B0038M1ADS EBOK (36 page)

For veterans eligible for VA health-care services, there are medical facilities with outstanding mental health services available nationwide (and in the
U.S. territories). You can visit www.va.gov or wwwl.va.gov/health for more
information on eligibility, services, and to find the closest facility. OIF and
OEF veterans can benefit from priority in VA services for five years after discharge from the military. Note that VA mental health clinics are not the same
as VA Vet Centers. Vet Centers are located in the community and are specifically focused on readjustment counseling for combat veterans, while the
mental health clinics are located in VA medical facilities that offer the full
range of health-care services for both physical and mental health problems
to all eligible veterans, including those without combat campaign badges. Also, there are many more VA mental health clinics than Vet Centers, so
depending on your location, they may be the only option.

Both the military and VA health systems can be complicated and frustrating to deal with, but are staffed with professionals who are dedicated to helping warriors. One source of information that may be helpful in identifying
resources in your area or in answering questions is the Outreach Center of
the Defense Centers of Excellence for Psychological Health and Traumatic
Brain Injury (www.dcoe.health.mil/). Their toll free number, 1-866-966-1020,
is staffed twenty-four hours a day. Two other sites with extensive information
include the Deployment Health Clinical Center (www.pdhealth.mil) and the
VA National Center for PTSD (www.ncptsd.va.gov).

E) Emergency Departments, Crisis Centers

If you're in crisis or experience suicidal or homicidal feelings, the quickest
way to get into treatment is to call one of the crisis lines (e.g., 1-800-273TALK) or to go to the nearest emergency room. Emergency departments
generally have mental health professionals available on call who can conduct an evaluation and either make a referral to outpatient treatment or
facilitate hospitalization if necessary.

Species of Mental Health Professionals

There are several types of mental health professionals-including psychiatrists, psychologists, and clinical social workers-who as a group are also
referred to as "therapists," "psychotherapists," "counselors," or mental
health "clinicians." It can be confusing trying to figure out which discipline or clinic offers what you need. In most health-care settings, including DoD and VA, mental health professionals of different disciplines often
share the same clinic setting, which may be labeled "Behavioral Health,"
"Mental Health," etc. Mental health professionals also frequently work in
non-mental health settings, such as primary care, occupational health,
and rehabilitation medicine.

Mental health professionals generally can be grouped according to
the services they provide and their level of training, with psychiatrists,
clinical social workers, and psychologists being the most common. All are required to be licensed by the state they are practicing in, or any state if
they work for the federal government.

The outpatient treatment services generally fall into two categories:
medication treatment and psychotherapy (also called "talk therapy," "therapy," or "counseling"). Professionals will be able to provide one or both
of these treatment types. Psychotherapy can be administered on an individual or group basis.

Psychiatrists are medical doctors who completed four years of medical
or osteopathic school and at least four additional years in a psychiatry residency. They have the authority to prescribe medications. They may also provide psychotherapy, depending on the setting they practice in, their training,
and their own inclinations. However, since they are reimbursed at a higher
rate than other mental health professionals, in most medical settings the
appointment times for psychiatrists are too short to allow for psychotherapy,
and their practice is restricted largely to medication "management." Medication management includes evaluating the need for medications, prescribing
medications, and monitoring their effectiveness. Generally the first visit lasts
approximately one hour, and subsequent visits are limited to ten to thirty
minutes, unless the psychiatrist is also providing psychotherapy.

Clinical psychologists and clinical social workers are both trained to
provide psychotherapy services, generally in fifty-minute appointment
increments, but this may vary depending on the type of services. Social
workers and psychologists have either a master's level or doctoral level of
education after college. Some professionals (usually doctoral-level psychologists) also have specific expertise in administering complex and lengthy
psychological tests designed to provide additional information that may be
helpful in diagnosis and treatment. A few doctoral-level psychologists are
also licensed to prescribe medications. However, in terms of your needs,
the education level of a social worker or psychologist is not as important
as their level of clinical experience, and whether or not they have been
supervised for long enough to be permitted by their organization to practice independently without supervision by another licensed professional.

There are several other professional disciplines that work in mental
health treatment settings, including psychiatric nurses or nurse practitioners; occupational therapists; and other types of counselors, such as alcohol and
substance abuse counselors, and marital and family therapists.

General types of counseling are also available in nonmedical settings.
Most notably, many clergy members are trained in counseling, and can
provide emotional, social, and spiritual support to individuals and families
for a variety of problems that don't require specific medical treatment or
psychotherapy. Within the military, chaplains play a central role in providing counseling services in battalions, and often facilitate in helping warriors get treatment from other mental health professionals. Additionally,
there's a rapidly expanding industry called "life coaching," or "personal
life coaching," which has emerged from the human resources and positive
psychology fields. Coaching involves hiring a person (a coach) to help you
achieve life goals through a structured process that includes examining
values and beliefs, setting goals, defining a plan to achieve those goals, and
monitoring changes and progress. Life coaches go to great lengths to distinguish themselves from therapists or mental health counselors, although
many of the same principles underlie coaching and more-traditional forms
of counseling, particularly in the use of positive psychology and cognitive
behavioral approaches. Coaching is certainly not a treatment for PTSD or
any other mental health disorder, but it can offer skills that are useful in
achieving measurable goals.

