Nicole L. Sawyer, PsyD
Chairman Miller, Ranking Member Filner and Members of the Committee:
Thank you for inviting me to participate in this important discussion regarding the “quality versus quantity” dilemma facing VA mental health care.
I want to convey my appreciation for the efforts of this Committee and its clear commitment to the mental health care of our veterans. I recognize that mental health is only one of the vast concerns under your authority and I value your diligence in this matter.
I am a licensed clinical psychologist with a primary focus on the treatment of trauma in both the veteran and civilian population. In addition to having worked at a VA medical center, I have worked in a number of clinical settings including federal prison, an urban psychiatric inpatient facility, a college campus, two community mental health centers, and currently in my own private practice where the majority of my caseload consists of combat veterans and adult survivors of such traumas as childhood sexual abuse, domestic violence and sexual assault.
In addition to my clinical practice I am an appointed member of the New Hampshire Legislative Commission on (military service-connected) PTSD and TBI (SB102), an active member of the New Hampshire Psychological Association Continuing Education Committee, and I am also a training board member and mentor for psychology interns and post-doctoral fellows working in my local community mental health center.
In October of 2009, in addition to my established private practice, I took a part-time position as the Local Evidence-Based Psychotherapy Coordinator for the mental health service line at the Manchester VA Medical Center in Manchester, NH. My job was to coordinate clinician training and implementation of the Evidence-Based Psychotherapies (EBPs) the VA had been rolling out since 2005. I soon found that I needed to be more involved with the structure and function of the service to do my job effectively, so I took a significant role in the Mental Health Systems Redesign Committee and began working on several projects important to improving the function of our service line and thus the application of EBPs in our clinic. In these roles I had the opportunity to work closely with our veterans and also work intimately with the clinicians on the service. I met with clinicians regularly, both formally and informally, to discuss their needs as providers and the problems they were encountering clinically and with regard to self-care. In addition, my roles brought me into close and frequent contact with the leadership of our mental health service where I worked to get training opportunities approved and lobbied for clinic and clinician availability to provide the treatments required by the Uniform Mental Health Service Handbook. My role also required at least monthly contact with other EBP Coordinators in the network and nation-wide as well as attendance at required conferences and trainings that brought all of us together to discuss the successes and failures we were facing at our respective facilities.
Due to increasing ethical concerns about the care and treatment of our veterans in Manchester, I chose to resign my position this recent February. I hope to share with you here some of the concerns that led to this difficult decision, as well as the impact that VA culture and common practices have on the ability of dedicated clinicians to provide quality mental health care to our veterans.
PTSD and the Veteran’s Dilemma
Many of the men and women that cross the threshold of a VA medical center have been faced with decisions, and taken action, on matters far out reaching the imaginations of most. Many have made choices, and followed orders, that carry weight impossible to endure alone, though they try. For most, the decision to seek mental health treatment is an admission of failure, an inability to “hack it.” For many, the decision feels humiliating and shameful; it is the admission of weakness and the declaration of vulnerability.
Many combat veterans spend years trying to cover their invisible wounds; they carefully tend the scabs they have created to protect those exposed places. Many of the symptoms of PTSD are reinforced through misguided attempts to tend and protect their mental injuries. They may avoid things that remind them of experiences and actions they would rather forget. They may push loved ones away in order to ensure no one sees their weakness. They may drink to numb the memories, the nightmares, and the pain. And tragically some take their own lives to escape the hurt, or to protect others from the hurt that they believe they will inevitably cause.
“If she only knew…” is an all too common phrase I hear in my therapy sessions with combat veterans. The deep belief, and fear, that if others, especially loved ones, “knew” what they had done, they would no longer love them. They would be ashamed, angry, and worst of all, afraid of them.
Most of us have only the vaguest sense of the experience of combat and war. The successful military leaves its civilians largely ignorant of war’s horrors. Combat veterans are no longer ignorant, but try to play along, because for them, even at home, the job never ends.
Entering into mental health treatment is wrought with gut-wrenching decisions. Admitting the need for help is the first one, making the telephone call is the second, showing up for the appointment is the third; but the fourth is the heaviest of all, speaking the pain.
Endless research, and certainly my experience, informs me that the closer together decisions 1 through 3 occur, the more likely the veteran will commit to the task. This is not rocket-science: the more rapid the decision-making process the less likely any of us are to let our doubts and fears derail us. But VA health care facilities too often fail our veterans before they are even faced with the critical fourth decision – unburdening themselves of the trauma they have experienced. This was clearly demonstrated in the recent OIG report that identified the lack of timely access to mental health care, resulting in a majority of veterans having to wait more than 50 days to begin treatment.
