PTSD: The VA's New Approach

They are the invisible wounds of war, the battered minds and bruised spirits we have come to recognize as posttraumatic stress disorder, or PTSD. By one estimate, more than 300,000 of the nearly 2 million U.S. servicemen and -women deployed since 9/11 suffer from the often-debilitating condition, with symptoms that include flashbacks and nightmares, emotional numbness, relationship problems, trouble sleeping, sudden anger, and drug and alcohol abuse. The number of cases is expected to climb as the war in Afghanistan continues, and could ultimately exceed 500,000, according to a new study by researchers at Stanford University. Mental-health experts say PTSD is the primary reason suicides in the military are at an all-time high; 256 soldiers took their own lives in 2008, the highest number since that data was first tracked, in 1980.

As NEWSWEEK and others have reported, the Department of Veterans Affairs has struggled to address this mental-health crisis, and thousands of veterans have suffered as a result. Now, thanks to new leadership and a new openness to collaboration, things appear to be changing at the VA, if slowly. Veterans still often face insufferably long waits for treatment and steep bureaucratic hurdles when filing disability claims. But there is a new sense of urgency under Eric Shinseki, the retired four-star Army general appointed to head the agency by President Obama, to change the culture within the 77-year-old VA. Shinseki has made PTSD a priority, with efforts underway to address concerns from the way claims are processed to the development of new, more effective treatments. "Brain injuries and the psychological consequences of battle are not new to combat," Shinseki tells NEWSWEEK. "We know from past wars that with early diagnosis and treatment, people can get better."

The agency has already trained more than 2,000 mental-health clinicians to administer PTSD treatment using new, evidence-based treatments. Among the most surprising steps the VA has taken is to reach out to mental-health professionals in the private sector, something that never happened under past regimes. Just last month the agency launched a joint venture with the Boston Red Sox Foundation and Massachusetts General Hospital to treat potentially tens of thousands of PTSD sufferers and their families in the Boston area. The VA also recently began what press secretary Katie Roberts called a "collaborative relationship" with Give an Hour, a national nonprofit network of some 4,500 therapists that provides free counseling to returning troops and their families. Barbara Van Dahlen, a psychologist who founded Give an Hour four years ago, says that when she contacted the VA in the past she was turned away. "The VA finally gets that PTSD is a public-health crisis," Van Dahlen says. "They still haven't taken full advantage of the fact that we have 4,500 therapists eager to help, there isn't really a collaborative relationship yet, but the new leadership is showing sincere interest. That's a start."

Shinseki, a wounded vet (he lost part of a foot in Vietnam) who clashed with former defense secretary Donald Rumsfeld in the run-up to the war in Iraq, spelled out the VA's new approach in a July speech to a medical symposium. "We have looked at ourselves closely and have decided to make advocacy—yes, advocacy—on behalf of veterans both our culture and overarching philosophy ... It will involve a long-term process in reorienting our workforce and our work habits toward this philosophy. Culture change will take longer."

One practical application of the new philosophy: the VA has launched its first-ever nationwide search for veterans in rural areas who suffer from PTSD but are unable or unwilling to travel long distances to a VA office. Given the fact that 38 percent of veterans live outside big cities, which the VA acknowledges, this rural outreach seems especially overdue. Dr. Harold Kudler, a VA psychiatrist since 1984 and associate director of the agency's Mental Illness Research, Education and Clinical Centers, heads a program in North Carolina that will partner with rural health centers and National Guard armories to find and treat veterans in outlying areas, using specially equipped vans for house calls. "We should be up and running in three months," says Kudler, adding that similar programs are being developed around the country. "The VA is no longer going to wait for veterans to come to us—we have to go to them."

