Thank you for inviting me to share a perspective on issues with VA’s Mental Health Program
Management at the Atlanta VA Medical Center. As the Atlanta alumni manager with Wounded Warrior Project, I have the privilege of working daily with wounded warriors, many of whom have been patients at the Atlanta VAMC. I am also a career Army veteran and a wounded warrior who has been treated at VA facilities, including Atlanta.
I appreciate the work you and others on the Senate Veterans Affairs Committee are doing to help our veterans from Iraq and Afghanistan are struggling with the psychological wounds of war, and appreciate the opportunity to assist in your important inquiry today.
Over the past 23 years I’ve had the honor of working with Soldiers and wounded warriors, and I’ve seen first-hand the devastating impact that almost 12 years of continuous combat has had on our fighting men and women. In my experience, those who go to war are forever changed by it. But many bear such profound invisible wounds to their hearts and minds that they have developed Post Traumatic Stress Disorder. I’ve struggled with PTSD myself, as well with as residuals of Traumatic Brain Injury from three IED blasts in Iraq. As a Warrior Transition Battalion First Sergeant at Fort Stewart and now as the Atlanta Alumni Manger for the
Wounded Warrior Project I have seen families and lives ripped apart and ended when mental health care has been inaccessible or not appropriate.
Those struggling with PTSD or with combat-related depression or anxiety can’t always pinpoint its origin. But in my case, I’ll never forget kneeling in the middle of an intersection in Kirkuk, Iraq holding one of my Soldiers as blood flowed from his nose and ears. He was trying to say something to me but the blast left me unable to hear him. I looked up and hundreds of Iraqi’s were converging on our position! One month later I returned from combat in Iraq to bury my 16 year old son, Jonathan Jamal Brown, who had been killed by an elderly driver. I was emotionally devastated but I had to be there for my wife and the entire family. I couldn’t allow myself to process the scope of my own psychological wounds. I had to be the strong one. In my mind that didn’t include asking for help.
I immersed myself in my new role at the Warrior Transition Battalion but did not do everything I needed to take care of myself or my family. I didn’t realize how hard it would be to cope with wounds no one could see. As a leader I repeatedly told my Soldiers that asking for help showed strength not weakness. Eventually I began to realize that I was not heeding my own advice and that I needed to ask for help.
There are countless stories of warriors and families who suffer alone and never ask for help but the ones that concern me the most are the ones we are here to address today. The rising suicide rate alone argues for more attention to evidence that a majority of soldiers deployed to Afghanistan or Iraq are not seeking the help they need. While stigma and organizational barriers to care are cited as explanations for why only a small proportion of soldiers with psychological problems seek professional help, soldiers’ negative perceptions about the utility of mental health care may be even stronger deterrents. This may be a bigger challenge than the VA alone can handle, Mr. Chairman, and Wounded Warrior Project agrees with your view that community partners have much to contribute.
Veterans who DO seek care from VA for war-related mental health problems have benefitted from this Committee’s oversight and legislative work. For example, your focus on unreasonable waiting times for needed mental health care led VA to increase its mental health staffing. Nevertheless, my teammates at WWP and I still see gaps in VA’s efforts to provide mental health care, gaps that are also evident at the Atlanta VAMC.
I do want to acknowledge Director Wiggins’ efforts to improve mental health care in Atlanta, but believe that there is still a long way to go. I continue to hear from our warriors about difficulty getting appointments when they need them, about being handed from one clinician to another, and about difficulty in developing rapport with their providers. Equally troubling, the experience of many warriors in the area –whether they are being treated by VA clinicians or VA contract providers -- is that they are too often offered medication to ease symptoms rather than provided talk therapy that might help resolve their deeper problems. Group therapy is offered, but it often takes extensive time in individual therapy before a warrior with severe PTSD is ready for and can benefit from group therapy. The upshot is that medication seems often the only treatment being provided.