The Fourth Decision: Speaking the Pain
In my experience, and from my perspective, nearly 70% of the work of combat trauma treatment is in the telling. The telling doesn’t have to be to the therapist, though it often is at first. But the telling must occur. Speaking the story, the pain, the regret, the guilt, and the shame that are fixed to the experiences that drive a veteran into treatment marks a beginning on the road to recovery, but it is NOT the beginning of treatment.
Treatment begins long before the story is told. It begins with trust. Our veterans must trust in the system meant to serve them, trust in the process of therapy, and trust in the clinician assigned to their care.
Trust for the combat veteran does not come easy. Trust is the belief that one’s story will not be judged, that the individual’s feelings will be validated and accepted, and that despite having spoken one’s pain to another soul, the veteran remains in control of that information. For a person who has done things, seen things and felt things that – if they had occurred at home – would be considered monstrous and evil, trust is a myth. Don’t get me wrong, a soldier knows trust, he knows what it is to believe that the person next to him cares as much about his life as he does, but to trust in a person who does not share your pain is a risk exceeding all manner of bravery. Fear of judgment tends to lead the pack of fears held by those considering mental health treatment. They fear that their actions and the feelings attached to them are rare and will be misunderstood by those unfamiliar with war.
Most VA clinicians are ready to hear the pain. They are well trained, dedicated, committed and passionate about veterans. They understand the fears and reservations and are prepared to knock them out at a pace that provides safety and comfort for the veteran sitting across from them. Most do not know the pain themselves, but they know what it takes to connect with their veterans and they know what it means to trust.
But trust takes time, and time is NOT what most VA clinicians have when it comes to the treatment of their veterans.
The Clinician’s Dilemma: Professional Ethics or Performance Measures
Mental health is subjective. It is not easily defined and nearly impossible to measure. It does not fit neatly into a medical model the way the diagnosis and treatment of hypertension or diabetes often does, and the stigma associated with the need for care is nearly unmatched by any other health issue. But the VA, like most managed care organizations, attempts to squeeze mental health care into a medical framework. Inevitably, corners are cut in order to make it fit.
Psychotherapy is a process, not a prescription. It is work that takes time and builds upon the successes and failures of the previous sessions, and life lived in between. The professional psychotherapist is trained to help the patient identify needs, feelings, and goals that are often hidden or buried under old habits, experiences, and beliefs about themselves and the world. We are all shaped by our experiences and we all develop methods for understanding and coping with those experiences, for better or for worse. For some, our strategies for coping and understanding lead us astray and we find ourselves drifting or trapped in patterns that are harmful and destructive. Psychotherapy is intended to steer us back on track with new strategies and better understanding that will lead to acceptance. Some types of psychotherapy are strictly guided and directed, other types are more evolving and flowing; both have their place in quality mental health care, and both require the patient to trust in the process and in the clinician, to be successful.
The VA struggles to understand and value the importance of trust in the success of mental health treatment. We all value trust in our lives. We trust our children with babysitters, we trust our accountants with our money. We took time to develop trust in these individuals. Why is it not obvious and a priority to value the development of trust in the service of mental health treatment? It is not a difficult task to achieve, hire competent staff and give them the time to do their jobs well: trust will follow.
Given a small mental health staff relative to the ever-growing numbers of veterans seeking mental health care, the dedicated clinicians with whom I worked at the Manchester VA Medical Center faced a daily ethical dilemma: the veterans sitting before them were often in great need, and might be motivated and anxious to open up old wounds, air them out, and begin the healing process. But often, the clinicians could not join them in this journey. Ethically, they could not rip open those wounds. Faced with a patient caseload that was growing exponentially, and no open appointments in sight, that clinician could not, and rightfully would not, open a wound only to let it fester untreated for the weeks or months it might take to see that veteran again.
As I said, psychotherapy builds upon the successes and failures of the previous sessions; it requires consistency and predictability in scheduling and frequency of appointments. Trauma cannot be treated haphazardly based on random blocks of availability. Trauma treatment demands a session every week or every other week. Too much time between sessions allows suffering to linger too long after wounds have been opened. Too much lingering leads to re-traumatization and bolstering of the negative patterns the treatment is intended to dismantle.
It is apparent that at many facilities across the country, VA clinicians are overrun with veterans in need. Mental Health Service Lines are pushing as many veterans into clinician schedules as possible to meet their performance measures, but those veterans are not getting effective treatment. Effective treatment takes time. It requires a full and timely evaluation of needs, a chronic and nationwide deficit noted by the recent OIG report. It requires a frequency of sessions in a timely manner consistent with the clinical needs identified by that full evaluation, another chronic deficit noted by the OIG. It requires trust and predictability. Too often, under the circumstances which VA facilities and mental health clinicians are working, an emphasis on addressing “quantity” is overtaking a commitment to the quality of treatment.
