For me it's more about trying to artfully combine the idealized 'roadmap' of how a person gets from, say, 'clinically depressed,' to 'recovered'
One of the issues I have is that VA National (and, by extension, all of VA administration down to the local level) appears to be pursuing 'full rollout' of the EBT protocols under the assumption that the main (or even only) barrier to EBT uptake is the clinician at point of care, i.e., that the clinician is somehow choosing not to encourage veterans to engage in a protocol or somehow (I suppose, due to laziness) sabotaging the process or at least not giving a full effort to enroll their patients in these protocols. In my view, this is a result of the organizational schemas (core beliefs) that are often enacted by VA administration that basically fall under the umbrella of a core belief that 'If something isn't working, it's the provider's fault.' Unfortunately, prior to doing therapy on the 'front lines' of a post-deployment clinic for the past four years, I kinda bought into this assumption (and that's what it is...an assumption) as well. What I have found is that the vast majority of the time the barrier is on the client-side rather than the therapist-side of the equation. I actively encourage (with a blend of psychoeducation, motivational interviewing, and even leveraging of the therapist-client relationship as appropriate) full participation of the veterans I work with in an EBP protocol (say, CPT or PE for PTSD and even the full range of other protocols available at our facility). There are multiple reasons why a veteran would choose to decline an offered course of an EBT for their mental health condition and some of them relate to other systems-level issues. For example, in my clinic, I have 'program manager' folks accepting consults for psychotherapy from veterans who live up to FOUR HOURS drive away from our facility when there is a CBOC 10 mins away from them and they even have to pass another two CBOCs on their way here. This is a ridiculous barrier to weekly therapy. But when I raise the issue, they say, 'it's the veteran's preference and we respect veteran choice.' My perspective that it is inimical to the prospect of full engagement in a weekly psychotherapy process falls on deaf ears as does the empirical observation that I've never had a single case who had to travel so far for 'psychotherapy' that lasted more than 1-3 or so sessions. There are other realities that VA admin refuse to acknowledge such as the obvious reality that some veterans do choose to malinger or at least amplify their symptom self-report for various reasons (avoiding employment, avoiding responsibilities, generous benefits for themselves/spouses/children, etc.) and this, I suspect, does serve as a disincentive to participate in any rigorous process of treatment/assessment of their underlying service-connected condition. And of course there's the garden variety avoidance that is part and parcel of PTSD (and, frankly, any psychopathological process) to any trauma-focused therapy approach. Working through this--even skillfully utilizing techniques that are appropriate to such reluctance--is often anything but a straightforward process with anything like 100% efficacy. It's my observation that the more a person in the system is removed from daily provision of direct care to patients who walk into an open access mental health clinic, the more they are likely to be facile with their response to any lack of 'uptake' on the part of veterans being that somehow the provider hasn't 'done their job' or been 'convincing enough' in their psychoeducational efforts. Of course we're imperfect as providers and of course we could always improve anything we're doing clinically. However, I think that there is a pretty big gulf between the assumptions of some of the 'higher level' MH folks within the VA system and what actually happens routinely at the point of care delivery.
