Improving Veterans Affairs Services by Embracing a Communitarian Model for Mental Health Providers

The Veterans Affairs (VA) health care system currently employs over 4,400 psychologists, 10,000 social workers, and 2,900 psychiatrists. It also provides training to vast numbers of students, including over 1,900 psychology trainees, 1,100 social work students, and 3,400 psychiatry residents annually. Mental health providers who are fortunate to work in the VA system have wonderful opportunities to develop professionally, collaborate on interdisciplinary teams, learn new skills, and touch the lives of the brave men and women in uniform who have served our country. We are lucky, indeed. In addition, administrators and managers at all levels are committed to continuous improvement, exemplified by numerous national rollouts of evidence-based practices, the development of new treatment options for veterans, an immense growth in the provision of a range of psychiatric services to veterans living in rural areas through community-based outpatient clinics (CBOCs), the use of telehealth technology, and the implementation of a recovery model of care.

Nevertheless, the imminent retirement of a sizable cohort of experienced providers and an influx of new, often younger providers present a unique opportunity to focus VA’s efforts toward recruiting, developing, and retaining a healthy, productive workforce. One way to support this process is to embrace a communitarian model, in which mental health professionals engage in mutual awareness, accountability, and support.

The communitarian model

A communitarian approach to professional ethics refers to an interdependent, collectivistic mind-set wherein individual responsibilities are balanced with obligations to the community. This mind-set of interconnectedness and collaboration is exemplified by the African philosophy of ubuntu and poignantly conveyed in the Zulu idiom, “I am what I am because of who we all are” (1). According to communitarianism, to live a happy, fulfilling life, we must support each other and serve as our brothers’ and sisters’ keeper (2). In the context of the provision of health care, providers feel some “accountability for the competence and well-functioning of their colleagues; show less reticence and suffer less shame about exposing imperfections, emotional distress, and need for assistance to colleagues; and share a concern for the common good of all those served by their professional community” (3). According to Johnson and colleagues (3), this communitarian ethos should be infused in mental health professionals’ “education, training, professional ethics standards, and credentialing criteria.”

A communitarian model for VA mental health

At the VA, the current need for a communitarian model is especially great because of four factors. First, the demographic characteristics of VA providers are shifting dramatically. Large numbers of new providers are entering the workforce, some of whom have recently completed their training. VA can benefit from their energy, fresh ideas, and new perspectives. Simultaneously, some more mature colleagues who have the benefits of experience and institutional knowledge are beginning a transition to retirement. Both groups need each other. As happens informally in some facilities, creating opportunities for mutual support and mentoring are vital.

Second, working at the VA at this time has some challenges. Large numbers of veterans returning from Iraq and Afghanistan are presenting with acute symptoms, while the burden of care for older veterans with chronic conditions continues. Mental health staffing has indeed grown recently, but some positions (particularly psychiatry positions in rural areas) are notoriously difficult to fill. In response to President Obama’s 2012 executive order (“Improving Access to Mental Health Services for Veterans, Service Members, and Military Families”), the VA has hired 1,607 new mental health professionals in the past nine months.

Simultaneously, however, the number of VA enrollees has risen from 6.8 to 8.6 million between fiscal years 2002 and 2011; similarly, the number of outpatient visits per year has risen from 46.5 to 79.8 million during the same period (4). According to VA Undersecretary for Health Robert A. Petzel, M.D., 1.3 million veterans received mental health care from the VA in 2012, up from 927,000 in 2006 (5). Because of this influx of veterans, providers at some sites are experiencing increased caseload sizes and challenges in reorganizing clinical programming to meet patient care needs, resulting in decreased time for team building, staff development, and peer consultation.

Another challenge of working at the VA is the high rate of suicide among veterans. According to the VA suicide prevention program, about 18 to 22 veterans die by suicide daily (6). Media scrutiny of both the Department of Defense and the VA regarding mental health care and suicide is considerable. In addition, some VA providers have large caseloads involving trauma-processing work, which can increase the risk of compassion fatigue and vicarious traumatization (7). Finally, as the VA broadens its care to rural veterans, more providers are providing services at CBOCs, where they may be the only mental health professional, increasing their risk of feeling isolated and decreasing their access to peer support.

Third, the VA annually disseminates performance measures that set standards for various aspects of patient care. Although these directives are often effective in achieving positive outcomes (8), monitoring and changing processes to meet these standards can be time consuming. Work groups of staff at some facilities expend tremendous effort addressing these highly scrutinized standards, efforts that can increase provider stress levels and decrease the time available for team building, staff development, and discussion of challenging cases.

Finally, the formats for peer review and performance appraisals at some facilities are largely grounded in assessing compliance with VA standards and directives and monitoring mistakes, such as failures of documentation, number of suicide attempts by one’s patients, and number of patient complaints. There is much less focus on quality of patient care, innovation, and program development activities. Assessment of actual patient care, admittedly, is challenging, but it can be accomplished in creative ways, such as use of a one-way mirror, recording sessions, and cotherapy. Overall, the current approaches to peer review and performance appraisal can increase provider anxiety, deter providers from sharing uncertainties and insecurities, and increase isolation.

Implementation of communitarianism

The VA has many opportunities to strengthen the workforce of mental health providers; doing so will continue to enhance care for veterans. The implementation of a communitarian model will likely differ depending on each site’s specific needs and personnel. Broadly, the VA might consider the following five ideas, some of which may be available at selected sites already but not throughout the entire system.

First, managers may specifically allot time for consultation or participation in mutual supervision groups with both mental health colleagues and interdisciplinary teams. Such activities can be successful only when employees are strongly encouraged to participate and are given designated time away from patient care responsibilities. Simply offering these activities as an optional activity is not likely to attract the participation of busy clinicians (9).

Second, like some places in the private sector, the VA can encourage self-care at an institutional level, allotting time for physical exercise during work hours and encouraging participation in employee wellness programs. Third, ensuring that employee assistance programs (EAPs) are available for mental health providers may be helpful. At some sites, staff clinicians themselves provide in-house EAP treatment; as a result, these providers don’t have access to this benefit.

Fourth, the VA has created some excellent national programs to mentor staff working with veterans with posttraumatic stress disorder (PTSD). These programs include the National Center for PTSD’s mentoring program and the PTSD consultation program, which allow frontline clinicians to consult with experts about PTSD treatment, assessments, resources, and programmatic issues. Similar programs to encourage and structure mentoring opportunities could be created at the local level. For example, managers could offer to match new staff members with an existing clinician to help welcome them to the facility and provide support in the transition. Finally, the VA can support mental health personnel by giving protected time for duties associated with various professional roles, such as supervision, teaching, research, and committee membership. Mental health professionals bring many skills to these important activities, and having a diversity of roles can protect against burnout (10).

Conclusions

The military encourages a strong reliance on an interdependent community, striving to build a cohesive “got your back” mentality among its troops. This may be necessary for survival on the battlefield. This same sentiment should be encouraged among VA mental health professionals as they work together to fulfill the honorable mission of caring for America’s heroes. VA mental health providers need each other to advocate for one another, to challenge each other, to hold each other accountable, and to support each other, as they strengthen the competent community of VA providers and thereby improve care for veterans.