Rand: Civilian mental health providers don't 'get' the military

2014-11-21T10:09:42-05:00

From: Marine Corps Times

A new survey by an influential think tank finds that civilian mental health care specialists sorely lack an understanding of military culture and appropriate treatments for service-related health care needs.

A Rand Corp. survey of 522 psychiatrists, psychologists and licensed clinical social workers found that just 13 percent met the study's criteria for "cultural competency," meaning they understood military mores, language and background, and delivered appropriate care for illnesses unique to the military, such as combat-related post-traumatic stress disorder and depression.

The results are important, Rand researcher Terri Tanielian said, because insensitivity and unfamiliarity with proven treatments may keep troops and veterans from getting quality psychiatric care.

"These findings suggest that when service members, veterans or family members seek care from providers not affiliated with the Defense Department or Veterans Affairs, they may encounter providers who are not as well prepared to deliver culturally sensitive care," Tanielian and the other authors wrote.

DoD and VA have broadened their mental health services in the past five years, with VA hiring more 3,300 mental health providers, peer specialists and apprentices since 2011.

But former troops, as well as active-duty service members and their families, often prefer to seek care outside the military and veterans health system for convenience, privacy and other reasons.

But the study found that many civilian providers are ill-equipped to handle the military community's needs.

According to the results, 70 percent of the civilians surveyed who work at a military or VA treatment center had a high degree of military cultural competency, but just a quarter of providers who are registered Tricare providers scored well.

Among those who are not working directly with troops, veterans or family members, just 8 percent scored well for cultural competency.

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In terms of familiarity with proven treatments for PTSD and combat-related mental health issues, licensed counselors scored the highest, with roughly half reporting they had been instructed on evidence-based practices.

The study found 6 percent of those surveyed had served in the military and 62 percent of the psychiatrists who participated had worked for VA at some point in their careers. Just a third of psychologists had worked for VA and only a fifth of the social workers had.

According to a new VA study, about 13.5 percent of 60,000 post-9/11 veterans screened positive for PTSD.

Another VA-funded initiative — the National Vietnam Veterans Longitudinal Study — estimated the prevalence of PTSD in combat Vietnam veterans at slightly more than 11 percent, even 40 years after the war.

At a Senate Veterans' Affairs Committee hearing Wednesday, lawmakers said they were alarmed by the report, given that Congress passed a law in August expanding access to non-VA providers for veterans who live more than 40 miles from a VA facility.

"I am very concerned about whether VA and local communities are prepared with the resources, policies and training to help veterans in serious crisis," said Sen. Patty Murray, D-Wash. "While our men and women in uniform have the courage to come forward and ask for help, VA must be there with not only high-quality and timely care but also the right type of care."

Josh Kassel, an intern for Rep. Gwen Moore, D-Wis., spoke at a press conference on the Rand study and said DoD and VA must do more to help civilian providers understand and treat their active-duty and former military patients.

Kassel said three students from his high school class school in Burlington, Wis., died by suicide after returning home from serving in the military, even though all had sought mental health treatment.

"It wasn't like I was in a super-rural town. We definitely had the resources available to help. But what is being and can be done from the Defense Department to reach out to people like my classmates and figure out what help they need and where they can get it?" Kassel asked.

Earlier this year, DoD launched an online course on military culture for health care providers.

Four years in the making, "Military Culture: Core Competencies for Health Care Providers," developed at DoD's Center for Deployment Psychology, covers four subjects: health care provider beliefs and biases; military definitions, language and culture; military functions; and the role of military ethos in health behavior.

A nationwide rollout of the course is underway, according to a Center for Deployment Health official, and health care providers can earn continuing education credits by taking it.

Telemedicine — counseling and therapy provided to patients via a computer link or telephone — also appears to hold promise for veterans in rural areas, according to research published Wednesday in JAMA Psychiatry.

A study of 265 veterans with PTSD found that 55 percent who were engaged with their providers via telemedicine received cognitive processing therapy, an evidence-based treatment for PTSD, compared to 12 percent of patients engaged in "usual care."

