Department of Veterans Affairs Contribution to

the Social & Treatment Stigma of Post-traumatic

Stress Disorder
FLASHBACKS of Organizational Deficiencies Leading to the Disintegration of Treatment
Routine of Recent Combat and Non Combat Forces: Internal Dynamics of Competition for
Treatment in Health Care and Congressional Politics
Synopsis: Oral Arguments By Vietnam Veteran on the Organizational
Structure and Strength of Department of Veterans Affairs Staff
Militancy and Pathological Organizational Survival Strategy To Thwart
Combat Veteran Post Traumatic Stress Recovery Research
Fall 2014
Robert Osenenko, Ed.D., LCSW
Medicare Services US
57 South Main Street #279
Neptune, New Jersey 07753
Invocation
Joseph Campbell wrote in The Masks of God, Vol. I Primitive Mythology in 1991 Whenever men have
looked for something solid on which to found their lives, they have chosen not the facts in which the
world abounds, but the myths of an immemorial imagination.
About The Author
Robert Osenenko lives in the New Jersey Pinelands Reserve area. Robert is a past member of the American
Folklore Society. He is considered an expert in social psychology and holds a New Jersey State Board License
in Clinical Social Work. In 2013 he wrote, Family, Faith, Land and Mysticism an historical fiction account. He
is a recipient of ten military related service awards and trained at the Centers for Disease Control. He is a
decorated infantry combat veteran. He went to the State University of New York and Goddard College. His
doctorate is in education.
Preface to Argument One
Visiting the Stockton State College campus in the Fall we ate at a nearby shack that was a former gas station.
The owner made a great SOS of creamed beef and grapes were a side order. He stated that he became successful
based on an old adage popular in the South, Im from Missouri. You gotta show me. In these pages I hope to
do that.
The two theories surrounding higher rates of compensation claims for related post-traumatic stress disorder
payment focus on the reasons why non-combat and combat veterans make the claim. Rather than covering the
subject as Over-reporting bias and the modified Stroop effect in Operation Enduring and Iraqi Freedom
veterans with and without PTSD, (Constans, Joseph I.; Kimbrell, Timothy A.; Nanney, John. T.; Marx, Brian
P.; Jegley, Susan; Pyne, Jeffrey M. In Journal of Abnormal Psychology, Vol 123 (1), Feb 2014, 81-90.) I would
like to discuss the issue in another context.
That is, most academic discussions do not address the role of the government in this process. What I mean is
does the government encourage the veterans claims process. If we believe it does not, then our conclusion
denies the historical context of the governmental role to gain participation in its programs not only to cure the
ills of society, but to encourage the utilization of its services. Often, we learn later that the service duplicates
another, then another well managed program bites the dust, and in place of it the duplication thrives at the
federal level. Is the public served well by a federal duplication of veteran service beyond the short term goal of
agency survival?
Department of Veterans Affairs (DVA) as it runs into public disrepute is the downfall of the once healthy
human organization. DVA is a duplication of state and local priorities. To resolve duplication the President
Ronald Reagan administration instituted Reaganomics. It did so without a strategic safety net and created a
devastating gap among combat veteran services in the DVA versus what civilian services were available. There
was a certain kind of carelessness that Vietnam combat veterans perceived was personally levied against them.
Reaganomics was not logical either because at the time DVA hospitals were functioning as leaders in the health
care field and regarded highly.
In one of his famous clich President Ronald Reagan remarked, Government is the problem. He acted and cut
back DVA 160,000 staff making no friendships at DVA. Later, President William Jefferson Clinton cut another
160,000 and President Bush and Obama sliced more. Based on this history, we cannot conclude fiscal cuts were
along political party lines. No politician seemed to like DVA. All presidents followed essentially the same call
for corporatizing the DVA. We do not know whether President Reagan regarded knowledge and research,
health care and wellness services purely as a private sector endeavor. There was nothing creative about these
cuts and they were brutal bringing credibility to Vietnam combat veterans to call for reform. Sometimes the call
was perceived as militancy.
