The Department of Veterans Affairs (VA) operates the largest integrated healthcare delivery system in the United States. Counseling has had an important and increasingly prominent role in the VA healthcare system since its establishment over 60 years ago. Administered by the Veterans Health Administration (VHA), the VA healthcare delivery system contains the nation’s largest mental healthcare system. The VA is the largest provider of mental health services in the country and is among the nation’s largest employers of psychiatrists, psychologists, social workers, and mental health nurses.
To meet the diverse psychosocial needs of veterans, the VHA provides a full spectrum of counseling services, including individual, group, and family psychotherapy; intensive case management; vocational rehabilitation; medication management; psychoeducation; skills training; psychological, cognitive, and neuropsychological assessment services; and psychosocial rehabilitation (PSR) for veterans with serious mental illness. Counseling services (and related psychological services) provided by VHA emphasize evidence-based approaches to a variety of mental health and substance use disorders (including comorbid conditions) and behavioral medicine conditions (e.g., smoking cessation, sleep disturbance, weight management, medical adherence) and to facilitate readjustment to and maximum functioning in the community.
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Counseling services are provided to veterans in both VA medical centers (VAMCs) and in VA community-based outpatient clinics (CBOCs). As of January 1, 2007, there were 155 VAMCs and over 700 CBOCs. In addition, a range of readjustment counseling and outreach services (e.g., bereavement counseling, military sexual trauma counseling, vocational counseling, referral services) are provided to veterans and eligible family members in 209 VA Vet Centers located in all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.
Continuum of Care
Counseling services in VHA are provided across the full continuum of care, including inpatient and residential settings, outpatient mental health and behavioral health settings, and general and psychiatric long-term care settings. Within the inpatient sector, the VHA provides a large array of individualized counseling and related services. In addition to services provided in general and psychiatric hospitals and psychiatric intensive care units, the VHA provides 24-hour therapeutic treatment in psychosocial residential rehabilitation treatment programs to patients with severe mental health symptoms requiring care in a residential setting. Mental health residential treatment services are also provided in VA domiciliaries, which provide homeless veterans with coordinated rehabilitative clinical care in a structured residential treatment setting. In addition, a variety of counseling services are provided to older and younger veterans in VA nursing homes and other long-term care settings as well as in hospice and palliative care settings.
In recent years, the VA has placed increasing emphasis on community-based mental health care and support services in an effort to promote independence and recovery and reduce the focus on acute stabilization and rehospitalization, even among the most seriously mentally ill veterans. As part of this effort, the VHA has established the Mental Health Intensive Case Management (MHICM) program, which provides evidence-based psychosocial and community support services to veterans with serious mental illness, based on the Assertive Community Treatment (ACT) model. MHICM teams travel to patient homes and throughout the community providing a variety of individualized services to improve patient functioning, community adjustment, and quality of life as well as to reduce hospitalization.
Outpatient counseling services are provided in a variety of specialty settings, including those for mental health, behavioral medicine (e.g., psycho-oncology, smoking cessation), primary care, and rehabilitation (e.g., spinal cord injury, blind rehabilitation). As a comprehensive integrated delivery system, the VA provides unique opportunities for providing interdisciplinary care, which often leads to enhanced safety, efficiency, and clinical outcomes. In many of the outpatient and inpatient settings where counseling services are provided, VA mental health staff serve as active, fully integrated members of treatment teams. This model of care is different from more traditional, fragmented approaches to providing counseling services. The VA’s system-wide electronic medical record system further promotes professional coordination and collaboration in the delivery of care.
Research and Training
In addition to providing health care to veterans, a major part of the VA’s mission involves conducting clinical research and providing education and training to healthcare professionals and trainees. These functions have become major VA roles in the area of mental health. The VHA is currently a national leader in research on mental illness and mental health treatment. In 1998, the VA established the first three mental illness research, education, and clinical centers (MIRECCs) to conduct clinical research and provide education to promote best practices in VA mental health care. There currently are 10 MIRECCs, each with a specific area of focus (e.g., substance abuse, causes of serious mental illness, schizophrenia, suicide prevention). In addition, VA geriatric research, education, and clinical centers (GRECCs), which now total 21, work to promote quality of life and care for aging veterans. The VA National Center for Posttraumatic Stress Disorder (NCPTSD) promotes research on and treatment of PTSD and stress-related disorders and is widely recognized as a world leader in PTSD research, education, and training. In addition, the VA has several mental health Centers of Excellence that conduct cutting-edge research in mental illness, posttraumatic stress, and substance abuse.
