It might be a fair observation – although open for debate – that those intimately involved in the field of psychology and more recently mental health/behavioral health have been relatively unaffected by the swings in the political/public policy gestalt, as reflected by the media, over the past several decades. Thanks to the efforts of APA and APS, those in academia have become increasingly successful in obtaining additional research funding and those in practice have found expanding markets for their services. As the profession has matured, more colleagues have obtained positions of administrative responsibility and have become increasingly involved in the legislative process, including serving as Governor and in the U.S. House of Representatives. One should, of course, recall that John W. Gardner served as Secretary of the Department of Health, Education, and Welfare (HEW) under President Lyndon Johnson during the Great Society era, prior to becoming President of Common Cause. There are increasing signs, however, that this relatively protective state of invisibility might be changing, especially as technology has become more integrated into our nation's health care environment.
On July 22, 2016, President Obama signed the Comprehensive Addiction and Recovery Act of 2016 (P.L. 114-198). This bipartisan legislation was crafted to "address the national epidemics of prescription opioid abuse and heroin use." The USPHS Surgeon General: "Nearly 2 million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C." Included within this legislation is a provision which establishes a special Commission to examine the evidence-based therapy treatment model used by the Department of Veterans Affairs (VA) for treating mental health conditions of veterans and the potential benefits of incorporating complementary (CAM) and integrative health as standard practice throughout the Department.
This is at a time when the VA indicates that, after examining over 55 million records, in 2014 the number of veteran deaths by suicide averaged 20 per day. To put this staggering figure in perspective; since 2001, the nation's adult civilian suicide rate increased 23%, while veteran suicides increased 32% during the same time period. After controlling for age and gender, the risk of suicide for veterans was 21% higher than for non-veterans. Most members of APA are not aware that although VA is the largest employer of psychologists, APA does not have an office of Veterans or Military Affairs, even though one in 10 adults is a veteran and one in 6 Americans is either a military service member, veteran, or their dependent.
The legislatively created Commission will: (1) examine the efficacy of the evidence-based therapy model used by VA to treat mental health illnesses and identify areas of improvement; (2) conduct a patient-centered survey within each VISN (Veterans Integrated Service Network) to examine: the experiences of veterans with VA and non-VA facilities regarding mental health care, the preferences of veterans and which methods they believe to be most effective; the experience, if any, of veterans with respect to the complementary and integrative health treatment therapies, the prevalence of prescribing medication to veterans seeking treatment for mental health disorders through VA, and the outreach efforts of VA regarding the availability of benefits and treatments for veterans for addressing mental health issues; (3) examine available research on complementary and integrative health for mental health disorders in areas of therapy including: music therapy, equine therapy, service dogs, yoga therapy, acupuncture therapy, meditation therapy, outdoor sports therapy, hyperbaric oxygen therapy, accelerated resolution therapy, art therapy, magnetic resonance therapy, and others; (4) study the sufficiency of VA resources to deliver quality mental health care; and (5) study the current treatments and resources available within VA, as well as assess the effectiveness of such treatments and resources in decreasing the number of suicides per day by veterans, the number of veterans who have been diagnosed with mental health issues, the percentage of veterans who have completed VA counseling sessions, and the efforts of VA to expand complementary and integrative health treatments viable to the recovery of veterans with mental health issues as determined by the Secretary to improve the effectiveness of treatments offered by VA. The law further requires the Secretary, when informed by the Commission's findings, to commence a pilot program to assess the feasibility and advisability of using wellness-based programs to complement pain management and related health care services.
Do Commissions make a difference? In our experience, they do. P.L.113-146, the Veterans Access, Choice, and Accountability Act of 2014, established the Commission on Care to review a requested comprehensive independent assessment of VHA (Veterans Health Agency) care delivery and management systems, examine access to care, and look more expansively at how veterans' care should be organized and delivered during the next two decades. This Commission held 26 days of public meetings receiving testimony from a broad range of experts and stakeholders and conducted site visits to VHA facilities. The Commission's conclusions: "The next 20 years will see continued dynamic change in health care, well beyond the Commission's capacity to forecast the future. What is clear, though, is that the concept of access to care is itself undergoing marked change. The potentially explosive growth of telemedicine, increasing emphasis on preventive care, and likely proliferation of technologies that permit routine home-based health monitoring and care of patients with chronic illnesses will dramatically affect access needs. We are also witnessing profound changes in the nature of patient-provider engagement and in where and how care is delivered. VHA must keep pace with, and even be a leader in, these changes…."
"The Commission's report underscores the importance of transforming VA health care delivery and the systems that underlie it…. (C)hange that requires new direction, new investment, and profound reengineering. Some will question that view, and perhaps challenge the notion that the nation should invest further in the VA health care system. None, however, should question the nation's obligation to those who sustained injury or illness in service, or who are at increased health risk as a result of deployments to combat zones or other service-related experiences…."
"(T)he Commission recognizes the VA health care system has valuable strengths, including some unique and exceptional clinical programs and services tailored to the needs of the millions of veterans who turn to VA for care. For example, VHA's behavioral health programs, particularly with their integration of behavioral health and primary-care [which was a high priority for Toni Zeiss as the VA's chief consultant for mental health], are largely unrivalled, and profoundly important to many who have suffered from the effects of battle and for whom VHA is a safety net…. Transformation is a difficult process that will require careful stewardship, sustainable leadership, and unwavering focus and commitment to the long-term vision and strategy…. Our nation's veterans deserve no less."
Those colleagues who have been working with the military will especially appreciate the Commission's sensitivity to their unique environment. "In addition to addressing the needs of minority veterans and vulnerable veterans populations, VA must address military-specific needs and ensure that all providers in the VHA Care System have sufficient military competency (i.e., knowledge of specific issues and health care needs of those who served in the military)…. Health care disparities often result from patients' lack of trust in their health care provider; therefore, enhancing the patient-provider relationship is paramount in overcoming these disparities. Stereotypical thinking on the part of the providers about certain patient groups, including veterans, may unwittingly influence their prognosis."
Specific reasons for the increase of health care disparities within the military population include the following: * The cultural norms of the military are such that to admit or display any signs of perceived weakness, especially related to mental health issues, discourages military personnel and veterans from seeking medical care and treatment. * Changes in the demographical makeup of the civilian population result in similar changes to the military population. * A small but gradual increase in the number of foreign born personnel who have joined the ranks of the military. * And, A disengaged provider culture that may have become more immersed in the medical culture than the military culture. "VA must make cultural and military competence a strategic priority…." The Commission further noted that women are the fastest growing group within the veteran population. As of 2011, approximately 1.8 million (8%) of the 22.2 million veterans were women. By 2020, women veterans will comprise nearly 11% of the total veteran population.
This summer the VA proposed to amend its regulations to permit full practice authority for its Advanced Practice Registered Nurses (APRNs) relying upon its federal supremacy authority. By the close of the public commentary period, an extraordinary 223,000 comments had been received, with approximately 60% supportive. This modification would essentially establish national licensure for APRNs. Who is next? Change is definitely in the future. Aloha,
Pat DeLeon, former APA President – Division One – September, 2016
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