an invasive procedure with risk for devastating consequences to theoretically decrease sympathetic tone when you can just use a sympatholytic medication?" - preview of what one will be asked on the stand when they are being sued for complications of a SGB

I can see trying it when one has no other options (AKA the "throw things at the wall and see what sticks" phase of treatment), but the problem is that patients hear about it and then don't want to try other things that actually do work.
 
How much of a pipe dream is it to think about applying to short term details? I know there’s the “my development plan” in TMS that seems like a bunch of fluff. I think I could make a convincing argument and my supervisor would more likely than not support it, but our hospital leadership is close-minded about anything outside of loading us up with an unreasonable amount of patients. Has anyone here done one before or know a VA psychologist who has?
 
Not a psychologist, but I know a social worker who did

Edit: Oh wait, I do know a psychologist from my last job. So, yes!
 
AcronymAllergy said:
This seems to be a pretty universal experience. Good MSAs are a huge boon; unfortunately, there are many more...less good MSAs out there who are very happy to do the bare minimum. And MSA leadership, in my experience, have been some of the most stubborn, unreasonable, non-team-oriented folks in VA.
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Glad to hear I'm not alone. MSAs can be hit or miss but generally I get most are trying. The MSA leaders...they seem to exist just to say "no" and talk about how hard things will be instead of finding solutions
 
I have known two psychologists who have done details. They ended up taking the positions afterward!
 
cara susanna said:
Not a psychologist, but I know a social worker who did

Edit: Oh wait, I do know a psychologist from my last job. So, yes!
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Shiori said:
I have known two psychologists who have done details. They ended up taking the positions afterward!
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I would love to connect with these folks to learn more about their experiences! I saw a couple details that looked intriguing enough that I want to apply to them. And I’ve been job searching as well. Please PM if they are open to chatting via email, thank you!
 
Of all the clinics I passed out Pride swag to, the CLC was the most excited. They are always so lovely and warm. It was a good year too! Everyone was at least friendly. We couldn't fly the flag, but the hospital as a whole has been more open to hanging up signs. I have gotten an influx of interest in gender affirming care consults and people wanting to join the LGBTQ+ support group. In all the chaos, it's been really nice to see some wins at the local level.
 
psycho1391 said:
I had 2/4 so pretty close. Who knows what's going on.
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I TECHNICALLY had 3/4 but one was an advance cancellation and with a very good reason, from someone who never cancels, so I didn't want to include them in my statistic

Sanman said:
How's the weather by you? I feel like that determines half the no show rate.
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It's raining so maybe that's it!
 
Know what I love? Being a program manager for an integrated pain program with no direct plan for a physical therapist.

Back story: Our PT gave less than a month's notice. Her last day was last Friday. The PT department had been showing as the dashboard as overstaffed for the past several quarters, so they have not been able to backfill any positions. So right now, they are down 7 positions.

The coverage plan is for the CRH to cover our virtual vets, but we have no one to cover in person.
 
psycho1391 said:
Know what I love? Being a program manager for an integrated pain program with no direct plan for a physical therapist.

Back story: Our PT gave less than a month's notice. Her last day was last Friday. The PT department had been showing as the dashboard as overstaffed for the past several quarters, so they have not been able to backfill any positions. So right now, they are down 7 positions.

The coverage plan is for the CRH to cover our virtual vets, but we have no one to cover in person.
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This is pretty much everywhere right now. So, if anybody leaves no backfills. Pray your weekend coverage does not quit if you have SARP or Inpatient in your hospital.
 
Sanman said:
This is pretty much everywhere right now.
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Yep. There is some PMOP funding that will give us money for 3 years, but its having this PT supervisor work with me so we can submit a RFA. Working with other disciplines can be like pulling teeth sometimes!
 
Grenth said:
We were told today we MUST complete all VA and non-VA medical forms and provide medical statements per a VHA policy.

There goes all my admin time filling out ESA letters and crap. We've had a pretty firm clinic policy of not doing forms/letters unless desired by both provider and patient so it's agitating they're coming down so hard on this from up above.
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That is ridiculous, at least to anyone who has worked at a VA hospital/facility.

Can you schedule a f/u appointment and use that time to complete the paperwork? They can come in, provide an update, and you can complete the paperwork while minimizing how much "extra" time eats into your day.
 
Also been having a lot more no shows and cancels recently.

My 4 today are consistent attenders so I should be full but I went 0/4 one day last week.

Feels like this happens every summer that I’ve been with the VA and I think people in private practice experience something similar.
 
AcronymAllergy said:
"Back in the day," we were explicitly told by our supervisors and service line leadership to refuse to complete DBQs, and we were tacitly encouraged to refuse to complete ESA documentation. They even gave a presentation on DBQs and why it can be problematic for clinical MH staff to complete them. This change, by itself, would make me consider leaving a VA job. Sorry to hear you're having to now deal with it.
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I can't believe they still do ESAs, given what we know in the research. If a veteran is suffering with PTSD, giving them an animal is going to do what? I think animals are great, especially dogs and cats. I think a lot of people would benefit from having an animal company (i.e. pet). However, that doesn't mean I think ESA are the correct solution.
 
Fan_of_Meehl said:
Wait til you have another provider pre-emptively write your treatment plan for you (without consulting you) under your name for a patient your haven't even had the opportunity to evaluate yet, lol.
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That still hasn't been fixed?! I remember hearing about this a year (?) ago or more.
 
AcronymAllergy said:
Don't forget to supplement with Healing Touch and various Whole Health treatments, as needed.
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Better go w. Reiki bc touching patients is weird, but "tapping into their energy flow"* is non-invasive and spiritual.

*I have no idea if this applies to Reiki, but it sounds like something a Reiki provider would say.
 
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