The VA is the nation’s largest provider of clinical training in mental health care delivery, offering practicum training, predoctoral internships, residencies, and postdoctoral fellowships at VA medical facilities throughout the country. Between 1946 and 2005, the VA funded approximately 36,000 training positions in psychology alone. During the 2006-2007 training year, approximately 11% of all psychology predoctoral internship positions and 11% of postdoctoral fellowship positions were in VA facilities.
The VA’s roles in conducting innovative clinical research, delivering high-quality care, and providing broad clinical training are enhanced by the agency’s close working relationship with the academic community. VA medical centers throughout the country collaborate closely with universities and academic medical centers in each of these three areas. The intellectual and resource partnership has spawned a very successful long-term and mutually beneficial relationship.
Transformation of Care
To most effectively meet the current and anticipated mental health needs of veterans, the VA is in the process of transforming its mental health care delivery system. In April 2002, President George W. Bush’s Executive Order 13263 created the President’s New Freedom Commission on Mental Health and charged it with conducting a comprehensive study of the U.S. mental health care delivery system and with providing the president with recommendations for improving the service system. In July 2003, the commission issued its final report, in which it called for a transformation in the nation’s mental health care delivery system to improve service access and quality. In July 2003, the undersecretary for health of the VHA charged a workgroup to review the New Freedom Commission’s final report “to determine the relevance of the Commission’s goals and recommendations to veterans’ mental health programs and to develop an Action Plan that is tailored to the special needs of the enrolled veteran population.” This effort led to the development of the VHA action agenda: “Achieving the Promise: Transforming Mental Health Care in America.” In June 2004, a mental health task force was established to operationalize the goals and recommendations outlined in the VHA action agenda. This culminated in the development of a comprehensive VHA mental health strategic plan (MHSP): “A Road Map for Transforming VA Mental Health Care.” Since 2005, VHA has implemented over 40 mental health enhancement initiatives, which directly implement key provisions of the MHSP. Among the most significant and unique aspects of the MHSP and the mental health enhancement initiatives is the focus on innovation and expanding the process of care.
In an effort to increase access to high-quality mental health services and promote care coordination, the VHA has developed a national initiative to integrate mental health services in primary care. This model of care is designed to break down the traditional “silos” of specialty mental health and primary care settings and allow highly specialized resources to be concentrated on serving veterans with more serious mental health needs. As part of the MHSP, the VHA is also promoting the delivery of evidence-based psychological treatments throughout the VA health care system. The VHA is implementing several dissemination initiatives designed to increase the availability of state-of-the-art psychological treatments for PTSD (e.g., cognitive processing therapy, prolonged exposure therapy) and other mental health conditions.
Also consistent with the recommendations of the President’s New Freedom Commission report and the MSHP, the VHA is moving toward a recovery-based model of care for veterans with serious mental illness. In the recovery-oriented treatment culture, the focus of care is on instilling hope, optimism, and individual potential through a process of psychosocial rehabilitation. Several VHA initiatives have been developed to expand psychosocial rehabilitation services throughout the VA healthcare system.
Several initiatives are also underway to reach historically underserved populations, such as individuals living in rural areas and older adults with chronic and disabling medical conditions. As part of this effort, the VHA is expanding the availability of telehealth services for veterans in remote areas and is enhancing specialty mental health staff throughout the country to provide mental health assessment, treatment, and prevention services in the homes of homebound veterans with chronic and disabling medical conditions.
Among the VA’s highest current priorities is effectively providing for the mental health needs of returning veterans serving in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) conflicts. In addition to the initiatives noted above designed to increase access to and quality of mental health services, several outreach, screening, and treatment initiatives have been implemented with a specific focus on OEF/OIF veterans. Providing individualized, effective, and accessible care to these and all veterans in the years ahead is a challenge that the VHA is actively meeting. Significantly, with the implementation of the MHSP, there has been a steady increase in the number of mental health providers employed by the VHA. As of January 1, 2007, the VA employed over 9,000 front-line mental health providers.
In short, counseling has enjoyed a rich and continuously evolving history in the Department of Veterans Affairs. Over the course of its 60-year existence, the VA has become widely recognized as a world leader in mental health care delivery, research, and training. With the nation’s largest integrated healthcare system, the VA provides unique opportunities for providing innovative, interdisciplinary mental health services in a wide variety of treatment settings. In the years ahead, the mental health care landscape in the VA will continue to evolve, as the VA works to transform the process and culture of mental health care to ensure the availability of accessible and effective mental health services for the veterans of today and tomorrow.
References:
- Association of Psychology Postdoctoral and Internship Centers. (2007). APPIC directory: Appendix. Retrieved from http://www.appic.org/directory/appendices/2006-2007_AppendicesAB.pdf
- Baker, R. R., & Pickren, W. E. (2007). Psychology and the Department of Veterans Affairs: A historical analysis of training, research, practice, and advocacy. Washington, DC: American Psychological Association.
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