We should just call this the VA shuffle. It's kind like the hokey pokey, you dip your right foot in then you take you right foot out and run away for a little while.
Absolutely. 60 - 80% of my sessions are focused on significant lack of engagement as the target of therapy, explicitly attempting to psychoeducate and engage with the patient in problem-solving overt barriers to engagement such as:
- lack of attendance (no shows, cancellations)
- coming late or leaving early in sessions
- not completing measures or between-session worksheets / assignments
- the fact that therapy is focused on SELF-change and not complaining about the state of the world/VA/society, not an endless recitation of (labels for) traumatic events and re-experiencing symptoms (nightmares, memories, 'flashbacks'), not an audition for service-connection or higher percentages thereto
- not a forum for re-litigating service-connection percentages, aid and attendance or 'caregiver' denial letters, or an opportunity to get a 'prescription' for a service dog or medical marijuana
Generously, approximately 40% of my caseload represents veteran mental health patients who have legitimate / authentic mental health diagnoses (including actual PTSD) and only about half of these (20% of entire caseload/ appointments) are in any significant manner 'engaged' in the active psychotherapy process. Not so generously, you could easily cut those percentages in half--depending on the week--to result in about 10% of my sessions actually engaged in high-level specialty psychotherapy services with willing participants.
And now they are (nationally, I believe) rolling out an additional template required in notes for all PTSD patients we're having sessions with prompting us to type in (I do this, naturally, anyway at the end of an episode of care, but now they're hand over hand prompting us with the new template, I suppose) the scores for pre-post PCL-5 or PHQ-9 readings. Which implies, at some point, they are going to crunch/publish the numbers on how many veterans just keep coming back for monthly (or less often) 'psychotherapy' appointments for decades on end with PCL-5 scores being elevated (and flat over time, or increasing steadily over time (I see this a lot)) as a result of decades of 'psychotherapy.'
As backdrop to all of this, I have seen a steady decline in numbers of psychotherapist positions (especially generalists or people who actually carry real caseloads and are not some boutique 'specialty' provider who doesn't have to see people long-term or complete MH Suite treatment plans--they just 'specialize' on disorders of the left pinky fingernail or some such...not the whole veteran) and we are under a de facto hiring freeze where we are being told that vital positions (full-time staff positions in the PTSD specialty clinic) will not be backfilled. We've lost 2 out of 4 full-time positions in the past year in PCT (so, 50% clinician capacity) and I am now backed up 3 months and rising.
But we have 'too many' clinicians.
Interesting times ahead.