Had anyone in government realized that once you lay off the gatekeepers and kingpins of the internal DVA
system, it could bust the entire organization at its seams. What becomes of the field offices nearby the leaders of
Congress who wish to have more and more constituency services for all former service members and combat
veterans to bring in the votes. Internal governance of the DVA did in fact crumble under the pressure of its own
weight corresponding to the well known decay of historic buildings that were ignored and robbed of new mortar
and joint compound. It is the pragmatic result of what we did and shared as a nation. In a nutshell, we have the
veterans' system we created and need to decide whether this is what we want, or get to be busy and replace the
decay with a well maintained structure. It's worthy of having a conversation about the largest influential health
care organization serving defense veterans in the world.
Most voters realize that the nation as a whole has entered a period in which all values need to be reevaluated. In
health care data needs to be examined on what the health care of war is. With the high incidence hearing loss,
low incidence post-traumatic stress disorder, and intense physical wounds research can show us a light on what
needs attention. It may be a justification to reallocate funds from one program to another and as important as the
weapons firing protection gear. Before the researcher begins their enthusiasm to make such important findings
their goal, lets get into the weeds and part the grass while peaking in on two logical places for that new age
research to occur. Most likely researchers are interested doing their research collaboratively with the
Department of Veterans Affairs (DVA) and the inpatient post-traumatic stress disorder program as well as the
outpatient side embodied in the Readjustment Counseling Service Vet Center Program.
When characterizing Vet Centers, they are in non-traditional medical facility office locations. These offices and
visible locations have not removed them from ties to the medical mission of the DVA organization. They have
a clinical responsibility to tie themselves into the DVA medical center and make any continuity of care possible
while extending it to civilian health care mental health practitioners.
Argument One
Treatment approaches used in the diagnostic process of post-traumatic stress disorder resulting from combat are
devised outside of organizational models and function by the American Psychiatric Association. All treatment
models get defined this way until once tried on the site of the intervention. Then, during this phase, they run
trials and are refined or abandoned. It is no small task to find the correct juncture of the trial, then ultimately put
a diagnostic theory into practice. The process could take years, if it involves medication. In the age of fiscal
responsibility these traditional approaches may need to be altered by a preliminary consideration of the
organizational response to new theory and its implementation by outside entities. Spending time toiling on the
front lines at treatment locations, interviewing staff, and gaining some knowledge about how their current
processes work, are invaluable for development of appropriate theory and can provide a framework of
limitations.
An accurate diagnosis of combat post-traumatic stress disorder should include where the patient is treated.
During the diagnostic theory phase the military, DVA post-traumatic stress disorder program, and civilian
treating counterparts of combat veterans' data should come together to create a picture of the diagnosis. But as
positive as these considerations are, researchers may not always be welcomed in the organizational
environment. Barriers to performing preliminary research may include the surreptitious resistance. It may come
in the form of rumor which are potentially devastating to the credibility of the data.
Taking such consideration to account the following argument is offered. It comes in the form of a nonfiction
participant observation of the difficulty one can expect researching and working with the Department of
Veterans Affairs (DVA). Organizational history buffs will recognize the various internal changes as the
Department has altered itself to correspond with changing demands inherent in working with the public. It
begins with this opening statement to the audience:
I appreciate your time as I seize the opportunity to address the activities of the Department of Veterans Affairs
(DVA) and Vet Center program and the role it plays in providing outreach and mental health care for veterans
returning from combat operations. I ask that you read this narrative on your desk from the point of view as a
mental health provider. It is my contention that this content may be useful when considering the proposed
changes by the President to meet the mental health need of the combat force, and the needs of those retirees and
others departing the combat force. The key point is to look for the healthiest part of DVA where you may
envision research can be conducted in all of its phases without disruption and resistance.
To the communities and military bases in the Continental United States (CONUS) this return will be
transformative for the nation. Twenty combat veterans will die today from suicide. In all probability this
number could have been reduced by an effective DVA plan of continuity of care not more DVA Vet Centers.
