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.
Landreth: The transition home is difficult for a lot of these guys. They tell me things like, "There's no structure," or "I go to work, and the problems that civilians have, they mean nothing to me now."
McCracken: Respect, I would think also is something.
Landreth: Yes, that's another big issue. You have a 21-year-old platoon sergeant who is managing troops in the heart of Baghdad, responsible for their lives. And then he comes back here, and he's just treated like an average guy. They've seen things, they've been in situations that no 19-, 20-, 21-year-old should ever be exposed to.
McCracken: Well, nobody of any age should be exposed to, but especially a 19-year-old. At a checkpoint and a ten-year-old kid is walking towards you, and they're not stopping—are you going to have to pull that trigger or not?
Landreth: We've had two significant events just recently here in Chicago that are very bad for guys with post traumatic stress disorder: 4th of July and the air show. I was hearing about those a lot. When I tell that to veterans, many start realizing, I'm not the only one who is hyper vigilant or has this startle response. A lot of guys say to me, "I can't have PTSD. No one close to me was shot. I didn't see anybody blown up." But that's not the issue. The issue is that stress, that relative stress daily.
McCracken: My own first real shocker was in a PX in Hawaii [right after I served in Vietnam]. I had a panic attack there. To me, it felt like way too many people gathered together, because my recent experience was, that's not safe. And I was an interpreter. The guys who were out in the bush, their experience was way worse. And for the guys in Iraq and Afghanistan, there aren't any rear areas.
How are you dealing, especially in substance abuse, with the old guard staff that have been there for years and years and think that the idea of harm reduction is bull and that abstinence is a requirement for service?
Landreth: This is a culture change. And for the longest time, we've had clinicians who have done a good job but haven't used evidence-based psychotherapies. And that's okay. But the VA is trying to step it up a few notches. We're not asking clinicians to change the paradigm in which they've been working for years. We just want them to consider that there are alternative treatments and to give these alternative treatments a try. If you really think about it, prolonged exposure is not that different from what the old school clinician understands as systematic desensitization in vivo exposure. It's the same thing, just a little twist here and there.
McCracken: Right. I'm noticing that you guys are doing an addition paradigm by the staff rather than a replacement paradigm. I'm glad to see that. The idea that people are going to stop doing what there doing? Well, no, they're not. Once their office door is closed, they're doing what they used to do. Adding something different, that may be something they may be willing to try.
Landreth: We're also looking at the entire system. The VA now has a VISIN-wide system redesign person who helps us, and we also have system redesign people embedded in each VA looking at changing systems. We go through six sigma training, a process in which we improve the function of our systems. And we have lean training, where we cut out the waste.
One example would be wait times. We measure wait times, and we decide that if now the standard is waiting in a line for Methadone for as much as two and a half hours, we're going to cut that down to five minutes. We actually did that in our Methadone Clinic. We extended our hours and changed the tour of duties for some employees. And now our medication dispensing time has stretched out through the entire day as opposed to maybe three two-hour intervals throughout the day. Five minutes, ten minutes at the most to get his medication.
One of the big issues that we haven't really discussed yet is suicide. And that's a very serious problem that we have with our troops who are deployed and the veterans post-deployment. I can't even tell you how seriously we take this at the VA.
McCracken: I'm assuming that you're embedding suicide screens into primary care as well as mental health?
Landreth: Yes, we sure do. We have depression screens. We have positive depression screens. Once they walk into our hospital, we make sure that they've seen a clinician within 14 days. If they're being discharged from an inpatient psychiatry unit, a clinician is seeing that veteran within seven days because the data shows that suicide rate is highest in that seven days.
At Jesse Brown VA, we actually have a person who will meet with the veteran within 48 hours and then with a licensed clinician within seven days. So that makes it kind of a warm handoff, a transition from inpatient to outpatient that works. We're monitored on this from Central Office.
McCracken: What are you using for the screens? Do you have a unique screener that's specific to this population?
Landreth: Yes. And there is a committee at the VISN level who is putting together a more brief but more thorough suicide assessment tool. And so we hope to have that implemented or start implementing it in October, I believe.
McCracken: Can I get a copy of this? I should be teaching that to my students.
Landreth: Sure. Did you know that we have suicide prevention counselors? We have people who will follow a veteran who has suicidal ideation or who has attempted. They will follow that veteran. What we'll do is we'll put a flag in the chart.
McCracken: Is it a community outreach kind of thing? Do they go into the person's home?
Landreth: Yes. They will go into the home. They will call the veteran weekly. They'll do whatever they can to stay in contact. So if they're not hearing from this veteran, they'll be knocking on the door. So for 90 days they will follow that veteran with a weekly call, minimum. That's in addition to the psychiatrist, the psychologist, the social worker, and the outpatient clinic following this veteran. So if that veteran misses a session that suicide prevention counselor is on the phone calling that veteran to follow up.
McCracken: That is really impressive.
Landreth: And then after 90 days, then there's a meeting with the clinicians to determine whether or not this veteran should be taken off the high-risk list. Because we don't want that label to follow that veteran, but we want to also make sure that that veteran is safe.