EXPERT ANALYSIS AT THE APA ANNUAL MEETING
ATLANTA (FRONTLINE MEDICAL NEWS) – It may be time for the U.S. Department of Veterans Affairs’ Veterans Health Administration to consider new ways of integrating its approaches to mental health care to better serve its patients, Dr. Harold Kudler said at the annual meeting of the American Psychiatric Association.
The VA’s original mental health program began as one designed to bridge a gap in services for the thousands of American veterans in need of psychiatric care at the end of World War I. The program, as promoted by Dr. Thomas Salmon, involved the concept of mental hygiene, which encompasses a dynamic balance between personal, environmental, and biological factors, and includes the possibility of recovery.
However, the release of the DSM-III in 1980 – which established the diagnosis of posttraumatic stress disorder – marked a shift toward the “medicalization” of mental health. This medicalized approach largely left the person, the family, and the community out of the mental health care equation, according to Dr. Kudler, adjunct associate professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C.
Readjustment Counseling Services (RCS), also called vet centers, emerged as an answer to this problem.
“Concurrent almost exactly in time with the release of DSM-III and its medicalization and inclusion of PTSD was a rising awareness of post-deployment mental health issues among Vietnam veterans in very human terms,” explained Dr. Kudler, also chief consultant for mental health services at the Veterans Health Administration. “As VA medical centers [VAMCs] embraced the zeitgeist of medicalizing mental health, the vet center system was designed to engage veterans on their own terms rather than in medical terms, in very deliberate ways.”
Readjustment Counseling Services provided a critically important alternative to the VAMCs, as they approached deployment mental health in personal, family, community, and cultural terms, he said.
Vet centers are “specifically not medical,” Dr. Kudler said, noting that they are physically separate from VAMCs, have separate administrative and fiscal structures, have separate training and systems of records, and involve different paths for different veterans.
He described these differences as “good fences,” each of which helped to establish the vet centers as “a critically important pathway for veterans of Vietnam and other military operations before and since.” Still, the emphasis on distinguishing vet centers from VAMCs may reflect “the underlying tension of a conceptual bifurcation in the VA’s approach to deployment mental health, which is rooted in the debates of late 20th-century mental health and continuing today,” Dr. Kudler said.
Emphasis on evidence
The “essential missing link” in the VAMC approach is the therapeutic relationship. That is, the VA’s Clinical Practice Guidelines reflect “landmark success” in identifying and disseminating evidence-based best treatments. In fact, the VA is recognized by the Institute of Medicine as a world leader in training its own mental health staff in evidence-based treatment for PTSD, he noted.
But most evidence-based treatments disseminated by the VA are manualized therapies, such as Prolonged Exposure and Cognitive Processing therapy. Training typically focuses on mastering specific skills and maintaining adherence to the manuals rather than on the strength and nature of the therapeutic relationship, and on the disciplined assessment and management of the therapeutic relationship as a key component of psychotherapy, he said.
The APA Interdivisional Task Force on Evidence-Based Therapy (Divisions 12 & 29) addressed the matter of the therapeutic relationship and concluded that the relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment, and that it contributes at least as much to the success or failure of treatment as does the particular treatment method.
The task force stated that practice and treatment guidelines should address explicitly therapist behaviors and qualities that promote a facilitative therapy relationship, and that efforts to promulgate best practices or evidence-based practices without including the relationship “are seriously incomplete and potentially misleading.”
“And I would just add, unscientific,” he said.
“The VA could significantly advance the field of mental health by modeling integration of EBTs [evidence-based treatments] and bringing attention to the therapeutic relationship, and it needs to be built into our clinical practice guidelines,” he said, noting that this suggestion is based on more than a century of research and clinical experience, and that addressing the therapeutic relationship in the guidelines will be modeled worldwide and will result in insurance companies “paying for people to pay attention to the therapeutic relationship.”
VAMC and vet center staff could enhance the effort through a convergence of their conceptualizations, engagement strategies, and approaches to care, he added.
He stressed that he is not suggesting a merger of the two, but rather that the VAMCs learn from what has made the vet centers so successful, so that clinical outcomes at the VAMCs can be optimized.
Start with the RCS’s highly individualized, culturally competent approach to veterans, he suggested, adding that practical steps toward this approach might include:
• Joint training of VAMC and RCS clinical and administrative staff, which could raise awareness of history, functions, and opportunities for collaboration.
• Creation of new venues for formal and informal discussion between RCS and VAMC teams about shared cases while preserving separate record systems.
• Development of formal sharing agreements between VAMCs and vet centers to ensure that veterans have needed access to the unique benefits of each program, with coordination between programs.
“These recommendations restore balance and shared strategic direction of the VAMC and vet center programs,” he said, noting that they also would “bring us full circle to Salmon’s vision of mental hygiene in which veterans, families, communities, health professionals, health systems, policy makers, and government at all levels partner to recognize and address mental health problems, deployment-related and otherwise, and – whenever possible – prevent them. Such an integration would truly promote veteran-centered care,” he concluded.
Dr. Kudler reported having no disclosures.