There must be a deliberate and forceful drive away from the DVA culture and club mentality which prevents
DVA and Vet Center operations from becoming as sophisticated and effective as the military. They have
managed to integrate some medical and psychiatric function into primary care. Civilian mental health care is
seeing combat veterans through Medicare. These may be data collection sites less complicated than DVA.
Time to time there have been many
i
DVA Office of The Inspector General reviews about the Vet Center
program. In all of this critique one theme consistently emerges. The Vet Center program in 1979 is much the
same as it is today in failing to curb the suicide rate. This may be because the DVA location of facilities is not
being vetted by the state government establishment.
It has been
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questioned, whether relocation of, Vet Center and DVA Community Clinics have been free of
political interference. So it is that on the state level a health care facility must go through consumer scrutiny to
locate in our communities through the certificate of need process. The process may be far from perfect, but it
relies on need without particular preference given to a specific politician. Assuming it is by coincidence, a
former Congressional chair of the House Veterans Committee has several DVA facilities in his district. It can be
assumed that because these facilities did not pass the process afforded to the state requirement no particular
consensus was necessary and no continuity of care strategy planned and written for.
To the point, most Vet Centers are still permitted to operate primarily in the proximity of a DVA medical and
community based facility. So when the Vet Center program is called outreach it is a mythical description of its
function to further assume it gets outside this geographic bubble. Due to its physical proximity to large DVA
medical centers more accurately Vet Centers are a nearby less threatening office space. Naturally, these
clustering services have contributed in leaving other geographic and service areas neglected. There can be as
many as two Vet Centers and two community clinics, one DVA medical center in close proximity, but
organizationally tied to another DVA medical center sixty miles away. When researching Vet Center data it is
important to realize that one recorded visit may be almost simultaneously (that day or month) be recorded by
another site at the same city using another diagnosis. On the surface the data may be reported as several visits if
it occurred the same day when actually it was one visit to the DVA. All aggregate data from the DVA should be
scrutinized and validated as on first appearance, it might seem like there are more patients but are the same
patient having more visits.
There is a substantial need for community based coordination of health care and clinical services, but the
need may far outweigh the qualification of DVA Vet Center staff. Caution should be exercised when
considering staff as experts. DVA continues to be a self-contained organization much like a fraternity,
not an agent accustomed to collaborating with the professional equivalent in their communities except to
enhance productivity.
The 1979 personnel hiring standard use the job title Readjustment Counseling Therapist. The term Veterans
and Health Affairs qualified (VHA) does not correspond to any state license classification, state license
academic preparation, and is a purely mystical array, and jumbled requirement that is impossible to measure. In
other words, it represents the mental health counselor positions that were predominant in about 1979 as they
tapped peer counselors to do outreach. In a bipartisan New York mental health counseling and the use of such
generalized meaningless titles such as readjustment counseling therapist were made null. Either one is or is
not a licensed psychotherapist no matter how artful one dances around credential issues. A Readjustment
Counselor may not be state licensed.
Mythology plays a major role in the DVA organization and is responsible for misleading information that
cannot be verified. Such as, Arthur S. Blank, MD and Alfonso Batres, PhD Vet Center directors have supported
the use of Readjustment Counseling Therapist while expressing combat veterans can only know combat
veterans treatment. Since 1979, Vet Centers have developed no PTSD treatment model for public and
professional use on any aspect of PTSD that has been vetted in the civilian sector.
Vet Centers provide a little readjustment clinical counseling, but the other coexisting side of, Vet Center
intervention is a hodgepodge of patchwork job counseling, substance use counseling, peer type rappers, benefits
counseling, referrals to community services, self-help, and other entitlement services as Vet Center perceived to
be needed in particular localities. The Vet Center program has resisted any move to make it a singular clinical
service or a singular benefits service. DVA PTSD inpatient units and Vet Center do not have written
coordination plans between them. Intake information does not exist in transparent form to allow for continuity
of care, forcing patients to repeat a continuous story of war trauma. There are no aggregate data publicly
available for each DVA organizational location, as all data seems to be duplicated by other state and local
agencies near its urban locale.