The results also showed that those in the Telemedicine Outreach for PTSD group had larger declines in scores on PTS diagnostic tests.

"This trial introduces a promising model for managing PTSD in a treatment-resistant population. Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD," wrote John Fortney, a researcher with the University of Washington, and others.

http://www.marinecorpstimes.com/story/military/benefits/health-care/2014/11/21/mental-health-troops-veterans-care/19324407/

Response by TSgt Private RallyPoint Member made Nov 21 at 2014 10:30 AM

2014-11-21T10:30:28-05:00

What?!?

Are they seriously suggesting that the life experiences of civilian doctors don't adequately allow them to translate the life experiences of those who volunteer to serve their country?

I am shocked, truly shocked.

The unmitigated gall of such an accusation!

Response by Maj Chris Nelson made Nov 21 at 2014 10:31 AM

2014-11-21T10:31:55-05:00

This is exactly why most vets will not talk about what they have seen/done to anyone except other vets. There is an immediate understanding, regardless of branch of service. Many people will not even tell family members for the simple reason that "they won't understand". The back side of this knife means that one of the most valuable tools, talking and releasing the issues instead of bottling them up, is not being used. Sad situation, but true. There is much that I won't talk about to anyone that is not/has not been military...and in some cases, can't discuss with those that have not been deployed. Only time will tell how bad (or if) this thought process will come back to haunt me.

Response by PO3 Laura Thompson made Nov 21 at 2014 11:28 AM

2014-11-21T11:28:06-05:00

I completely agree. I was a hospital corpsman for 10 years . I have been out for 20 years. I currently work in the health care field and I know this is a fact! Many people getting out of the military who are suffering from a number of issues like PTSD and TBI as well as MST will seek help from civilian sources and they are just not prepared to understand the traumas that military life brings.

Response by SPC(P) Private RallyPoint Member made Nov 21 at 2014 11:53 AM

2014-11-21T11:53:18-05:00

This is a civilian volunteer who specializes in helping veterans with PTSD.
services dogs truly help out with it as i've seen many vets finally come out and rejoin society after working with them. I post think link not to have people sign up, but for information on what is out there. this is based in Alaska. give them a call they can help with service dog laws and education of such. http://midnightsunservicedogs.com/

Midnight Sun Service Dogs

Paying it forward, one paw at a time!

Response by SPC Jack Hunt, JR made Nov 21 at 2014 12:23 PM

2014-11-21T12:23:03-05:00

I have news for many of you! My experience with the VA Mantal Health system hasn't been stellar. My psychologist I had regular sessions with started FALLING ASLEEP during the session. I finally told him after my last session that he should maybe eat a lighter lunch or possibly just do the job that he was being over paid for. And then he actually had the nerve to ask me if I wanted to set an appointment for the following week. I had to just walk out before I snapped on him.

Response by 1SG Michael Blount made Nov 21 at 2014 12:34 PM

2014-11-21T12:34:37-05:00

It's taken a survey nearly 13 years to figure this out?

Response by SSG Private RallyPoint Member made Nov 21 at 2014 12:46 PM

2014-11-21T12:46:34-05:00

I don't doubt this at all since we are our own sub-culture in American Society. I don't fault the mental health workers for this but for them to be successful they need to understand military culture just as if they were attempting to work with various cultures and ethnicities.

Response by SFC Mark Merino made Nov 21 at 2014 12:56 PM

2014-11-21T12:56:21-05:00

Oh boy someone just struck a nerve with Uncle Mark!!!!!

