PTSD/Substance Abuse Committee Update July/August 2022

BY THOMAS C. HALL, PH.D., CHAIR

When we returned home from war and sought help for the invisible wounds that resulted from our experiences, the behavioral health services of the VA did not recognize PTSD as a real concern. Veterans were shuffled around to psychologists and psychiatrists and generally told they weren’t eligible for services or they were misdiagnosed. A few people were treated in very extreme cases—and only for a short period of time.

As many of you know, after years of pressure from VVA, Congress finally began the process of establishing Readjustment Counseling Centers, commonly known as Vet Centers. The founding principal of the Vet Centers in 1979 was to create a place for peer-to-peer counseling organized around the needs of the veteran. Vietnam veterans—including myself—saw this as a significant improvement and began to use Vet Centers to get the behavioral health support they needed and deserved.

However, as more veterans have become eligible for this care — along with a national shortage of mental health providers and more and more requirements from the VA moving Vet Centers more toward medical models and standards — they have strayed far from the path of peer to peer.

The Committee is getting reports from veterans working in Vet Centers that their leaders have begun a campaign of intensification. That is to say that the Vet Centers leaders are pressuring counselors to see many more veterans than the numbers recommended by their own clinical Capacity Group, which is made up of Vet Center directors and counselors.

This push for increased capacity is happening despite a 2015 internal VA report prepared by a volunteer group of Vet Center leaders and counselors that analyzed the clinical capacity workload for the centers and concluded that many of them “have exceeded their real capacity.” The report recommended that the productivity standards for counselors be set at 18 visits (clinical hours) per work week, two fewer than the standard at that time.

And yet VA leadership now wants the standards to be increased to a goal of 30 client contact hours per week. This recommendation does not take into consideration the amount of time needed to effectively work with clients on their concerns and help them carve out a life. It is merely based on having a number that appeases congressional pressure and paints the VA in a positive light.

A FACTORY MODEL

Aside from meeting with veterans, therapists have may other critical duties. That includes holding staff meetings, charting each client, making phone calls to set up resources, seeing clients in crisis who walk in, and attending required agency training sessions. The 30-contact hour expectation or goal fits a factory model of the 50-minute hour a veteran has to see counselor.

One of the most important activities of a Vet Center is to see veterans who request help in a timely manner. With 30 required visits, where is the wiggle room for an in-session crisis? Where is the time to see a walk-in client in any meaningful way? Where is the time when a scheduled client develops a crisis or that client finally opens up to address long-held concerns? What happens when a veteran needs more meetings, not fewer? The result is a counselor seeing a person in need less often.

Counseling must be fluid and mental health oriented. Many issues require expanding the 50-minute hour. You can’t tell clients to leave or see you less often as if they’ve used up their time on a tennis court. Going from 20 contact hours to 30 pushes the counselor to do just that and essentially speeds up the production line under the guise of doing more with less.

Metrics are an important way to see that agencies are performing the services. But metrics can also overburden a system not designed for such constraints. Metrics above recommendations places unfair burdens on those providing services to the veteran. Many Vet Center counselors work well beyond full time hours because they care and want to help veterans.

In an attempt to meet the higher metrics, we are seeing an increased use of group sessions. Not all veterans like group or do well in group. Groups take time and deliberative thought to be developed. While the issues the veteran brings steer the direction the group, the counselor must also have a curriculum to help the group focus on processes that build knowledge skills and attitudes to achieve and maintain mental health—not to mention the charting required for each person after the group.

There’s also the toll that the increased metric places on the health and well-being of Vet Center staff and the quality of the experience for the veteran. Setting a goal of 30 contact hours rapidly becomes an expectation from leadership. This increased goal is a recipe for therapist burnout amid a national shortage of clinicians. These increased metrics are a powerful ingredient that could alienate an already skittish veteran because counselors have a bureaucratic stick pushing them to get to the next client. The result: They see their counselor watching the clock and shutting them down as they are finally willing to open up.

It is essential to remember that Vet Centers were founded because Vietnam War veterans were put off by the rigid structure of the VA’s behavioral health care when we returned from war. Vet Centers are supposed to be a peer-to-peer experience of non-clinical, welcoming, validating experiences and help with issues that were getting in the way of transitioning back home after military service. These metrics of 30 some contacts a week with clients and manualized clinical practices flies in the face of what has drawn generations of veterans to Vet Centers.

The quality of Mental Health and support consistent with the intention of Vet Centers is only available if counselors have the time to give it. Counselors have dedicated their lives to help us—to have our six. It is now up to us to have their backs.

I am asking you to reach out and tell your congressman and senators to demand that the Vet Center leadership in D.C. return Vet Centers to being client centered and not just another off-putting bureaucracy more interested in numbers than in treating veterans.

Tell them they can do so by supporting the Vet Center Improvement Act of 2021 (S. 1944 and HR.l 3575).