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VA Health Care Presentation

By Johanna (Hans) Buwalda

This is the text of my presentation at the IVAW Convention Panel on VA Health Care, July 9, 2010 in Austin, Texas.

A few days ago, I was sitting on the terrace of a coffee shop in my neighborhood in Chicago writing this presentation, when one of those giant firecrackers went off that sound like a bomb. I jumped. 16 years ago I left the war zone I used to live in, and I still jump. But that is not my point. Two women with two little girls, maybe six years old, were sitting at the table next to mine. So this bomb-firecracker went off and the one woman told the girls: "That is patriotism." A conversation followed between the four of them that went like this:

First woman: "To show your love for your country, you clean it."

First little girl: "you put trees in it."

Second little girl: "you take care of your garden."

The other woman: "And you stop using so much gasoline."

It just struck me that there would be no need to write this presentation or have this convention if we had all had such conversations with our parents when we were six years old.

I want to acknowledge that there are many VA staff who are competent, motivated and compassionate. There also are many veterans who get their health care needs met at the VA. Some VA hospitals do a much better job than others.

That said, there are many veterans who do not get their needs met at the VA, many who won't even consider going to the VA, many who can't access the VA for various reasons. As IVAW understands well, this is a problem. After all, the third principle of IVAW is: Full benefits, adequate healthcare (including mental health) and other supports for returning servicemen and women.

I am a therapist, I don't work for the VA, but I have had the privilege to work with many veterans over the past few years. I would like to share a few things that I have learned as a mental health provider about working with veterans, that may be useful for the VA to know as well. Here is what I have seen while working with veterans who have difficulty getting mental health services at the VA. Here is a letter to the VA:

Dear VA mental health services:

Outreach

Outreach is key. Waiting for veterans to come to your office is frequently futile. I know double booking takes care of the problem of filling all appointments, but it doesn't take care of all veterans. In fact, you may miss the veterans who need you most. I know you have established vet-centers, and that is a great step in the right direction, but they are still centers veterans need to go to. How about leaving your offices and going to meet veterans where they are at? I mean that quite literally. Go in the shelters, bars, under the bridges, veteran meetings, fundraisers, meet the leadership, listen for who may need help and offer it.

Checklists and Paperwork

I suggest that you put your checklists and paperwork to the side and listen first. My guess is that checklists and forms are an efficient way to learn about symptoms and that you want 'outcome measures.' However, your paperwork is also a very efficient way to turn veterans off. Checklists will tell you something about symptoms, but checklists will tell you nothing about a veteran's life, nothing about what veterans want for their lives and what they believe stands in the way of reaching their goals. Checklists and paperwork will not make a veteran feel truly heard and cared for. Military mental health services seem to operate with the goal of making service personnel 'combat ready.' I urge that the VA not operate with a similar goal of just helping veterans become 'civilian functional.' This goes beyond symptoms: veterans want to thrive.

Trust

Which brings me to another issue that seems to be understood by only a limited number of VA providers: trust needs to be earned. I don't envy you! Many of the veterans I work with see you as part of the same establishment that betrayed them every step of the way. You will have to work very hard, perhaps even harder than me, to earn that trust. I suggest that you take a good look at the providers who are best liked and respected by the veterans in your hospital. I bet that you will find that these providers treat their patients with respect, kindness and patience. That these providers are welcoming, listen, follow-up, always remember their patients' names, and often their spouses' as well. And that they don't see their patients as non-compliant when they don't follow doctor's orders, but that these providers try to find what concerns the veteran has, what happened that the veteran decided or wasn't able to follow through. They probably always assume that the veteran wants healing. I mean, nobody wishes what some veterans suffer through every day to their worst enemy!

I can assure you, VA health care, that I try to practice all of these things. I have never felt used or abused by a veteran, not even those that you sometimes seem to be so afraid of, the veteran with addiction problems. My phone is always on. No veteran has ever called me at three in the morning for some frivolous reason.

Please, VA, get rid of the idea that veterans are out to cheat the system. Maybe some are, but in my experience the vast majority are not. Even if they are, remember that they were betrayed many times over. They served in our name and are going to be affected all their lives, they have the right to be cared for and receive the best care possible.

Anger

Many of you seem to be more afraid of anger than seems reasonable to me. I understand that you need to keep yourself safe, and I know that some veterans are afraid of their own anger because they know what they are capable of doing.