When I was looking at being medically retired soooo close to retirement I was desperate to talk to someone in my situation. I NEEDED to hear that everything would work out and x,y,z, 1, 2, 3 is coming up and is to be expected. Sorry. It was early 2008 and during the surge far too many people got pushed to the side and rolled over. Back then, once they determined that you were too far gone to remain on active duty you only had 90 days by regulation to be seperated so that the VA could start your claim. They "owed that to you." Anyone medically retired and placed into the TDRL (Temporary Disability Retirement List) during that time period has been classified as a "Legacy" (aka: not set up for success). It was war. I get it......now. Anyone with a tattoo of a Bradley on their arm and 18.5 years under their belt can pretty much be considered a lifer. Mental health issues WILL arise when they are given a pink slip and shown the door.
I went to the VA for help and as one would imagine, the waiting list for mental health care was quite long. I BEGGED them to put me in their PTSD residential program. I was told I wasn't a priority because I didn't have legal issues DUI, assault, drug charges, etc. The wait list to even do intake with the Phoenix VA was 3 months. They referred new patients to the Vet Center on the outside. I went to the Vet Center and the best they could do was to give you group therapy with combat veterans, but no individual therapy. A Vietnam era social worker is not what I needed. I tried using Tricare (still TDRL) to get individual therapy and there was no one within 50 miles who even wore a uniform previously, let alone specialize in military trauma.
Eventually, I met the criteria for the inpatient PTSD care that I desperately needed from the VA. My self-destructive coping landed me in jail. Alcohol was not my friend. If it wasn't for the PTSD program in Menlo Park, CA I'm sure none of these conversations on RallyPoint would have ever taken place. Between the alcohol, anger, PTSD, self-pity, etc, etc......I would not have lasted much longer. I am CONVINCED, that had there been intervention by a trusted therapist (for me it needed to be a combat vet doing individual therapy) the transition would have gone much smoother for me.
Veterans with combat related PTS deserve veteran therapists; they understand us. Even if they had never been in combat, they speak the same language. I am speaking from a personal standpoint. There are great civilian therapists out there and they might know more about military trauma than anyone else on the planet, but in this kid's broken mind......
I went to school for psychology because I was desperate to spare at least one person from the mistakes I had made. I worked at Fort Wainwright, AK in their mental health department (PTSD dept.) and even without a PhD, I had great success with some really hard clients. It certainly wasn't because of my vast knowledge, skills, or education. It was purely a trust and rapport that came from the bond that we all share in the military. If a service member/veteran isn't confident that their therapist has a clue what it was like to serve, it will be very hard to make progress.

Response by MSgt Rob Weston made Nov 21 at 2014 1:09 PM

2014-11-21T13:09:54-05:00

This is the main reason I have dedicated to becoming a Mental Health Counselor after I retired from the Military. I'll specialize in vets, PTSD, military families, and military personnel. It takes someone who has lived the life to understand and connect with vets. A vet taking care of vets.

Response by PO3 Sherry Thornburg made Nov 21 at 2014 1:36 PM

2014-11-21T13:36:03-05:00

Reading through the comments, I had to laugh as the sarcasm rose out of the posts like marines jumping to for an officer entering the room.

This is a serious discussion though, and the problem is serious. The study quantifies the known problem. That is important. I never went near a combat situation, but did have counseling for a short time before leaving the service. Getting a contract psychologist who understands isn't easy. I think it took three sessions or more before she had a clue what I was dealing with. If I had been paying her, I'd have felt like I deserved a refund.

Response by SPC(P) Jay Heenan made Nov 22 at 2014 4:36 PM

2014-11-22T16:36:40-05:00

Does this actually surprise anyone??

Response by PO1 Private RallyPoint Member made Nov 22 at 2014 5:20 PM

2014-11-22T17:20:23-05:00

WTF? The military needed a Rand study to figure out what every single soldier, sailor, air force puke or marine already knew for a fact? WTF...seriously?

Response by LT Clint Davis made Nov 22 at 2014 7:43 PM

2014-11-22T19:43:04-05:00

Medicine is not a perfect art. People continue to be the variable involved. Because, there is no simple answers to many of the [behavioral] health problems we seek help for, the help we seek is never cut and dry! It is never as easy as walking in and saying "This is what I have going on... fix it!"