Seeing that there absolutely is a duplication of entitlement programs in urban areas there is a likelihood that Vet
Center is part of that array. Most people would not argue that if eligibility is duplicated then agencies must bear
the responsibility of duplication equally with Vet Centers. None of these agencies serving basic needs has the
congressional mandate to identify mental health issues as well. Wisely state and local governments keep mental
health criteria separate. Only Vet Center can diagnose entitlement and poverty problems with readjustment
problems. State labor and industry specialists should have exclusive domain over veteran employment issues.
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Immediate family members of eligible veterans are also eligible for certain Vet Center mental health services.
They have been impacted as well and in some ways trapped by the growing distraction of the Vet Center
program from the national priority of suicide prevention and mental health while working with an array of state
and local (duplicating) entitlement services. Programmatic confusion can lead to data problems.
At times, Vet Centers that wanted to move forward with mental health delivery could not due to the 1979
priorities disrupting Vet Center operations. This revealed that regional Vet Center management had not
supported the initial Vet Center congressional clinical mandate. The hallmark case example illustrating this was
known by insiders as the New Haven incident where the team leader had to be relocated for her safety when
she instituted the actual Vet Center clinical policy. There have been numerous incidents as New Haven since
1979. She was not alone as hundreds of qualified staff left the Vet Center and were forced out just for
implementing good clinical practices. Apparently that is where the Vet Center is today, for the choice it made to
support its role in entitlement program interferes with rather than enhances a clinical focus. This raises the issue
of whether outside researchers need to be escorted onto DVA and Vet Center facilities for their safety when
conducting research of a programmatic nature.
There is a broad offering of PTSD preparation in the public sector, and no particular reason why Vet Centers
whom are often in proximity to civilian mental health providers should not be replaced as data obtaining sites
by them. It is a logical step and one that DVA and Vet Centers initiated themselves by purposefully
implementing relocations in the proximity of likewise services. Perhaps this is intended as their
iv
location often
coincides with services and providers that may easily assume their caseload and function.
Military and civilian hospitals are working to improve
v
clinical recording guidelines across the healthcare
network in the Continental United States (CONUS). Essentially, this provides the written coordination of
continuity of care. The value of it cannot be underestimated for national needs and research that may arise from
sharing knowledge opportunities. Most healthcare professionals know that and have experienced it. It's called
interstate agreement of continuity of care. All continuity of care derives from a well written, managed,
transparent medical record. Well kept records can be a treasure trove of clinical data.
Vet Centers have an intake protocol specifically designed for this purpose, Vet Center counselors - many of
who were themselves combat veterans assess all returning veterans for depression, acute war zone stress
reaction, suicidal/homicidal ideation and other possible readjustment issues, such as emerging family issues.
But rarely, if ever conduct the structured triage of psychiatric assessment; something a Medicare mental health
professional does more extensively and as routinely required once for each new visit. Drawing a comparison,
Medicare ensures clinical information is available in the record through continuously monitoring professionals.
Perhaps to solve the unavailability of, Vet Center data, the Medicare personnel process should be adopted.
Apparently there is a movement underway in the Vet Center program to militate against recording clinical
work. Since the 1980s no successful effort had been undertaken to gain medical record recording compliance.
Probably this comes as a result of the assistant regional managers for counseling and their internal propagation
of this wives tale:
It has always been rumored that a fear exists within the Readjustment Counseling Service. It is based on the
notion that improving clinical quality means that the Service is setting itself up for being contracted out. This
of course is beside the point, because the focus should be on quality. Quality is what defines expertise in
professional intervention not job preservation.
Lack of focus, lack of integration, and lack of organizational governance showed some Vet Centers improved
while others did not. Since 1995 this has been a game of musical chairs between the DVA OIG and the Vet
Center program that has not advanced clinical documentation 100%. So that from 1995 through 2014 the Vet
Center program has never met the 100% clinical writing requirement. This is incomprehensible since the
majority of, Vet Center personnel are veterans and combat veterans or family members and know how clinical
recording plays such an important role in their care and in some instances their recovery from disabilities.
