Free Mental Health Care for Veterans? Not Necessarily

Veteran speaks with medical professionalEditor’s note: Craig Bryan, PsyD, ABPP, is a psychologist and director of the National Center for Veterans Studies at the University of Utah. His continuing education presentation for GoodTherapy.org, titled Brief Interventions for Suicidal Military Personnel and Veterans, is scheduled for 9 a.m. PDT on August 29, 2014. This event is available at no additional cost to GoodTherapy.org members and is good for two CE credits. For details, or to register, please click here.

I am often asked whether I think we need to make mental health care easier to access for military personnel and veterans, expand mental health services in the Department of Defense or the Department of Veterans Affairs (VA), or allow veterans to get more treatment from community providers outside of these systems. My answer to each of these questions is the same: “Not necessarily.” Many people are surprised at my response because I am a clinical psychologist and military veteran myself. Why wouldn’t I think that “easy-to-access treatment” or “more treatment” or even “free treatment” are good things? To answer this question, let’s take a brief moment to imagine a situation that many of us may confront one day or may have encountered already.

Comparing Options for Treatment

Think about someone you care about very much—perhaps your spouse, child, good friend, or family member—and imagine that he or she has an illness that significantly reduces quality of life and increases risk for early death. The illness not only negatively affects that person’s life, but it also negatively affects the lives of family and close friends. Imagine accompanying this person to a doctor’s appointment, during which the doctor runs some tests and procedures and arrives at a diagnosis. The doctor then presents and describes the following treatment options:

Treatment A Treatment B Treatment C
How many studies have been conducted on this treatment? Hundreds Dozens None
On average, how much do people’s symptoms decrease after this treatment? 50-75% 50-75% Unknown, but some doctors claim close to 100%
On average, how long does it take people with the illness to recover with this treatment? 6-9 months 3-6 months Unknown, but some doctors claim 1-2 days
On average, how likely are you to experience a life-threatening symptom within 2 years of treatment? 50% 15-25% Unknown, but some doctors claim almost 0%
Do most people like this treatment? Yes Yes Yes

 

When comparing these three options side-by-side, you might notice that Treatment A and Treatment B are very similar to each other. In general, both offer a reduction in symptoms of 50-75% and are fairly comparable in terms of time to recovery (Treatment A offers a 6–9 month recovery period, and Treatment B, a 3-6 month recovery period). Furthermore, both treatments have been researched fairly extensively, although Treatment A has received relatively more scientific attention, and patients seem to like both Treatment A and Treatment B equally. The primary differences between these two options are that people who receive Treatment B are half as likely to experience a life-threatening symptom during the next two years.

Craig Bryan

Craig Bryan, PsyD, ABPP

Treatment C is sort of the “wild card” of the bunch. Because Treatment C is new and hasn’t yet been studied extensively, it’s not so easy to determine whether it is better or worse than Treatment A or Treatment B; we don’t know how well it works, or, even worse, if it makes people sicker. We also don’t know how many people get better, or how many people experience life-threatening symptoms. What we do know is that patients like Treatment C, and a few doctors who prescribe it say that it works very fast and is very effective at reducing symptoms. The claims made by some doctors of immediate improvement within 1–2 days and the very low risk for experiencing a life-threatening symptom are certainly tantalizing, but we don’t know how often that occurs or how long that improvement lasts. Overall, Treatment C is a huge gamble given the potentially life-threatening nature of this illness, especially when we have an option (Treatment B) that has a strong track record of reliable results. Most of us, therefore, would not recommend this option for our loved one.

The Importance of Selecting an Evidence-Based Treatment

Like anyone else, military personnel and veterans have options for care. Some of those options have been studied more than others, and some of those options are clearly better than others, as in the case of Treatment B. For example, when we consider treatment options for military personnel and veterans with suicide ideation, we know that brief cognitive behavioral therapy that focuses specifically on suicide risk (as opposed to focusing on a psychiatric concern) contributes to 50% reductions in suicide attempts within the first two years of treatment, even though this treatment is often no better at reducing suicide ideation and symptoms of depression, anxiety, and hopelessness than others. In other words, many treatments help suicidal individuals feel better, but some treatments are more effective at reducing the risk for suicide attempt (i.e., the life-threatening symptom). This has been demonstrated scientifically in a sample of non-military individuals, and more recently in a forthcoming study conducted in a sample of active duty military personnel.

If we want to prevent suicide among military personnel and veterans, we should be making brief cognitive behavioral therapy easily accessible and free to military personnel and veterans. Although brief cognitive behavioral therapy isn’t necessarily better at reducing depression or anxiety than other therapies such as supportive therapy, psychodynamic therapy, person-centered therapy, or stand-alone medication therapy, it is better at reducing the likelihood of a life-threatening outcome. We should offer easy access to brief-cognitive behavioral therapy, and ensure that mental health professionals are familiar with this treatment approach and capable of providing it.