I would also ask all of us to step back and consider all of the roles that we as professionals hold. Soldiers, sailors, airman and marines are who we call when our nation, principals and constitution need to be defended or when there are others in the world who can not defend themselves. That being said, I will not ask any of them to perform neurosurgery on me. I don't call the police when I need to put out a fire and I do not look to a plumber to change my locks.

The reason that I took the time to differentiate the different professional roles was to shed a different light on some of the statements that got this discussion started. To say that mental health professionals can't help because they have not served in the military, to me, makes as much sense as saying a surgeon can't treat a gunshot wound unless they were in the military. The military culture does cast a different light on some of the issues and how they manifest themselves as symptoms but the underlying behavioral pathways remain the same. I would also tell you [from having seen it first hand] that there are folks in the military that brought there mental illnesses with them when they enlisted or were commissioned.

SSG Private RallyPoint Member Ultimately, you have to make the choice on who and how you access care. When I made the comment about "practicing medicine" this continues to happen as long as you practice medicine. What I mean to say is even when you see a doc who has been in practice for 50 years and clearly 'knows his craft' even he will tell you that he continues to 'practice'.

Moreover, you are correct in that you are "no one's guinea pig". That too, was never a perspective I was considering when I made the comments that I did.

Response by 1SG Private RallyPoint Member made Nov 22 at 2014 7:43 PM

2014-11-22T19:43:45-05:00

It is cool with me their do not understand us that means they judge us either.

Response by SSG Leonard J W. made Nov 22 at 2014 8:54 PM

2014-11-22T20:54:04-05:00

I find it alarming that this is just now being discovered. We have been at war for 13 years and counting, and people have been shot at, blown up, and otherwise shaken from the lives that they once knew prior to serving abroad. They need help, and it starts by understanding what trauma is. Some civilians are okay, but then there are others who are more concerned about collecting a paycheck than performing the duties of the job. This is upsetting, but at least something is in progress. I just hope it leads to productive change.

Response by MAJ Robert (Bob) Petrarca made Nov 27 at 2014 10:17 AM

2014-11-27T10:17:58-05:00

You have to find the right ones. I have thankfully. When it all boils down many, "military" issues are not uniquely military. PTS & TBI for instance can happen among police, fire, medical, construction, any profession that has potential danger and possible encounter with traumatic injury or worse. People witness tragedy and death all the time. Yes our situations and circumstances can be unique - deployments, isolation away from home, combat, sea duty onboard a ship, etc. but there are a lot of similarities in the symptoms, effects and treatments.

Response by 1LT David Moeglein made Nov 27 at 2014 8:05 PM

2014-11-27T20:05:08-05:00

I just went into private practice as a Licensed Independent Clinical Social Worker. I signed up to be a Tricare provider. We recently just got a soldier referred to our practice. Tricare was very determined that the soldier see me, and nobody else. Tricare apparently is very serious about identifying which providers are veterans.

I also know that there are are service members who steer clear of the VA. I have worked with special operators who get the run around from the VA, because officially the missions they were on didn't exist. It's difficult for most civilian mental health professionals to figure out who was a high speed service member, and who is a PX ranger.

Response by 1LT Private RallyPoint Member made Nov 27 at 2014 9:18 PM

2014-11-27T21:18:09-05:00

Marine Corps Times. Don't dismiss every civilian practitioner because they may not at first seem to be culturally competent because they have not served in a search and destroy combat unit. There are many extraordinarily capable civilian practitioners who are combat veterans, have been trained by combat veterans, or have a broad enough experience with combat veterans to be helpful. In some cases it is cathartic enough just to be able to speak with another veteran or a group of veterans . . . regardless of professional competency or counseling skills. But, sometimes it helps to connect with a practitioner with extraordinary diagnostic, medication, and counseling skills to survey, understand, empathize, and help to reframe the most horrid experiences. And . . . to be very honest . . . sometimes the civilian practitioner can help us cope better with the transition back into civilian life / civilian cultural experiences.

