Reaching the Unreachable: Strengthening Mental Health Care Services for Veterans
By Julie Wheeler, WI-HER Associate, Operations and Human Resources
Story Highlights
> The VA’s limited resources and budget hampers its ability to improve accessibility to VA mental health care and decrease the incidence of veteran suicide.
> Veterans experience a number of barriers when seeking mental health care for PTSD.
> The author provides recommended solutions and a path to improvement to better serve veterans and their mental health care needs.
> The piece ends with a message of encouragement and resources for those who struggle with PTSD.
It’s early November. Brian* would have been 35. As Veteran’s Day approaches, reality sets in. My friend is gone. Although I am sad he’s not here to make me laugh or impress me with his knowledge of medicine, I am relieved he is no longer in mental turmoil. He was a hero to his family, his lovely fiance, his Marines, his fellow Navy Corpsmen, and to the people he risked his life saving on the battlefield. But it wasn’t enough. He couldn’t silence the demons he lived with for so long, so he took his life.
According to the Department of Veterans Affairs (VA), an estimated 16.8 per 100,000 veterans succumb to suicide every day. While that is an improvement from 23.3 per 100,000 in previous years, something must be done to reach the veterans who remain. Brian sought care at the end of his enlistment, and the physician who did his final physical told him to follow up with Veterans Affairs. The VA has a mandate to support our veterans and they are doing the best they can given their limited resources and budget. Yet, there are gaps that can be addressed to improve and strengthen the system to better reach and serve our veterans—just as they have served us.
What Happens After the Trauma
Many veterans struggle with Post Traumatic Stress Disorder (PTSD) and other mental health challenges. Brian served two tours in Afghanistan and was a first responder in numerous bloody battles with his unit. He didn’t openly talk about his combat experiences, but those of us who worked with him knew he ran toward gunfire and explosions to save lives, and when he couldn’t save lives, he compartmentalized his grief in unhealthy ways to survive, including after he returned home. Alcohol abuse nearly ruined his life, and adrenaline-seeking behavior almost killed him. Still, he did not seek help until prepared to be discharged from the Navy. After a couple of visits to the VA, I remember him saying that the VA wasn’t helpful.
Brian was far from alone in his feelings. According to a 2018 Evaluation of the Department of Veterans Affairs Mental Health Services, around 55% of veterans reported not seeking mental health care services. Among those who did seek mental health care, about one in three sought care outside of the VA system.
Barriers to Mental Health Care in the VA
Veterans who seek mental health care within the VA system have many barriers to overcome. Among the most common barriers identified in a Veteran-centered analysis include stigma, financial, and personal obstacles as well as physical disabilities, lack of VA health system confidence, navigating the VA health system, and fear of privacy and security breaches. To better understand the barriers to care that veterans encountered, I spoke with three veterans with varying degrees of PTSD.
Limited Access to Care
VA appointments are currently few and far between, especially initial appointments. Cindy,* a Marine Corps veteran, receives 100% disability for her PTSD and is a high-priority veteran, yet she waited a month to be seen by her initial psychiatrist and therapist. “They asked me how I wanted to be seen and treated… I didn’t know what treatments were available or what medications I should be on… I was never offered virtual appointments. That would have been convenient.” She stopped using the VA two years ago and has inconsistent therapy at a civilian clinic, “when I can afford it.”
As for Dave,* a Navy combat Corpsman, he waited about two months for his initial appointment. Recently, he had an episode and reached out to talk to his therapist via virtual appointment: “I was able to get a virtual appointment three months out. If I wanted an in-person appointment, I would have had to wait almost a year to see my therapist.”
Stephanie,* a Navy Independent Duty Corpsman, also waited about two months to see her initial provider, whom she ultimately didn’t feel comfortable with: “I felt like a number and my concerns were not being addressed.” Stephanie requested a different provider and waited another six-to-eight weeks to see her current therapist. The VA has recognized this barrier and has since made some improvements, such as night and weekend appointments. As a result, the VA reported a 9% decrease in new patients waiting more than 20 days for mental health care.
Lack of a Referral System and Health Insurance Obstacles
Veterans who live close to a VA facility are ineligible to receive covered mental health care outside of the VA, which often leads veterans to pay out of pocket to get care. This barrier is the case for Cindy. After bad experiences with one of her social workers, Cindy decided VA mental health care was not for her. “She discouraged me and made me feel bad about my rage symptoms.” Since she lives within 60 minutes of two VA facilities, Cindy is not eligible to seek care outside of the VA system. She sporadically seeks care for her mental health at a civilian clinic and would rather pay out of pocket for her care because of past experiences with the VA. She said, “I have two jobs and I can’t afford to see my therapist at the civilian clinic. I can’t pay my medical bills.” She has tried to get the VA to cover her civilian therapy but hasn’t succeeded.
