A University-Based Mental Health Center for Veterans and Their Families: Challenges and Opportunities

The New York–Presbyterian Military Family Wellness Center (MFWC) at Columbia University Irving Medical Center (CUIMC) and New York State Psychiatric Institute (NYSPI) was established in 2016. Its primary goal is to provide evidence-based assessment and treatment to individuals who do not qualify for, do not benefit from, or feel reluctant to use publicly available options such as the Veterans Administration (VA) health system. This novel center has distinct advantages in four areas: ease of access and cost-free services, minimal bureaucracy, confidentiality and privacy, and a wide range of high-quality treatment options. Since inception, the MFWC has prioritized collaborations with regional public and private institutions, seeking to complement existing resources rather than to compete with or replace them. This column details the MFWC, elucidating the needs that sparked it and its progress and emphasizing the development of public and private partnerships, present and future.

Rationale

Rates of psychopathology are high among U.S. active duty service members, members of the National Guard and Reserve, and military veterans, particularly for posttraumatic stress disorder (PTSD) and depression, estimated at between 15% and 30% (1). The many debilitated troops returning to New York State from Iraq and Afghanistan has further strained an already overtaxed veterans’ mental health system (2). Family members of service members and veterans, particularly military spouses and caregivers, also report elevated rates of depression compared with the general population, heightening the general impact (3). Multiple factors exacerbate the challenges facing the current generation of veterans and their families and the resultant burden of care, such as increased number of deployments and greater injury survival rate (1, 4).

The VA and Department of Defense (DoD) have taken steps toward addressing these concerns (5), yet data on mental health utilization remain discouraging (6). Seeking treatment through the VA requires vaulting several potential hurdles, including lack of qualification for services, inconsistent quality of care, long wait times, lack of trust in the VA or government agencies, and concerns of privacy and confidentiality (2). A study conducted in New York, where the MFWC is located, found that nearly 50% of veterans prefer to seek care outside the VA system (2). Consequently, there have been increasing calls for private-sector services to allow veterans to seek community care. Yet use of community resources has been criticized for inconsistent quality of available services (7).

Forming Strategic Partnerships and Securing Funding

The PTSD research and treatment program at CUIMC has a long and successful history of partnering with trauma and PTSD academic centers across New York City (NYC) to address mental health crises, such as the shortage of trained mental health providers following the events of September 11, 2001 (8). In 2016, this time responding on behalf of many veterans and family members not eligible for or amenable to VA services, the PTSD research and treatment program at CUIMC formed strategic partnerships with two NYC PTSD academic centers, the program for anxiety and traumatic stress studies at Weill-Cornell Medical Center and the Steven A. Cohen Military Family Clinic at New York University (NYU)-Langone Health. Together, Columbia, Cornell, and NYU-Langone compose a collaborative, noncompetitive consortium operating in the interest of better serving the military family community in the private sector. Whereas the NYU program secured its funding independently, the Columbia and Cornell programs partnered to jointly receive a 3-year grant from their common hospital, the New York–Presbyterian Hospital, to establish parallel mental health clinics known as the MFWC, each offering no-cost mental health care to military families. The CUIMC site has since secured additional funding from the Bob Woodruff Foundation, Stand for the Troops Foundation, and anonymous private donors.

Forming this partnership presented challenges. The three academic institutions operate independently and have overlapping yet differing visions of best practices and resource sharing and different treatment priorities. For example, the Columbia MFWC provides interpersonal psychotherapy (IPT) for PTSD and depression; the Cornell program specializes in exposure therapy, including virtual reality technology; and the NYU Military Family Clinic offers family therapy, neuropsychological evaluation, and treatment for co-occurring disorders. Both the Columbia and Cornell programs treat active-duty service members and active National Guard and Reserve members, whereas NYU does not. As recognition of differences between the programs began to emerge, logistical and communication questions arose: Can an individual receive concurrent or sequential treatment across sites? Under what circumstances do we share confidential treatment-related information, and with what kind of consent required from patients? How can we coordinate research efforts, and what kind of agreements are required for data sharing?

Leaders from each site met regularly to address these and similar concerns. The meetings produced a series of informal agreements to standardize procedures, such as when and how to refer patients across sites, and organize data collection to ensure that some common measures are administered at standard time points. These agreements have been modified over time to account for shifts in each program’s funding priorities and services offered, as well as changes in the local veteran landscape.

The meetings have been instrumental in establishing mutual trust and goodwill and have yielded other collaborative benefits. Over the past 3 years, the three sites have shared training in assessment and treatment; presented information about the consortium and treatment outcomes at national and regional conferences; and supported one another in developing new initiatives, such as training programs for students and the use of telemedicine. Of course, problems occasionally emerge, and some issues, such as an agreement for data sharing, remain unresolved. Nonetheless, key players at the three centers have established comfortable and effective relationships.