But maybe you need to understand that anger is much more than a symptom of PTSD, that veterans have very good reasons to be angry. Some of them feel cheated or dumb or gullible because they bought into what the recruiters promised, what they learned as children (the US is the greatest country, serving in the military is an honor, etc). They are angry about being forced to fight in an unjust war, angry about trusting a leadership that turned out not to be trust worthy. Angry about not being taken care of when returning, about civilians not being particularly aware that a war has been going on, about not getting welcomed home after deployment, about being betrayed over and over again.

And I am sure that you know that veterans were trained to not express their sadness, frustration, anxiety, grief, unhappiness and other emotional pain. Only anger was useful in combat.

Believe me, I don't like anger very much either, but I know the veteran dealing with it likes it even less. In my experience, the anger is seldom if ever about me or even directed at me, and is almost always something that a veteran wants to talk about resolving. You have to handle anger and you have to learn not to get caught up in it. Also do not deny veterans services because they expressed their feelings with anger. They may actually need you the most during that time.

Moral injury

Some veterans have told me that when they tried to talk about their moral questions about the war, the US's involvement in the war, and their personal involvement and actions in the war, they are being told that the VA is not a place to talk politics. However, how can providers consider treating veterans without talking about the moral questions that veterans ask themselves every day? The questions that make it so hard to get up and face themselves? Am I still a good person, Will I still be loved if my family would know what I did out there? Will they be afraid of me if they knew what goes on in my mind when I am angry?

These are very hard to talk about, and very hard to listen to as a mental health provider as well. But these questions are at the heart of healing.

We are not dealing with internal issues only, as a provider we have to be willing to look at the larger social political issues surrounding the veterans' life.

If you cannot hear those stories, you cannot work with veterans as a mental health provider. I suggest though, that you practice very good and comprehensive self-care.

Military Sexual Trauma (MST) and Women

I want to say something about MST and women. I am so glad that some of you have realized how intimidating your VA medical centers can be for women. Just entering one of your hospitals can bring up a slew of memories of being a woman in a sea of males. Maybe my point here has more to do about outreach than MST and women. I let women choose where they want to meet because I want them to feel as safe as possible. Even though my office is in a very small wellness center, the women seldom choose to meet there. Even if you have separate women's clinics (and I applaud you for that), she still has to go to the pharmacy for example.

In my experience, 100% of women have some level of MST ranging from feeling unsafe to rape. But please don't forget that while women are still not supposed to be in combat positions, they are. Seeing dead bodies, losing buddies, and/or killing people, has become gender non-specific. Please remember to deal with combat related issues. In women veterans, PTSD is not limited to MST.

On the other hand, please also remember that in male veterans, PTSD is not limited to combat. In my experience, 10% of male veterans have experienced some level of MST.

Racism

I have noticed that veterans of color who have used the VA have not discussed their experience with racism. Maybe this is not across the board and just limited to the veterans I have met. I hope so. But just in case it is not, I want you to know that when I meet with veterans of color, racism almost always becomes a topic of conversation. When discussing stressors and trauma while serving in the military and/or while deployed, experience with racism almost always turns out to have a major impact on the mental health of that veteran.

Dear VA providers, some of you are going to say that I care too much or that I don't know how to keep appropriate boundaries. I don't agree with you. I believe that we should all care, we can't care enough. This country sent these, often very young, men and women out into grave danger in our name, for our sake. We have more than an obligation to care for them. They didn't go home at 5 o'clock thinking that the nation could wait being safe till tomorrow. They still can't go home at 5 o'clock free of suffering the aftermath of war.

If the VA doesn't have enough people to provide that level of care, they need to get more. It all boils down again to the fact that we have an obligation to those we sent out to defend us, regardless of how misguided these wars may be.

A couple of days ago, a veteran posted a video entitled "All is Not Okay (music by Seether)." The video was powerful, but it was actually a comment below the video that caught my eye. It said: "Douglas Barber, an Iraq vet tried to get help from the VA for two years after his return from the Bush quagmire." That comment just struck me as being at the heart of the issue. Douglas Barber should not have needed to try the get help from the VA for two years. To me, it should have been the other way around. The VA should have tried to help Douglas Barber for two years or for as long as it took to support him. I mean, VA, is Veterans Administration, not Administration Veterans. If the VA, would truly be able to put Veterans before Administration maybe veterans like Douglas Barber would still be alive. Instead, Douglas Barber committed suicide.

Thank you for listening to me. Please feel free to contact me with any questions and/or concerns.

Hans Buwalda is one of VVAW's Military Counselors.