Lack of Continuity of Care
When veterans have multiple providers, they’re forced to relive the trauma and tell their story repeatedly to each new provider. Studies have shown that continuity of care is among the most important factors related to veteran’s mental health care, including substance abuse disorders and other psychiatric disorders. This, too, was a common theme among Cindy, Dave, and Stephanie.
Since 2015, Cindy has had upward of 14 different providers for her medication management and more than 10 different therapists and/or social workers through the VA. Dave has also had several providers since 2009: “There was a lot of turnover in VA providers. I have had like six different providers.”
Stephanie’s story is a bit different in that she has only had a couple of providers since seeking care for PTSD in 2015. However, she credits this to her previous experience in the Navy as a psych technician and knowing how to advocate for herself.
Perceived Severity of Trauma Experienced
Some veterans feel guilty that their trauma isn’t severe enough to seek care. In particular, veterans working in the medical field often face this barrier. Like Brian, many medics and Corpsmen compartmentalized their grief, and they feel guilt and shame when comparing their experiences to those who have suffered severe injury or loss. Dave said, “I tried to do group sessions. But I just felt so guilty when I would look across the room and see the guy missing a leg. Or hear about how his buddy got blown up right in front of him.” Stephanie, on the other hand, felt guilty and minimized her symptoms because of her experiences as a psych tech: “I knew there were other service members who needed the services more. I wasn’t a harm to myself or anyone else, so I was low priority. But I couldn’t sleep.”
Understaffed and High Turnover
According to the Veterans Health Administration (VHA), 1,380 VA facilities provide care to over 9 million veterans annually. That is roughly a patient load of 6,500 per facility, which does not consider the resource limitations facilities face in providing mental health care. The staffing shortfalls and lack of accessible facilities in the VA healthcare system no doubt contribute to the barriers veterans face, despite recent improvements to the VA mental healthcare system.
For example, Dave and his therapist worked out a treatment plan and how often he should be seen for therapy. “She would say I want to see you back in 3 weeks. I would go to make the appointment, and there wouldn’t be availability for months.” In other cases, Dave would leave messages through the patient portal. “They have 48 hours to return a message. But I never hear back from her directly. It’s always her nurse or the tech who calls me back about a week later.” But this wasn’t the case with Stephanie. “I have a great rapport with my therapist and psychiatrist. I see my therapist in-person regularly and my psychiatrist every three months for medication refills via virtual appointments.” While different types of facilities have different challenges in improving mental health care service delivery, it is important to consider those challenges when brainstorming solutions.
Limited Understanding of Patients’ Trauma
How providers approach their patients can be another barrier for veterans. A systematic review of 32 studies showed that trauma-informed care significantly improved both PTSD and anxiety symptoms in patients in 11 out of 23 studies. Both Cindy and Stephanie reported that a lack of empathy and trauma-informed care affected their rapport with providers. One of Cindy’s social workers diminished her experience with sexual trauma so badly that Cindy said, “ I would do anything not to have to see her again.” While other male providers, “treated me differently than they would a male.” They would treat her, “like I wasn’t even there. They never acknowledged anything was done. That’s why I only have females now. [They] seem to be the ones that care and believe us.”
In Stephanie’s situation, her first therapist was near retirement when she started going to the VA: “He didn’t approach my situation with the empathy and understanding that I felt I needed. I had an anxiety attack during my first appointment. Because of his approach to my case.” Dave said, “It’s very difficult for a provider who has never been to combat to understand what veterans are going through. They do not know our culture and what we’ve been exposed to.”
Perceived Stigma
About 60% of active duty military members report not seeking mental health care for fear of the stigma associated with mental illness. This fear often leads to veterans concealing their illness due to worries about having their weapons access removed, deployments canceled, security clearances revoked, and ultimately, their careers halted. There is also a significant fear of being treated differently by leadership and losing respect among peers for being “weak.” One study in 2021 found that Marines were less likely to seek mental health care because of negative leadership support and the fear of appearing weak. This is what happened with Cindy. “It was hard to get help because I’m a Marine, and I’m supposed to be tough and strong.” Dave had some hesitations in getting therapy but ultimately realized he needed it. He also feared appearing “weak.”