Referencing this report and read to see it:
Report No. 10-00628-170 May 17, 2011 DVA Office of Inspector General (OIG), Washington, DC
Underlying problems not mentioned by the DVA OIG that impact accurate data collection and suggested
remedies.
I. Vet Centers are run by Readjustment Counseling Service (Readjustment Counseling Service) and
obviously are tied in the DVA Regional Medical Education Conference, a kind of college. To educate,
Vet Centers should be tied into regional military and/or civilian academic medical hospitals in the
emerging new training discoveries of post-traumatic stress disorder within primary care models.
A. Cross training should be conducted with post-traumatic stress disorder military and civilian experts
immediately. Not just for cost efficiency, but exchange of therapeutic approach.
B. Vet Center personnel that have an interest should be assessed by the DVA Vocational Rehabilitation
Service and a way toward clinical academic improvement charted out. Those with degrees should be
worked with to obtain licenses because the avenue for this exists in all states. Supervisors should be
licensed by their state boards to be supervisors which will improve their standing and reduce personnel
issues. This may be an important step for DVA and Vet Centers to discover the need and use of clinical
practice, criticism, and retain its professionals. At the conclusion of successful credentialing, they
should be posted to the website indicating degree, licensure and specialization.
III. Clinical recording software is available at a lower cost than ever before for clinicians. Vet Center staff
should be using this so that when DVA files are ultimately transparent across health care networks post-
traumatic stress disorder patients can benefit through the Vet Center clinical record. Most such software are of
the same general quality.
B. Without Vet Center staff clinical improvement, and licensure, a staff members assessment
cannot be used as evidence for a DVA claim. Thereby ruining the chances that a full admission
during therapy in a Vet Center must be repeated to another more qualified clinician at the DVA
medical center.
IV. A DVA OIG criteria not mentioned in their report are the continuous clinical monitor. It is strange that
such a basic simplistic mechanism that exists throughout the mental health system does not exist in the
Readjustment Counseling Service. There exists no hospital based utilization review committee standards in
Readjustment Counseling Service. The DVA Regional Medical Centers should be tasked with including Vet
Centers in their current continuous monitoring of DVA OIG clinical deficiencies and additionally:
C. The Department of Veterans Affairs could establish a Vet Center utilization review/quality
assurance guideline (continuous monitor program) during the interim between DVA OIG
inspection periods in an effort to protect the quality of care and referral, discharge planning of
patients, and protect ongoing staff improvement momentum. It can have unified goals such as to
reach the post-traumatic stress disorder inpatient being discharged. Yet no one in DVA seems to
have any idea of how its organizational structure could be improved to foster communication
around these roles.
D. Readjustment Counseling Service at a drop of the hat produces much internal closely, held to
the chest, data on the number of referrals it makes to DVA medical center programs. But this
alone serves to hide the true story. DVA medical centers do not routinely refer its discharged
psychiatric patients to Vet Centers part-and-parcel of discharge planning. In short, the
Readjustment Counseling Service's contention of successful clinical coordination is but a wives
tale of mythical proportion. Additionally, it is shameful that Vet Center does not have qualified
staff to make a 100% rate of performing a complete psychiatric intake to ensure DVA medical
center hospitalization visits get a triage that could be used to obtain disability benefits. There is no
excuse for not performing it at the community level where the combat veteran and family is. No
visitor should have to beat the bushes to locate a professional contract to accept the information
and record it. DVA medical seems to have withdrawn itself from the benefits process.
E. All Vet Centers should be inspected by the Society for Hospital Social Workers or equivalent
from the Joint Commission on Healthcare Organizations.
IV. Vet Centers have long been stating that they possess a secret knowledge and expertise of post-traumatic
stress disorder. Readjustment Counseling Service has not dispensed evidential these delusional beliefs, are true.