Finding veterans with PTSD is one problem; persuading them to be treated is another. As many as seven in 10 veterans refuse mental-health treatment even when it is offered, according to a 2008 study by the RAND Corporation. Further complicating matters is the fact that there is no universally accepted ideal treatment for PTSD. But Dr. Matthew Friedman, who runs the VA's National Center for PTSD, says extensive research by the agency has concluded that two approaches appear to be the most effective. One, called cognitive-processing therapy, seeks to help the sufferer by identifying and changing dysfunctional thinking, behavior, and emotional responses. The other, prolonged-exposure therapy, consists of reliving and confronting the trauma and learning to think differently about it. In an innovative effort to reach the younger generation of veterans, the VA is studying a variation of prolonged-exposure therapy that uses technology similar to a videogame to re-create as realistically as possible the original traumatic events. "Younger, tech-savvy veterans have shown a real willingness to participate in this 3-D approach to PTSD treatment," explains Dr. Anne Sadler, an associate director at the Iowa City VA who is heading the study. "Virtual-reality therapy is a way for a generation comfortable with joysticks and videogames to deal with their horrific experiences."

Shinseki is also working to improve the agency's strained relationships with veterans' services organizations. "The culture at the VA is changing," says Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America, the largest nonprofit, nonpartisan group for veterans of the current war. "They've reached out to us, and they're saying the right things and bringing in good people." But Rieckhoff, an Army first lieutenant who served in Iraq, warns that implementing these changes will be a "massive challenge" and that the VA still needs to adopt more of an open-door policy. "The VA has to accept that they're just one component of a comprehensive solution to the veterans' mental-health problems that must also include the Department of Defense, veterans' organizations, and the public."

With the national dialogue focused on civilian health care and the economy, Shinseki's efforts to transform the VA have flown mostly under the radar. But people have begun to take notice, and even some of the agency's harshest critics are guardedly optimistic. Paul Sullivan, a veteran of the Gulf war who worked at the VA as a project manager until 2006, is executive director of Veterans for Common Sense, which, with another veterans' organization, sued the VA over its slow response to veterans' disability claims. Despite the lawsuit, which is still in the courts, Sullivan calls Shinseki "a breath of fresh air at VA. But VA isn't out of the woods yet; it remains in crisis due to decades of chronic underfunding, unresponsive leaders, and overly complex policies that often result in unfair delays and denials for health care and benefits. There's still a long way to go." The huge agency, with more than 200,000 employees, continues to be plagued by inefficiency and corruption. In August it was revealed by the VA's inspector-general that in 2007 and 2008, while veterans waited for their delayed disability checks, managers at the VA's technology office awarded $24 million in bonuses to thousands of employees.

Most veterans interviewed for this story agree with Sullivan that the VA has a long way to go. Despite Shinseki's good intentions, veterans aren't necessarily feeling the love, at least not yet. Dorman Branch, a Marine sergeant from Clinton, La., who saw heavy combat in Afghanistan, was diagnosed with severe PTSD and degenerative disc disease and is on 80 percent disability. He says that to see a doctor he has to drive 130 miles to New Orleans. There is no rural outreach program yet in Branch's neck of the woods. "I don't see any real positive changes" in the VA, says Branch, who has trouble sleeping, hearing loss, memory loss, severe headaches, and anger issues. "All they do is give me Wellbutrin [medication] for my depression and ask me why I think I'm raging. Then it's 'see you in six months.' I can't work. My wife is in school. I was diagnosed with degenerative disc disease five years ago and just got surgery recently. I have a great caseworker, but she's the only one who's really helped us."

To date, the VA has diagnosed 111,239 Iraq and Afghanistan veterans with PTSD, but has treated only a small percentage of those. Of course, studies from RAND and many others suggest that the number of veterans with PTSD is far greater. But to date the agency is aware only of the veterans who actually contact it seeking treatment; its efforts to proactively identify other sufferers are just getting underway. Meanwhile, the lives of far too many veterans with untreated PTSD and unprocessed disability claims tragically deteriorate. And the problem will likely get worse before it gets better: up to 1 million new veteran patients are expected to flood the VA by the end of 2013, including an unprecedented number of women (11 percent of the total troops deployed since 9/11 are women). Navy Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, recognizes the importance of the VA getting a handle on this crisis. At a defense forum last month, recalling a meeting he had last year with a group of homeless veterans from past wars, Mullen said he worries that if efforts don't improve quickly, the nation could see another generation of down-and-out former soldiers on the streets. "Shame on us if we don't figure it out this time around to make sure that doesn't happen," Mullen said.

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