Bridging the Gaps
Expanding Access to Care
To start, expanding access to care means allowing veterans to seek care outside of the VA regardless of their location. Cindy, Dave, and Stephanie all struggled with a lack of access to care when they needed it most, often waiting six-to-eight weeks to see a therapist. Per the Uniform Mental Health Services in VHA Medical Points of Service directive, veterans who seek care in person are supposed to be evaluated the same day when requesting mental health care services. Veterans who reach out via telephone or text are supposed to be evaluated within 24 hours. This turnaround time isn’t happening, at least for these three veterans.
Meeting Mental Health Needs
Dave recognizes the mental health crisis in the veteran’s community is overwhelming the VA system. “There are just too many veterans who need help and not enough providers.” He says that continuity of care is a major issue that he faced, “because the private sector of mental health care is more appealing to providers. There is more money.” Stephanie thinks that the key to veterans seeking and receiving care can be addressed by adding more clinics, hiring more staff, and therefore providing better access to care.
Trauma Informed Care Approaches
Providing a safe space for veterans is of utmost importance. Cindy’s main suggestion is, “Listen to us. Don’t silence us. Actually follow up with treatment plans.” This recommendation goes back to creating a trusting relationship with an extremely vulnerable population. Dave had similar concerns but advocated for his mental health care when it came to his medications. “I felt like in the beginning I was being strong-armed into taking a medication I didn’t think was right for me.”
Veteran Advocates
Dave suggests creating a system where veterans, who are not familiar with available mental health treatments, can be paired with an advocate who understands the healthcare system to improve the veteran’s experience and support mental health-seeking behavior. By implementing this, veterans will have a sense of autonomy when it comes to their mental health care needs and know that they have an advocate who will listen and help them follow-up with their care.
Addressing Stigma Early
Addressing the stigma of seeking mental healthcare would likely improve the mental health-seeking behaviors of veterans. It starts at the unit level when veterans are still active duty in the military. Leaders in the military should check in on their people and encourage mental health interventions through positive reinforcement rather than negative. In one meta-analysis that examined 20 different studies, 44.2% of the participants felt, “My unit leadership might treat me differently.” Additionally, 42.9% felt “I would be seen as weak.” I witnessed this first-hand while we were deployed in Iraq, not to mention throughout my career as a Navy Independent Duty Corpsman (IDC). Oftentimes, Commanding Officers minimized and ridiculed the Marine, Sailor, or Soldier who clearly needed intervention.
A Path Forward to Improving the System
WI-HER’s iDARE™ methodology is a proven step-wise approach that fosters community and locally-led solutions to improve outcomes. For example, iDARE has been used at the community and facility level to improve health outcomes in reducing HIV viral loads, improve gender-based violence identification and response, and improve mass drug administration in the prevention of non-tropical diseases in Uganda, Kenya, and Tanzania. More recently, iDARE has been implemented with U.S. federal agencies to support leadership development and other culture- and values-based priorities like prioritizing mental health resources and learning how to work better in diverse team environments, highlighting the versatility of iDARE. The crux of iDARE focuses on engaging with populations who are at the heart of an intervention.
In this case, through the use of iDARE, the VA and other U.S.-based health systems can engage with veterans to understand their concerns and develop solutions that specifically address the most common barriers veterans face when battling PTSD. By involving veterans in the creation of solutions, the VA can decrease the incidence of suicides, improve confidence in the VHA, and bring real solutions to improving the mental health of veterans.
Call to Action
The good news is that we are learning and doing better. Leaders are learning they need to support mental health-seeking behavior, not minimize it or mock it as being weak. By addressing the gaps that veterans like Cindy, Dave, and Stephanie experienced, the government can strengthen the VA mental health care system and the care offered. Then, one day we won’t have to mourn brave women and men like Brian.
A Message of Gratitude and Hope
I would like to thank my brother and sisters in arms (my sea babies) for allowing me to share their experiences and their stories in an effort to improve a system that is supposed to support us when we return home. I know how difficult it must have been to relive your trauma, and I am eternally grateful you trusted me to do it. I love you all and want you to know I am here for you anytime, day or night.
If anyone, military or civilian, is in need of mental health care, or knows someone who is experiencing suicidal thoughts and ideations, I urge you to reach out to the Suicide and Crisis Lifeline by calling or texting 988 or the VA’s mental health care crisis line by texting 838255. These call centers are available 24 hours a day, 7 days a week, with experts who can help. You are not alone, and there is light at the end of the trauma.
* Real names concealed for privacy.
Learn More About the Veterans Featured in this Story
Disclaimer: This blog post reflects the personal analysis, perspective, experiences, and research of the author, Julie Wheeler, a former military leader and medical provider with 20 years of experience. These opinions do not necessarily represent the official position or policies of WI-HER. The content is intended to offer an informed viewpoint and is not meant to advocate for any specific agenda or cause.