The effects of a “quantity over quality” approach to mental health treatment has obvious and not-so-obvious repercussions for veterans. Some veterans cling to the hope for years that somehow those randomly occurring sessions with their therapist will help them find relief from their demons. They arrive for every appointment, but as I have discussed, little in the way of demons can be explored. Others drop out quickly, angrily muttering about the “waste of time” and conclude that therapy can’t help them. Often, they never return, to the VA or elsewhere, for mental health treatment. But what is most tragic is that many of those veterans blame themselves for not getting better. Like most people, they do not know what effective mental health care is supposed to look like. They assume, deep in that place where their guilt and shame lay, that they have failed to get better, that they are too far gone to be helped. I have heard those words from the mouths of the veterans I have had the honor to treat, on the off-chance that they gave psychotherapy one more try.
Caseload and Productivity
Staffing is an obvious weakness in VA mental health care and Secretary Shinseki’s announcement last month of 1900 additional mental health staff is a welcome attempt at strengthening this service. But how do we know if 1900 is enough?
In order for a service to be able to evaluate its need for staff and resources it must be able to assess the demand on its clinicians. The VA, however, lacks any definitive expectation for clinical productivity. Without such parameters it is impossible to identify a clinician’s caseload as “full” and therefore it is impossible to determine if the flow of veterans into the service exceeds the capacity of the clinic. Without this critical information a service struggles to know how many clinicians it needs to meet the demand.
Determining clinician caseload is exceedingly important and must be a priority for VA. Community mental health clinics and other mental health facilities, including group practices in the private sector have defined the expectations for their clinicians. The factors that go into making these determinations exceed the scope of my testimony, but the benefits to clinicians, patients, and to organizations are clear. When a clinician has a productivity expectation, that is, a clear expectation of how many hours per week he or she is expected to be providing direct services to veterans, he or she can build into their day the time necessary to meet the administrative demands essential to effective treatment. The clinician can plan for writing of session notes, treatment plan reviews, formal consultation with other providers on a case, and returning patient phone calls. The clinician might even have the flexibility to see more urgently, an established patient who is on the verge of a crisis, and stave off an emergency. All of the tasks I noted here are basic requirements of effective mental health care. They are tasks demanded by the ethics that govern all mental health professions, and yet, in my experience, they are seen as luxuries at the VA. These important tasks are given no priority because the system relies on so-called “workload” data, and this important work is not easily captured.
When productivity for a clinician is defined, a caseload definition easily follows. The size of a clinician’s caseload can be somewhat flexible when consideration is given to the intensity of treatment needed by each veteran. When a clinician’s productivity is measured based on the number of hours they spent providing therapy that week, the caseload is defined by how many veterans that clinician can treat in a clinically responsible way. For example, in a community mental health center in which I worked, clinicians in the adult outpatient department were expected to provide 22 hours of psychotherapy per 36 hour work week. This productivity expectation rounded out to roughly 40 patients on a full-time clinician’s caseload. The caseload would inevitably be composed of some patients in need of weekly sessions, some in need of every other week sessions, some coming only for monthly maintenance check-ins and still others who were not yet committed to a treatment schedule. The challenge for the clinician and the service was to juggle the number of outgoing (discharged) patients who had achieved their goals and were no longer in need of services with the number of new patients to accept into their caseload. This particular mental health center simply required all clinicians to conduct two “intakes” per week to be included in their 22 hours of productivity. It wasn’t a perfect system, but it provided an access expectation along with a productivity expectation that easily communicated our staffing needs and allowed us to prepare for and predict seasonal influxes of referrals. In contrast, at the Manchester VA and other facilities, a clinician could easily have hundreds of veterans on his or her “caseload.” Caseloads grew exponentially for a number of reasons: among them, 1) Incoming veterans were doled out like cards in a deck with no regard for the number of veterans each clinician was already trying to serve, no regard for availability of appointments, or expertise in the area of need. 2) When a veteran is only able to be seen on a sporadic basis with weeks and even months between appointments, psychotherapy is impossible and little clinical progress is made. With little clinical progress veterans do not achieve their goals and/or find relief from their symptoms, and without these markers a clinician cannot effectively discharge veterans from care. 3) Chronic understaffing, clinician turnover, and facilities refusing to backfill positions lead to other clinicians having to “pick up” hundreds of veterans left abandoned when a clinician resigns.