This well nourished pathological culture is built on the throwing salt over a shoulder theory. A true effort
should be made by Readjustment Counseling Service to contract to a psychiatrist, psychiatric nurse practitioner,
psychiatric practitioner or neurologist to be detailed to Vet Centers on a rotating basis.
In most states respective Department of Human Services has psychiatric day programs and senior day program
that is state approved and licensed. Psychiatrists, doctor of osteopathy, nurse practitioners and other MDs
which DVA and Vet Center might tap on a contract basis; these arrangements could be solicited for
participation in such an effort. MDs have traditionally been a useful source of professional education. One
lesson learned from the 8,000 veteran suicide deaths in 2013 is that the public needs to have research based
interventions that all levels of government can turn to if this trend is to be reversed. It makes sense that using
external civilian consultants currently in use by the states could offer a better community based clinical footing
than what exists now. That might provide a juncture for a researcher could use to study treatment and
demographic research. It would also transmit the interest in continuity of care the DVA and Vet Center decline
to participate in. After all, civilians still run the country, not the DVA.
Closing Statement and Recap- Argument One
In the absence of a policy position from the White House on whether to close the Department of Veterans
Affairs by Presidential actions, they have made it clear they will continue to pursue this path. President Ronald
Reagan had acted decisively to take away the clinical underpinning and foundation of the Department of
Veterans Affairs. Not just that, but he acted without hesitation to close the National Institute of Health Public
Health Hospital and Bureau of Indian Affairs medical facilities. His policies could be disputed were it not for
almost a total consensus by other Presidents that reform and program constraints must be initiated. That nearly
makes fiscal austerity a done deal. Part of the downsizing process should include unprecedented access for
researchers seeking answers to the veteran suicide and combat veteran concerns the public has. Not in the next
decade, but now. DVA is all but closed as it is lagging behind the civilian and military programmatic response
to post traumatic stress disorder.
The President giving the least support to Reaganomics was President George H.W. Bush, who was also a
combat veteran often scorning the theory as Voodoo Economics, a theory just for short term gain. Voodoo
economics were described as shifting money from Peter to pay Paul but not solving any specific dilemma. For
the DVA it meant the removal of clinical programs, a degree of expected rebuttal by employees (militancy), and
disintegration of service coordination.
Department of Veterans Affairs clinic services were reorganized into such patchwork systems that it became
impossible to determine the productivity numbers and the accuracy of whom it served. It was a survival strategy
after a while to effectively jumble productivity data. This served to thwart efforts to scrutinize its programmatic
response to possible medical service emergencies. From clinical services deep within the Department ranks
emerged what
vi
Jorge Taborga calls the organizational archetype of a resistant personnel that refuted leadership
productivity demands. We all know the result, eventually it became a management strategy that was encouraged
and rewarded. Mark Dr. Taborga, as his categorization will appear and reappear throughout the life of the
Department. Indeed, while the leadership may have made some effort for a search to destroy a pathological
culture of productivity reporting, the Department of Veterans Affairs organizational archetypes, standard
bearers, have survived decades of previous scrutiny.
Jumbled productivity schemes, is a tactic that inadvertently ruins all possibilities that the Department of
Veterans Affairs could be taken seriously, even by the half serious media attention given to the topic. Especially
after its research repeatedly fails the validity test, in the face of past university inquiry. Refer to the footnote
references. Researchers should be leery of the Department of Veterans Affairs archetypes and try to account for
them not as anomaly of the past but alive in the DVA culture. A type of game in elusiveness. See the
productivity now and watch the productivity disappear. There goes the DVA validity out the window.
The DVA has tried to make the research efforts of some universities and individual inquiry into a maze of
protocol. To resolve its transparency problem by working with the MITRE Corporation, which is a federally
funded nonprofit entity. No surprise the DVA solution to transparency is not to become absolutely transparent,
but to develop a bureaucracy like it. Kind of a reflection of itself through smoke and mirrors. Were DVA to
become transparent and allow first university based and independent researchers already under federal research
agreement to assess its clinical PTSD program, there would become a sufficient library of data stored that
would offer a well of possibility for more effective and integrated treatment models. The typical DVA strategy
reveals itself: to have a MITRE focus on external service integration while internal treatment models deteriorate
and do not fall under scrutiny by the public.