Your First Appointment with a Mental Health Professional

If at all possible, avoid your first and second appointment with the mental
health professional and start with the third one. When you show up for
your third appointment, act like you've gotten a lot out of the first two.
(Okay, just joking.)

The most important thing about starting treatment is to have patience
and an open mind. It generally doesn't matter which type of specialist
you start with, although it's nice to know who you'll see, so you can assess
if their orientation is geared more toward medicines (a psychiatrist) or
more toward psychotherapy (e.g., social workers, psychologists, and some
psychiatrists). Some clinics have everyone see an intake counselor to
gather initial information for the convenience of the psychologist, social worker, or psychiatrist; other clinics will have you start with a social worker
or psychologist, and then if they think medication is indicated, they will
make a referral to a psychiatrist (or vice versa). In some cases, primary care
doctors will work with psychologists or social workers to provide medication prescriptions.

The first session will generally last about an hour and will include discussion of your current problems, medical history, history of any prior
mental health treatment, alcohol and substance use, and your personal
history (e.g., upbringing, education, occupation, marital/family history,
current stressors). There will also be questions related to suicidal or homicidal ideation that are routinely asked. Bear in mind that the first session
is generally just for information gathering, although it can provide a great
sense of relief if you find a professional who seems genuinely concerned
and interested in helping you.

It's not uncommon for warriors to have bad experiences on their initial visit. This can happen for several reasons: First, the mental health clinician may not provide sufficient time or attentiveness for the warrior to feel
like their concerns are being adequately addressed. Mental health clinic
settings can be very busy places, and sometimes the first appointment feels
rushed or the clinician may be too abrupt. This can happen because the
number of patients has overwhelmed the clinician's ability to give everyone sufficient time; because the clinician seems more interested in communicating with the computer than with the client (which may reflect
cumbersome requirements for electronic documentation); because their
personality is abrupt in general; or because the clinician is having a bad
day or is suffering from their own mental health problems. Whatever the
reason, the warrior rightfully feels brushed off or misunderstood.

Second, the clinician might not adequately understand the military
context of the problems, or they might speak in a way that reveals their
own assumptions about the nature of the warrior's experience. They could
be perceived as judgmental or condescending, and this can get things off
to a bad start.

Third, the mental health clinician's recommendations, which they
provide near the end of the first session, might not mesh with the warrior's needs or expectations, both in terms of the diagnoses or the recommended
treatment. If the initial visit is with a psychiatrist, medications are more
likely to be recommended than if the visit is with a social worker, psychologist, or other counselor, although this is not universal. This can sometimes
relate to what the clinician is most comfortable with, rather than what's
best for the warrior at this moment. Many warriors are indeed ready and
willing to try medication, and there are many safe and effective options
available, but others are either unwilling to take medicines at all or need
time to think about it before making the commitment. The psychiatrist
will likely do a good job explaining the risks and benefits of several medication options, but may not do as good a job explaining the wider range of
psychotherapy alternatives.

On the flip side, if the initial visit is with a psychologist or social
worker, they may promote the specific type(s) of psychotherapy techniques they're most comfortable with and focus less on medications.
Again, this can relate to what the clinician is most comfortable with, not
necessarily what's best for the warrior. These comments are broad generalizations, and there are a lot of individual differences in the approach
that clinicians take.

If your initial experience is positive, you're off to a good start. If
not, don't lose hope, and try not to get frustrated; just accept that you'll
need more patience to work through this. You can tell the mental health
professional how you feel and let them know that the visit didn't live up
to your expectations; you can ask additional questions to ensure that
you understand the full range of treatments and that the professional is
giving you a complete picture of your options (both psychotherapy and
medicines); and you can ask the therapist what their experience is in
treating veterans with combat-related problems. Their response to these
questions and feedback will tell you a lot. You can also ask to see a different professional or you can go somewhere else. Just because your initial
visit wasn't a positive experience, don't let that affect your determination
to get the help you need and deserve, and to keep asking questions until
you get satisfactory answers.

Advice for Mental Health Professionals (and Considerations that
Warriors Generally Appreciate)

For any mental health professionals reading this, here is my advice for building a therapeutic relationship with a warrior: Be honest, direct, genuine,
accessible, and empathetic. Honesty means stating what you know from your
professional expertise and admitting when you don't have the answers (as is
likely, since treatment of mental health problems is never straightforward).
Being direct means maintaining eye contact with your client, not the computer screen (which also means that you'll probably have to write incredibly
brief notes to survive your busy schedule). If asked a direct question that you
don't have an adequate answer to, say that you don't know but will track the
answer down. Don't do what many of your colleagues do, which is to shift to
the highly effective (for them) defense mechanism of unintelligible jargon
when asked a question that they don't have an adequate answer to. Don't
make assumptions about military culture or the warrior's experience; ask
for clarification from the warrior if there's something that you don't understand, even seemingly minor things (which aren't minor to warriors), like
rank structure or occupational roles. Being genuine means being a good
listener and not beating around the bush; warriors can be very attuned to
the perception of being brushed off or to indirect forms of communication.
Treat everyone with the utmost respect and honor their service, whatever
rank or duty they had during deployment (private, general, government
worker, contractor, etc.). They are professionals who did highly skilled jobs
under very difficult circumstances. Being accessible means making it clear
how to get in touch with you and making yourself available with minimal
barriers when the warrior needs something.