Veterans' Administration Psychology

[edieb]

To those of you who work at the V.A., I am hoping that you could answer the following questions:
1 - is the culture of the V.A. mental health system is more of a long-term care model where patients become dependent on the clinic or if there is a greater emphasis on helping the patient work towards autonomy so he/she can function independently

2 - I heard the V.A. only likes evidence-based treatments -- true?

3 - What is the biggest difference between the V.A. mental health system and the mental health system outside the V.A.?

Thanks!

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[Therapist4Chnge]

I was just going over my list of fellowship apps, and I was thinking about the pros/cons of working at a VA Hospital v. Med School Hospital. I can give you my 2 cents, though I'd encourage others to share as I've heard it can vary greatly between VAs.....NYC/DC v. Midwestern v. Southern, etc.

My comments below are not endorsed by the VA, etc.

1 - is the culture of the V.A. mental health system is more of a long-term care model where patients become dependent on the clinic or if there is a greater emphasis on helping the patient work towards autonomy so he/she can function independently?

If my memory serves me (thank you 3 day hospital orientation!), the VA started as long-term care, but eventually shifted away from that. The latest reorganization was to Service Lines, which was a step towards streamlining care, has really helped cut down on service time. Does this translate to shorter stays and more independence.....I'm not sure. I found an interesting writeup that is worth a read: http://psychservices.psychiatryonline.org/cgi/content/full/51/10/1307

Anecdotally, I think there is a push in Behavioral Health to get people INTO out-patient (particularly OEF/OIF veterans), and help reduce in-patient stays, with the eventual goal of creating more independance. Some Veterans have gone through a combination of in-patient and out-patient stays for years, and I am sure most want to not be dependant, but I'm not sure how realistic it is for some of them. It is amazing the damage that has been done overseas, and many times it isn't something that can be cleared up in 8-10 CBT sessions. With that being said, I think there is a better chance of independance if treatment is done during service and/or right after discharge, unfortunately most wait until it gets so bad they don't have another choice.

2 - I heard the V.A. only likes evidence-based treatments -- true?

Yes. They are BIG into anything and everything EBT. We have to learn all sorts of fun stuff (CPT, PET, etc), which isn't bad....it is just a lot. They are pushing for staff to be trained and certified in the various treatments, so then they can train their staff, etc.

3 - What is the biggest difference between the V.A. mental health system and the mental health system outside the V.A.?

There is a different kind of red tape. It isn't about money for treatment, but availability. There are also issues with formulary and whatnot, but that can happen at some hospitals too. Money still plays a large role in the Veteran's lives (Service Connection....which is one way they get $ and benefits for their injuries), so you aren't completely absolved from dealing with it.

 

[Cosmo75]

Like T4C said, I think the answers to your questions may differ by VA.

1 - is the culture of the V.A. mental health system is more of a long-term care model where patients become dependent on the clinic or if there is a greater emphasis on helping the patient work towards autonomy so he/she can function independently?

The VA I was at seemed to have more of a long-term model of care that they were trying to replace but weren't very successful at it. This was especially true in the outpatient mental health clinic, where more traditional weekly psychotherapy is done. There were people who had been coming for decades, either with a staff member or had rotated through several interns and/or practicum students. The level of pathology varied greatly, so it's difficult to say who actually needed to be coming versus those who were dependent and not really making any progress. But the latter surely seemed to be the case with some. Other departments were trying to emphasize autonomy, but overall the population at the VA I was at was rather chronic.

2 - I heard the V.A. only likes evidence-based treatments -- true?

There is certainly a push from central office to implement EBTs. But as with any government agency, the pace at which mandates from on high are actually implemented is quite laborious. The VA I was at hired some new psychologists to implement these new treatments. However there are many on staff who adhere to less supported by research treatment modalities. Even when they are used (e.g. CPT for PTSD) they are often modified for many reasons, including what's being debated on the "science" thread in terms of client preference or willingness to use an EBT.

3 - What is the biggest difference between the V.A. mental health system and the mental health system outside the V.A.?