I had a hard time coping with my combat medical care experiences . . . and with the finding my way back into personally satisfying and productive civilian life. I went for a very long time believing I was bright enough and resilient enough to find my own way in the world . . . and not trusting any man because of what I saw men do to other men . . . and not trusting any women friends because they couldn't possibly comprehend the horror of the war wounds, triage, surgery, recovery, and air evac flight environment. Indeed, the focus of the entire military psych care system was on the combat soldier . . . and there seemed to be no one and no group focused on the military medical community / care givers. In the end, after exploring the VA, military practitioners, veterans groups, I finally connected with an extremely capable civilian practitioner who took the time to learn about the military medical community / care giver experience . . . as well as a broad range of other difficult previous experiences brought into the military with me . . . and over the course of several years brought me to the point where I could not only function well in civilian circles . . . but I was able to understand, trust, and relate to men again . . . and I found personal fulfillment in serving a variety of roles in military industrial, government, and private contractor services.

The short story . . . some civilian practitioners can understand and render first rate services for active duty, reserve, veteran, and retired servicemembers. I personally look for training psychiatrists and psychologists who are faculty at major trauma centers . . . who are older / have responsibility for training many other psychiatrists and psychologists . . . and who specialize in patients who have experienced severe trauma, terror, torture, and military medical community / care giver experiences. These tend to be exceptionally smart and unusually capable practitioners.

My point is that whatever general conclusions the survey reached . . . there are many exceptions to the conclusions.

Warmest Regards, Sandy

Response by Cpl Private RallyPoint Member made Nov 27 at 2014 9:44 PM

2014-11-27T21:44:57-05:00

I dated a shrink (in training) when I lived in CA who didn't understand military life. Then she got an internship at the Camp Pendleton family counseling center. Before that, we had several arguments where she "believed" that high divorce rates were due to the service members cheating on their spouses. After a week of couples therapy sessions she apologized for doubting me when I told her that is was primarily the civilian spouses that were cheating. Without giving any details, she said every wife she counseled of an SM was cheating on her husband.

Response by PO2 Private RallyPoint Member made Nov 28 at 2014 1:45 PM

2014-11-28T13:45:40-05:00

I have seem Military and civ. mental health folks, and I have found, ALOT of military DIDN'T help me! I have a civ. mental health person for OVER 15 years! She help with my P.T.S.D., depression, O.C.D., A.D.H.D., Anxiety, and stressssss!!!!!

Response by Sgt Timothy Sigafoos made Dec 3 at 2014 2:39 AM

2014-12-03T02:39:20-05:00

The study leaves out marriage and family therapist which would make the number even higher.

I have worked in the mental health field for over eight years. From my perspective is these mental health professionals are trained to find fault in almost everything. (as evident from DSM). In the military our mindset is to find a workable solution or make the best out of situations for accomplishment of the mission be it personal or professional. This idea baffles professionals who train in the current victim focused higher education system. Out of all the people I have had the privilege to serve with I know NO ONE that is the victim and would fight the label to be call the victim. There are some that I have met in mental health that understand the situation. One therapist I spoke with while I went back to grad school name Bob was also a veteran and gave me some perspective on the difficulties I would run into entering this field.

Response by LCpl Private RallyPoint Member made Jan 4 at 2015 11:12 PM

2015-01-04T23:12:22-05:00

Civilians don't get the military period. Why should shrinks and counselors be any different?

Response by SSgt Shane Karst made Sep 11 at 2015 1:19 AM

2015-09-11T01:19:55-04:00

They don't have to "get" the military. They deal with the issues we have. Honestly, I think you're making excuses. Rape victims suffer severe trauma. Stop trying to make yourself something "special". I served in combat and it's trauma, period.

Response by CW2 Private RallyPoint Member made Sep 11 at 2015 9:43 AM

2015-09-11T09:43:42-04:00

This hits so close to home. A veteran I know, just last month, went to see a VA counselor for combat related PTSD/anxiety. This 'counselor' told the veteran that since she wasn't injured and doesn't have a Purple Heart, there is no way she has PTSD. That you only get PTSD if a specific traumatic event occurs, like if you are shot or raped. Being in Iraq for over a year and watching your buddies die around you did not qualify. They sent this veteran away in tears, telling her that her problem is all in her head. Civilians that have no cultural competency and no compassion should not be working with veterans.

