Published in the Fall 2010 issue of SSA Magazine

Every war sends home soldiers who need help rebuilding their lives. For those among the nearly two million American troops who have served in Iraq or Afghanistan who are working to recover from physical and mental injuries, the Veterans administration (VA) is the place to turn. With an influx of new patients, many of whom are dealing with signature injuries from these conflicts, including posttraumatic stress disorder and traumatic brain injury, the VA is on the front lines of many human services.

In this issue's Conversation, Stanley McCracken, a senior lecturer at SSA, and Edward Landreth, the mental health lead for the VA's Veterans Integrated service network (VIsn 12), discuss integrated services, how the VA is tackling homelessness and more. With practice interests that include mental health, substance abuse and co-occurring disorders, McCracken is a U.S. army veteran who served for four years, including during the Vietnam War as an interpreter. He has consulted to a variety of public sector and nonprofit agencies, including the VA and the state Department. Landreth has a doctorate in clinical psychology and a master of clinical social work. Working out of the Jesse Brown Veterans administration medical Center, he serves as both a clinician and an administrator for the region.

Landreth: at the VA, we now have an OEF/OIF [Operation Enduring Freedom/ Operation Iraqi Freedom] program dedicated to serving the veterans from the Iraqi conflict and the Afghanistan conflict.

McCracken: separate from the other programs?

Landreth: yes. It's a program not only here, but across the nation. they even have their own separate outpatient unit with dedicated social workers, one psychologist and a psychiatrist who dedicate a hundred percent of their time to the veterans who are transitioning back post-deployment. Veterans come in and they meet their caseworker. and then they're assigned to different primary clinics throughout the medical Center. For example, they might go to a Post traumatic stress Disorder Clinic for treatment and then be followed in the background by a social worker and actually an entire oeF/oIF team.

It's a culture change. that's an important thing that I hope people are understanding, that this is not the old VA. this is the new VA.

McCracken: I'm familiar with the old VA. How is the new VA different?

Landreth: Well, I can honestly say that we're striving to offer world-class service, especially in mental health. In 2005, we implemented what is called the uniform mental Health service Handbook, and that lays out our goals and the basic services that we want to provide the veterans to assure that they're getting the best mental health care in the world. and this handbook addresses everything from evidence-based psychotherapy to how to treat PTSD [post-traumatic stress disorder] to military sexual trauma.

McCracken: What do you do for PTSD? you have the prolonged exposure therapy and then there's cognitive processing therapy [CPT], right?

[Prolonged exposure therapy helps patients remember and engage with the traumatic event(s), rather than avoiding reminders of the trauma, and CPT helps a patient learn how going through a trauma changed the way he or she looks at the world. Both are considered state-of-the-art treatments for PTSD.]

Landreth: We offer both.

McCracken: one of the things I had been thinking about is whether we should basically tell any veteran he or she can go into any community setting, to any hospital and get care. and it seems from what you've said that they're probably not going to get as good of care as at the VA, at least in a place like Chicago. My concern is more about the rural areas.

Landreth: We have within our VIsn seven medical centers and we have 33 community-based outpatient centers— they're called CBOCs. We go all the way up to Iron Mountain. We cover four states: Michigan, Illinois, Wisconsin and Indiana. There's a CBOC located so far north I thought they were in Canada.

McCracken: [laughs] Right. You get there, but it's by dog sled.

Landreth: We have a very good telemental health system in place at every medical center and at every CBOC. For example, Iron Mountain could be the hub where you have a psychologist or social worker or psychiatrist using telemental health with a veteran who's at a CBOC.

McCracken: you know where that came from? that came from rural mental health. In the early mid-'90s, the Department of Agriculture, I believe, provided funds for setting up centers where they could provide telemedicine to people living in rural areas. It's interesting to see that the VA is taking advantage of that. What about virtual exposure: are you doing that now?