In addition to forming the consortium with Cornell and NYU, we have developed beneficial relationships with regional stakeholders and organizations with vested interest in veterans’ mental health, such as the Veterans Mental Health Coalition, the NYC Veterans Alliance, the New York State Health Foundation, and the NYC Department of Veterans’ Services. These organizations regularly host or facilitate networking and educational meetings for veteran service providers, including other organizations specializing in mental health, and organizations targeting financial assistance, housing, claims benefits, and legal aid for military veterans and their families. We developed relationships with host institutions and other attendees by speaking with their leaders and representatives and by routinely offering our knowledge and expertise. Consequently, CUIMC staff have been invited to speak on a range of topics, including PTSD and mental health, psychiatric assessment, telemental health, the neuroscience of PTSD, and sleep disorders. We have developed a close relationship with the Intrepid Museum, which routinely hosts events for military veterans of all eras; the Columbia MFWC recently provided staff training and led an educational event at their site. These relationships have established awareness of and trust in our program, yielding four primary benefits: treatment referrals from other providers; increased contact with veterans and their families; access to posting on informational, cross-site listservs shared by veteran service providers; and access to training, education, and information.

Finally, the Columbia MFWC established close relationships with local VAs and vet centers. We regularly attend VA-hosted events and invite VA personnel to attend ours. We frequently present information about our program and services to VA staff and communicate referrals and opportunities. VA staff have expressed appreciation for the opportunity to refer individuals who do not qualify for care or who seek treatment outside the VA and for the treatment offered to family members of veterans. Likewise, we often encounter veterans who require longer term or higher level care than our center can provide, or who might otherwise benefit from other VA services, whom we refer to the VA.

Core Principles and Clinical Services

The aforementioned systemic challenges in accessing care, the need for treatment services for family members, privacy concerns, and the need for high-quality services in community settings were the principal reasons for forming the MFWC and the triuniversity consortium. Rather than duplicate VA efforts, our Columbia site aims to fill service gaps, such as those created by care limitations inherent within a VA or DoD framework, and to avoid the bureaucratic pitfalls that have impeded many veterans’ efforts to receive care. Core characteristics of the CUIMC MFWC site are listed below:

• • Broad inclusivity. The MFWC has no treatment restriction based on service era, length, or type; no VA disability rating requirement; and no restriction based on discharge status. Anyone meaningfully related to a veteran or service member qualifies for services.

• • Reduced wait time. Patients are typically evaluated within 2 weeks of contacting the center. We make every effort to treat patients quickly and efficiently, using a short-term treatment model.

• • Privacy and confidentiality. The MFWC exists outside the VA/DoD system. Patient information is never released outside the center without the patient’s expressed written permission, excepting emergency or court-mandated circumstances.

• • No cost. Thanks to generous funding, the MFWC does not charge for services.

• • Accessibility. The MFWC offers evening appointments to accommodate patients with day jobs. A HIPAA-compliant telemedicine platform increases ease of access for patients in remote regions or who find travel to our offices difficult.

• • High-quality, research-informed services. The center is embedded in the NYSPI PTSD research and treatment program, which is actively engaged in treatment studies, neuroimaging projects, and training programs. Accordingly, individuals treated at the MFWC have access to clinicians and researchers highly trained in evidence-based assessment and care.

• • Transparency and choice. All patients seeking treatment receive a thorough intake evaluation, yielding a diagnosis and treatment options. Therapists present and discuss the research and theory behind each treatment option to help patients make informed decisions.

The MFWC offers short-term (12–20 weeks), evidence-based psychotherapy and pharmacological treatment for veterans, active-duty service members, and adult family members. The primary conditions treated are PTSD, major depression, anxiety disorders, and adjustment disorders (e.g., readjustment to civilian life). Patients receive comprehensive serial assessment with standardized clinician-administered and self-report measures administered at treatment onset that are readministered mid- and posttreatment. Treatments include prolonged exposure, IPT for PTSD and depression, and cognitive–behavioral therapy (CBT), as well as pharmacotherapy, emotionally focused therapy for couples, and group CBT for insomnia. Most psychotherapy treatments are available via our telemedicine platform.

Discussion

The challenges facing military families are enormous. Although the VA continues to provide most of the care, nearly half of individuals seeking service-related mental health treatment in the New York region do not receive it (2). Many barriers, including bureaucracy, long wait times, ineligibility, confidentiality concerns, and inconsistency in care delivery, are longstanding problems without simple solutions. The Columbia University MFWC has established a record of excellence in addressing these gaps in service. Through focus on ease of access, privacy, and high-quality care, we have become a recognized and valued resource in the local military family community.

A key component of the center’s success has been the development of strategic partnerships with other regional organizations and stakeholders. These partnerships, including forming a consortium with two other academic NYC hospital centers, have facilitated referrals, enhanced outreach and education efforts, broadened the center’s ability to serve the needs of our clientele, and improved our knowledge and expertise. An important lesson learned has been the need to establish a cooperative stance in which we identify and work toward mutual goals through effective communication and sharing information and resources.

In this environment of rapidly expanding needs of military veterans and their families and shortfalls in publicly available options, partnerships between public and private institutions—for example, between VAs and academic institutions—are increasingly recognized as an ideal arrangement (9). Building on our success in developing such relationships, our center’s current goal is to establish a closer relationship with a local VA. As with the consortium effort, this relationship provides distinct potential advantages, including referrals, information and resource sharing, and reciprocal training. This arrangement will allow the VA to refer family members and those who do not qualify for or refuse VA services to a center with a reputation for high-quality care, rather than relying on community resources that may lack equivalent training and expertise (7). The MFWC at Columbia will benefit by expanding our ability to reach those in need and more effectively connect those in need of VA care to critical treatment.