And what about Treatment C? Unfortunately, there are a lot of Treatment Cs around these days, including “energy” therapies, thought field therapy, therapeutic touch, animal-assisted therapies, outdoor or wilderness-based therapies, and others. None of these treatments have been studied with actively suicidal patients using rigorous scientific methods, so although they might be helpful for some suicidal military personnel and veterans, it’s also possible that they are harmful. Therefore, we probably shouldn’t recommend that military personnel and veterans receive them as first-line treatments when there are “safer bets” available.

So why don’t I think that more access to free mental health care is necessarily a good thing? Because it depends on the treatment being offered. Easy access to ineffective or “alternative” treatments should not be supported, even if they are offered to military personnel for free or at reduced cost, because they have not been tested for safety. This is akin to your doctor prescribing a narcotic pain killer to treat your broken arm without setting the bone or putting it in a cast, and then not charging you for the prescription. Although this treatment plan will probably reduce your pain, it doesn’t really address the problem, and it increases your risk for another harmful outcome: narcotic dependence. Bad treatment is still bad, even if it doesn’t cost anything and even if a doctor has treated dozens or hundreds of patients in this manner for free. Few of us would choose such treatment for our loved ones, even at no cost; we shouldn’t choose it for our military personnel and veterans either.

This is not to suggest that brief cognitive behavioral therapy will prevent suicide attempts in all military personnel and veterans. Indeed, 15–25% of patients who receive this therapy make suicide attempts despite receiving the treatment as designed. Although we don’t yet have 100% efficacy, these treatments nonetheless have the greatest chance of working. That’s what clinical scientists mean when they talk about “empirically supported” or “evidence-based” treatments: They’re the ones to put your money on because they’re the safest bets.

Psychological injuries can be fatal, and many of us have lost friends, family members, and patients to these “invisible wounds.” The good news is that highly effective treatments do exist for many of these psychological injuries, and we’re continually improving them to make them work even better. The bad news is that these treatments are not yet widely available to military personnel and veterans. We as mental health professionals must therefore commit ourselves to learning and providing as many empirically supported treatments as possible. Our patients deserve no less.

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The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Virgil

    Virgil

    July 14th, 2014 at 7:22 AM

    I agree that it has to be a treatment that has been studied and proven to be effective, but I also think that there has to be more options available across the board, and that has to include access to any treatments that are deemed appropriate to the person. I don’t know how I feel that this has to be free or not, because someone has to pay for it, right? But the fact that having more opportunities out there for people would be the most important thing from my standpoint.

  • larinda

    larinda

    July 14th, 2014 at 11:22 AM

    sorry but if there is anyone who deserves access to free mental and physical health care then it is our veterans

  • Demian Brown

    Demian Brown

    July 14th, 2014 at 4:28 PM

    I agree with both of you to a certain extent. Trauma actually changes the brain itself… physically changes it permanently. It should be treated the same as any other medicine as far as coverage goes. Great post glad I found this blog. Therapy can help people adapt to changes in the brain, but can’t change the brain back…

  • Frank

    Frank

    July 15th, 2014 at 11:27 AM

    There needs to be some guidance there so that people will know if they are making the right choices when it comes to all of their options. Whta looks great on the surface may not necessarily be the best thing at that time, but could be a better choice for you later on.
    If there is someone there who can guide you then I think that there will be a whole lot more opportunities out there for those who are struggling to find some relief. But I do agree that just because it is there then that does not mean that is THE answer. It could be for some but then others may need to take a different approach.

  • jonathan

    jonathan

    July 16th, 2014 at 9:11 AM

    This needs to be true with any given healthcare event and with any citizen, veteran or not. We all need to slow down and make the best choices for ourselves and families, and it can’t always simply be based on what worked for someone esle or what we think will be the fastest fix. We all have to think about the decision that we are making and make sure that this will be the one that will not only offer us relief in the shortterm but also that it won’t be detrimental at some point down the road. It is hard to make a decison like that all the time when we are not too sure what the best one will be, but you have to not only think about the here and now but the future as well.

  • Cammie

    Cammie

    July 17th, 2014 at 6:19 AM

    It can be stressful due in large part that the frustration of the VA health system can be quite time consuming and often they feel like they have been waiting so long that they are just ready to feel better and could then illogically pick a plan that is not right for them. This is a shame because don’t they deserve the best? And then there are times that they are actually having to settle for the worst, all because of time issues.

  • Dr. Michael Picucci

    Dr. Michael Picucci

    September 29th, 2014 at 9:31 AM

    I am a seasoned traumatologist and I am willing to do some pro bono work with vets. I practice Somatic Experiencing and several other methods for resolution. If anyone know of someone interested in these services, please contact me.

    Thank you.

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