Landreth: In Madison we have Virtual Reality Iraq and Virtual Reality Vietnam. Currently we're looking into implementing it also at Jesse Brown VA Medical Center.

McCracken: What about families? What does that look like?

Landreth: We offer couples therapy, family therapy. It's not uncommon for me to see a veteran who will bring a significant other in. any clinician knows how critical it is to involve the family in treatment, especially when you're dealing with Post traumatic stress Disorder.

McCracken: one of the problems that I've run into, both at the VA and in the community, is that pretty much all programs are siloed and operating separately from each other. How do you deal with someone who has problems with, let's say alcohol dependence, PTSD, depression and homelessness, which I suspect covers, what about 30 percent of the vets that you have. Would they be getting services for all of the conditions—and would they have an integrated team that works together?

Landreth: Absolutely. Social workers or psychologists in the outpatient Psychiatry section work closely with the social workers in OEF/OIF. We all have access to each others' notes, and we set up team meetings. I also want to mention that we have embedded a clinician into the PTSD team who focuses on substance abuse.

McCracken: Excellent! It seems like the VA is one of the very few places where integrated mood disorder treatment is actually a reality and you're able to pull it off. That's very impressive.

Landreth: The VA's a very exciting place to be right now because we're putting all of these comprehensive services into place. When I was considering what I was going to talk about today, I was thinking about how it would be very difficult to cover all the new programs in this conversation. We also have, for example, the HUD VASH Program [Housing and urban Development, VA supplemental Housing]. Secretary Shinseki last year stated that he's going to end veteran homelessness within five years. And so this program offer vouchers to homeless veterans for them to obtain housing.

McCracken: are there supportive housing services that go along with it?

Landreth: Veterans in the HUD VASH program are assigned a caseworker who will follow them from getting the voucher all the way through to being placed into the home, help them obtain blankets, furniture, whatever they need. and, you know, a lot of these veterans, more chronic homeless veterans, they haven't paid bills in a long time. they don't have checking accounts. so the social worker will help this veteran with every aspect of getting back. this all falls under the paradigm of Housing First.

McCracken: For my students, especially the ones that are doing the advanced training Program for addiction Council training, I've been pushing them really hard to go to the VA, because they'll get exposure to evidence-based interventions. Plus, this is the place that's hiring. Jesse Brown hired one of my students, [the Edward Hines Jr. VA Hospital] has two or more. and the supervisor is glad to have them because they already have an appreciation for these kinds of approaches.

How do you orient social work students of all kinds and maybe even new employees to military culture? Do you have a formal kind of training on what military culture is and how it's going to affect the thinking?

Landreth: As far as I know, there's no formal class or anything. Through the individual supervision, working closely with the supervisor, that's where they're learning.

McCracken: I've talked with people about it some, and we talked about using words like honor and duty— words you don't hear as often in the civilian communities, at least not with the same degree of reverence as you do in the military. and I've had it pointed out that there are habits military people develop and stick with them. For example, I still have a hard time walking outside without a hat on. I mean, when you're outside, you're covered; and when you're inside, the cover is off.

Landreth: oh, sure. I've had veterans who have said to me, "I wasn't quite sure if I should discuss this with you because you really don't know what it's like. You're a civilian. Civilians don't understand."

McCracken: Is the VA doing much training of community providers? I did some of the trainings with Alexian Brothers [Hospital] on providing services to vets, which were really nice and the place was packed. One of the things that was interesting was that we started the day with posting the colors. And for a lot of the people, they've never even seen anything like this. I think that starting the day that way, since it happens on every post everywhere in the world, helps to kind of give a mind-set.

Landreth: Right. That's a good idea.

McCracken: It would be good to do some trainings for all of our social work students, at least those who want to work with people in active duty or vets. I'd like to see the Va take a stronger role in terms of training and education, not just for residents and fieldwork students, but also for community providers because of the number of vets that are being seen, both at the VA and the community hospitals. And it's not that people with no military background can't emphasize. They don't know what questions to ask.