I’d like to draw on a personal experience to illustrate the dangers of medicating individuals without providing accompanying therapy. I had a Soldier in the WTU at Fort Stewart, GA (FSGA) who was struggling with PTSD and overdosed; after two months of inpatient rehabilitation elsewhere he returned to FSGA. Soon after, his squad leader took him to the hospital because he was complaining of severe pain. They prescribed Codeine and sent him back to the barracks. I assigned a roommate/battle buddy who was a good Soldier to keep an eye on him but that night he took the Codeine pills, crushed them up and injected it. He died as a result. In questioning what I could have done differently, I came to realize how devastating PTSD can be, and how one must deal with it early on. Despite the many hours I spent trying to help him, the medicine that was continuously prescribed became a weapon he used to end his life. I struggle with the question, did I build a solid relationship with my Soldier or did we simply mask a serious issue by medicating him? Tragedies like this underscore why this hearing touches home for me and why it’s so important that we do all we can to assist these warriors to combat the devastating invisible wounds of war.
Let me draw on the experiences of a few of the many warriors with whom I’ve worked to sketch the outlines of some of the other problems that I think still need attention at VAMC Atlanta.
Joe Caley is a severely wounded retired Army captain who has attempted to get needed mental health care from VAMC Atlanta. He reports having been billed for care after his VA case manager referred him to a local health agency, and of receiving counseling at VA from two very inexperienced interns. He’s understandably further frustrated by having his primary care manager offer nothing more than medication and the advice to “develop coping skills,” and at being referred to a VA provider in the women’s health clinic whose specialty is women’s sexual trauma.
Joe LaBrenche, a veteran who had been treated at VAMC Atlanta, hasn’t seen his psychiatrist in a year, yet continues to receive medications that the provider prescribed but that he is no longer taking.
Let me emphasize that providing effective mental health care requires building a relationship of trust between provider and patient. Developing that kind of bond takes time and work. Certainly it can’t be achieved if there isn’t ongoing, sustained continuity of care. Too often, that is not our warriors’ experience at the Atlanta VA, a medical center that seems to have troublingly high turnover. To illustrate, another veteran, Jason Bush, reports that within a 3 1/2 year period he was seen at the Atlanta VA by three different psychologists, as well as different psychiatrists and social workers. Jason said that having to retell difficult war-zone experiences to a total stranger each time only exacerbated his symptoms.
It not only takes time, but some expression of caring to win a warrior’s trust. This is particularly true for those with PTSD, who may have been fearful or hesitant to seek care and likely remain anxious or wary. Rudeness, insensitivity, and disrespect – whether from a clerk or a clinician – certainly undermines the relationship you would hope would be established. A veteran with PTSD who was seen for the first time just last month by a mental health provider at the Atlanta VA left with the feeling that the provider “just wanted to get rid of me.” The warrior told me that the provider never introduced himself, didn’t try to build any kind of relationship, and “when I broke down during the meeting didn’t offer me a tissue or show any empathy.” He left feeling more depressed and broken than before. Understandably, this kind of experience would cause a veteran to lose hope and confidence in VA mental health care. Yet it is altogether different from the empathetic care I received as a polytrauma patient at the Washington, DC VA Medical Center as recently as last year.
Overall, the experience of our warriors -- who are still waiting too long between appointments and who are too seldom getting needed individual therapy – suggests that the Atlanta VA still needs additional mental health staff. But the goal cannot be simply to hit an arbitrary staffing number. The goal has to be to provide timely, effective mental health care. As I attempted to suggest in my remarks, providing effective mental health care is not just a phrase. It means more than simply providing medications to a warrior struggling with PTSD. It does have to start, though, with establishing a relationship of trust between provider and patient. That can’t be accomplished where there’s frequent turnover and no continuity. This (or any other) facility cannot expect to provide warriors effective mental health care if it entrusts that care to clinicians who don’t have experience with PTSD; who don’t understand military culture or the combat experience; who cannot communicate empathetically; or who aren’t given the opportunity to exercise good clinical judgment. In fact, effective mental health care is not solely about clinicians. It is also about instilling a culture of good customer service and accountability throughout the facility. Without that, no institution can thrive or provide good care.
Finally, let me suggest that the concerns I’ve highlighted are not unique to Atlanta VA or even to VISN 7. Based on discussions with Wounded Warrior Project staff around the country, I'm concerned that many of the barriers Georgia warriors are facing in trying to get effective mental health care exist at other VA facilities.
I understand that VA leaders here and in Washington have been working to make improvements. But I think there’s more to be done here in Atlanta and nationally to close gaps in VA’s mental health system. I do know Wounded Warrior Project is eager to work with the Committee and with VA to help in that important work. I’d be happy to answer any questions you might have.
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