The level of bureaucracy. Also the type of patients you see is pretty different in a VA. I'm in a "not for profit" academic hospital now. The clientele I see is vastly different than who I saw at the VA (low SES, minority mostly, with complex histories). Though I was told that even between VAs in the city I'm in there was a big difference in the backgrounds of the vets who came there. I truly enjoyed the work I did at the VA, but it was at times depressing. It was more difficult to maintain a sense of optimism and hope. This was a combined effect of what I said about the vets' backgrounds/status, the disparity in services due to demand exceeding supply (and that's only going to get worse as people come back from Iraq/Afghanistan), and the turtle-pace that a huge government bureaucracy moves at.

As an aside, we had a hard time getting the OIF/OEF vets into psychological treatment. If they did come in, they often dropped out. I wondered if this was partially due to them seeing the Vietnam-era vets who were the majority of the population. I couldn't imagine being a new vet with some PTSD symptoms coming into the VA and meeting a guy from the Vietnam war who came home 40+ years ago and was still going to weekly groups due to decades of severe PTSD symptoms.

 

[Therapist4Chnge]

As an aside, we had a hard time getting the OIF/OEF vets into psychological treatment. If they did come in, they often dropped out. I wondered if this was partially due to them seeing the Vietnam-era vets who were the majority of the population. I couldn't imagine being a new vet with some PTSD symptoms coming into the VA and meeting a guy from the Vietnam war who came home 40+ years ago and was still going to weekly groups due to decades of severe PTSD symptoms.

Getting the OEF/OIF Veterans in for treatment is a huge hurdle. I don't have any research to back it up, but it seems like the Veterans that come in soon after leaving the service are doing better than those who wait 2, 5, 10+ years. The problem is getting them in, getting past the stigma, and keeping them coming so they can make some meaningful changes.

The beauracracy is rough. The paper needed to file for Service Connection, the wait times for some services, and the sometimes inconsistant care can really turn Veterans off to seeking treatment. With that being said, I've had a number of the Vietnam Veterans tell me that it is vastly improved in the last bunch of years, and they wished they had these services available to them when they first got out. I'm lucky to be at what I consider a great VA, and be able to work with people who genuinely care about the Veterans. I've had friends at other facilities and heard mixed reviews, so this is definitely N=1.

 

[erg923]

In my experience, because of the VA's checkered past, I have found a culture of "appeasing" veterans in certain circumstances at my local VA. A very large, prestigous research VA.

For example, we were encouraged NOT to administer symptom validity/effort measures during our neuropsych evals to those coming into our WRIISC center. Keep in mind these are vets who have such complex cases that their local VA cant figure it out and they send them to us. Its typically a mixed bag of somatization, psychiatric issues, and unknown, vague neurologic/cognitive symptoms. I was told these are "sensitive cases" and not to rock the boat in not so many words. So basically, they were telling us that the very people who need SVTs the most (ie., the population with the highest base-rate for poor effort and symptoms distortion), were NOT to get them during a npsych eval. Yea, makes alot sense.... I know. My self and new supervisor who had just joined were so outraged by this that we were able to convince them that if we cant objectively establish adquate effort during our neuropsych eval, then our role in all this is all for not.

Besides this issue, I thought the actual care an attention given to vets at my VA was top notch. There seems to be more institutional pride at this VA than any other place I had worked at prior. One of the nurses on our tx team was like a cheerleader for the VA and veterans in general- always talking us up and taking pride in our vets and our VA great service, really advocate-like. I guess thats cool. Took some getting used to though.

 

[Therapist4Chnge]

Besides this issue, I thought the actual care an attention given to vets at my VA was top notch. There seems to be more institutional pride at this VA than any other place I had worked at prior. One of the nurses on our tx team was like a cheerleader for the VA and veterans in general- always talking us up and taking pride in our vets and our VA great service, really advocate-like. I guess thats cool. Took some getting used to though.

I see institutional pride around my VA too. It isn't perfect, but in general people seem to care and want to work here. I was pretty surprised to see so many 20+ year people in the various departments. There is a stigma associated with gov't workers sometimes, but I think most people are here for the right reasons.

RE Advocacy: Our DCT has really stressed advocacy as part of our work because the red tape and paperwork can be challenging. OEF/OIF Veterans get flagged for priority services, so we've seen an increase in the numbers coming in.