This lack of administrative management of caseload interferes with the quality of care a clinician can provide. While trying to attend to the veteran in front of them, clinicians are forced to think about how far out they are booked before asking a question, challenging a thought, exploring a perception. Knowing that the veteran is not likely to make his or her way back into their office for several weeks, if not months, is enough to derail what might have been a poignant intervention with big potential for healing. Clinicians are virtually gagged under such circumstances and stressed by the helplessness they face with unfettered inflow of veterans and minimal potential for outflow. This ongoing experience creates a chronic sense of failure and undermines the expertise and skill required to be an effective psychotherapist.
In short, development of productivity expectations and clinician caseload definitions are essential to the accurate determination of staffing needs at the facility level. Without this data there is no way to determine if 3, 5, or 20 additional clinicians will be enough to meet the demand of an individual mental health service. And without these parameters, there is no way a clinician and a service can ensure adequate frequency and timely access for a veteran to get the kind of care they deserve.
Why VA Can’t Fill Vacancies
Veterans, particularly combat veterans and victims of military sexual trauma, are an intense population to treat. From my perspective the rewards are unmatched, but in order to reap the rewards a provider has to be in a position to help.
The VA has 1500 vacant mental health positions for which they are currently recruiting. Secretary Shinseki recently approved 1900 more positions. I have already discussed the difficulty in knowing if this number will be enough, but one can reasonably ask how VA will fill these new positions when 1500 positions are currently sitting empty, and have been for months and even years.
But this is not the only pertinent question. Many VA facilities across the nation simply do not have space for more clinicians. Buildings are outdated, space is poorly distributed among specialty departments; services have simply outgrown their walls. At Manchester, for example, clinicians hired recently spend time dragging carts full of paperwork and other necessary resources around the hallways because they lack offices. They show up to work each day unsure whose, if anyone’s, office they might be able to use for the afternoon or maybe for an hour. This is not simply inconvenient, unprofessional and demeaning for the clinician, but it has a significant impact on the patient. Continuity and predictability are important aspects of quality clinical care. In particular, safety in their space and predictability in their environment are important to many veterans struggling with PTSD. Attending therapy sessions in a different office, possibly on a different floor of the building, every time they arrive, is distressing and can impede progress, possibly even contribute to abandonment of treatment. The lack of space is a significant barrier not only to quality care for veterans, but for the hiring and retention of staff.
Psychologists and psychiatrists, in particular, have among the highest turnover rates in the VA for mental health service. These higher rates are likely a result of the pay versus “hassle” ratio that is difficult to overcome in the current VA system. VA compensation for psychologists and psychiatrists, in most regions, is comparable, if not less, than what the same professional could make in another facility or on his or her own. It is not surprising that some psychologists and psychiatrists will choose to go elsewhere for employment. Those that do choose to work for the VA often become overwhelmed and frustrated by what some feel are ethical compromises and minimal respect.
Clinical social workers, on the other hand, face a different dilemma. VA compensation for a clinical social worker, in most regions, is well above, even double, what he or she could make at another facility in the community. The compensation can become a trap for these dedicated professionals. Seeking employment elsewhere is not typically an option but the chronic disrespect and ethical compromises some experience lead to burn-out and high levels of personal stress.
Much of the stress and disrespect felt by many clinicians stems from the very limited clinical independence most are afforded. In most facilities, clinicians have little or no control over their schedule or how their time is allotted, have no control over their caseload, and are required to provide services and use methodology that they believe clinically inappropriate for their veteran. And worst of all, many VA mental health clinicians must set aside their own clinical judgment in response to the overriding requirements dictated by Central Office performance measures and other mandates that direct how veterans are to be treated. The need to meet numbers motivates facilities to abandon some treatment modalities in favor of others, regardless of the clinical indication for the veteran. Clinicians are generally helpless to fight against this, though they try, as many clinicians at my facility did. This can be humiliating for a mental health professional with an advanced degree, passion, and experience in helping those in need.
Without a real effort to address these cultural issues, the VA will be hard pressed to hire and retain the quality professionals our veterans deserve.
In conclusion, I want to thank the committee again for the opportunity to share my experience and insights. I hope that if there is anything I have communicated here, it is that quality care – and by that I mean effective care – must not be sacrificed for quantity. VA has a responsibility to provide veterans timely, effective mental health care. Among the critical steps it must take to meet that responsibility is to establish a productivity and caseload model for mental health clinicians and ensure that adequate space is available to provide treatment. But it must go further: in raising the standard of care, it must also reinstate trust – a critical element in making VA a place where veterans in need want to get their care, and where dedicated, skilled clinicians want to be employed.
I am happy to answer any questions you may have.
Dr Sawyer has not received any federal grants or contracts, during this year or in the last two fiscal years, from any agency or program relevant to the subject of this May 8, 2012 hearing.