Response by MCPO Roger Collins made Sep 11 at 2015 10:28 AM

2015-09-11T10:28:04-04:00

Most of the staff and medical personnel that I have encountered at our local VA Hospital are either Vets or have been working with Vets for years. It has become the workplace of choice since the deconstruction of the Private Practice profession in medicine. I just tried to find a description of just what constitutes PTSD, it would appear as if just about anything that you can think of in included. If we could only separate the real from those trying to get a permanent check from Uncle Sam. we could focus on those that have real problems. I even read on one of the military social networks how an FBMer (you know Fleet Ballistic Submarine) had bad dreams and felt like that was PTSD. When you wrap your self up in a thick steel cocoon and hide, I'm not getting it. This is the new back injury of the 21st century for those that are looking for a check. Stop it, and leave the professionals to deal with those problems that could potentially lead to suicide due to their complex mental injuries. BTW, I was permanently retired after 21 years with a back injury and turned down the payment offered by the VA. I actually had to go to great lengths to do so.

Response by SSG Ricardo Marcial made Sep 11 at 2015 2:13 PM

2015-09-11T14:13:54-04:00

I'm on my 4th doc, first 3 were just not working for me. My current doc, a civilian completely changed things for me and helps me tremendously. If your doc is not working, find one that helps you. It's that simple.

Response by MAJ Ken Landgren made Sep 11 at 2015 6:43 PM

2015-09-11T18:43:38-04:00

I concur, they don't understand PTSD so their approach will be random and ineffectual.

Response by SSgt Joe V. made Sep 11 at 2015 8:34 PM

2015-09-11T20:34:39-04:00

I went through a 45 day in-patient program in Utah called Strong Hope out of Salt Lake Behavioral Health. It literally saved my life and while civilian in name and location, the program itself is a military specific therapy program that really does focus on the individual through group and individual therapy. I can't even begin to describe how good this program is...If PTS is starting to invade your life, go here as someone that is active duty...veteran...military - you won't be disappointed. One of the main therapists is a Marine Vet that saw combat and the other main therapist is a evil little woman that has an amazing knack for pushing every button you didn't know you had. It is like the best chiropractor you have ever seen...they break you to fix you and it works. Again, can't say enough about this civilian program for the military.

Response by Cpl Sabrina L. made Oct 29 at 2015 4:54 PM

2015-10-29T16:54:18-04:00

The BIGGER PROBLEM is that most military personnel don't trust the HEALTH CARE providers from active duty and Trusting the VA is like trusting an alligator not close its jaws on you and drown you at the bottom of a swamp until you're tenderized... THE VA loves it when you don't come for care...they get paid regardless..

Response by SSG Ricardo Marcial made Jul 21 at 2016 12:19 PM

2016-07-21T12:19:14-04:00

I never spoke to a military doctor about "my problems". After my 4th and last deployment, I reach out to my bad new CO, freshly promoted to CPT, with 1 tour as an NCO and then ran away from the ranks to become a 2LT. His complete assessment of me was to "suck it up" so I would not lose my clearance. It took me 4 tries to get the right doctor to listen and understand. It's been 4+ years since my last deployment, I'm now retired, spent 1 year homeless and living in shelters, 3+ years unemployed. Even with work, a roof over my head, I struggle. But my 4th doctor keeps me in the game and life continues. It's not pretty, but I do what I have to keep going.

For those out there struggling, don't take no for an answer from the VA or anyone else. Find a battle buddy, and pick up the phone when you feel you need help, even the smallest amount of help. And for that battle buddies out there, thank you for what you do. God bless.

Response by SFC David Reid, M.S, PHR, SHRM-CP, DTM made Aug 15 at 2019 9:46 AM

2019-08-15T09:46:22-04:00

I agree that the providers outside of the VA and DOD are not.culturally sensitive to the uniqueness of the military members and their families!