This leaves up and coming university researchers interested in post traumatic stress disorder with a challenge of
major proportion as they strive to inform the public and the medical community. Considering when and where
research should be validated with the Department of Veterans Affairs is perhaps like opening a clinical trial in a
burning city of Rome. Upon these ruins, field tests and validity are almost certain to fail unless a control setting
outside the Department of Veterans Affairs is used. In the next argument the audience will hear what happens
when bold and excruciating research does take place and the outcome. The issue of research validity is
contained there.
Preface for Argument Two
During the Department of Veterans Affairs (DVA) post-Vietnam period when the checks in the balances
began to be eliminated a new professional image came on the scene. It was the introduction of what was known
as the Veteran Militant. One of the campaigns and the goals of this group was to resist the efforts by
vii
Dr.
Kenneth Kizer an international health care consulting MD that instituted a unique policy to American health
care in the Department of Veterans Affairs. His plan began the Reaganomics initiative to downsize the
Department. Coincidentally, his regime coincided with the years when the most corruption riddled the hospital
program. When the medical department shrank it took with it a chunk of the academic program, and many of its
clinical chiefs who made their notches caring for WWII and Vietnam wounded. This militancy failed to
infiltrate the DVA.
Corporatizing the Department of Veterans Affairs was synonymous with politicizing the delivery of health care.
More Congressional inquiry, increased daily directives, drew attention away from traditional mental health
services like individual psychotherapy. Instead, Dr. Kizers clones had redirected activities to constituency
groups in the community, instead of clinical treatment planning for its most vulnerable and sick veterans. Dr.
Kizers research initiatives were said to be underwhelming particularly evident was this when
viii
the Centers for
Disease Control did a look back study and found one piece of important research could not be validated. The
corporate shift in political policy caused certain consumer groups to rally to speak out. Often attempting to
shout over local DVA medical director daily directives they found insulting. Some non-combat veterans groups
pushed for homeless initiative, and different causes that eventually came under the rubric of special population
needs. This meant uneven funding allotment as bed shortages developed. Radicalization and militancy had
found its way into the government health care system drawing away from its clinical focus. (Note that the DVA
domiciliary program was never intended to become a non-combat veteran program.)
These changes were not without critics and finger wagging as Vietnam combat veterans statistically showed an
increase in mortality. One of the most vocal was the
ix
American Hospital Association (AHA). Under better
circumstances, no health care organization or reputable professional would ignore the AHA, but it was not the
era of adherence to fact. It was the era of myth and old wives tales. Not the least of these had been the
Congressional need for reelection, which most people understand is not a hallmark of factual data. Right when
it would have been most useful to adhere to AHA warnings, at least for Vietnam Combat veterans with Agent
Orange exposure, Vietnam war casualties was not on the agenda for research. Despite personal testimony,
Congressional complaints, and many cries of families the Department of Veterans Affairs was otherwise
preoccupied with its own political survival. By 2012 the Vietnam veteran exposed to Agent Orange was roughly
the yearly total during the Vietnam Wars highest casualty year. In a nutshell, that is the strongest indictment of
special programs and political correctness. Similarly, the DVA in 2012 is substantially involved in spending a
vast amount of time investigating itself, having its shadow MITRE, and Congress in a pursuit of everything and
anything instead of the important clinical data of combat veteran deaths and illnesses.
Strangely enough, the Department of Veterans Affairs has returned full circle to another Vietnam veteran crisis,
arriving at yet another critical clinical juncture. Is the Presidential administration interested? Yes. In 2014 it
appointed a new regime to head the Department. The capacity of the Department to deliver research is at the
most critical stage for the Persian Gulf, Iraq, and Afghanistan combat veterans. With research the health care
community will know where and how to deploy financial assets for short and long term goals. The public can
discover what has been done and where we need to go. MITRE, a DVA creation will possibly do for its image
what their research did for the Agent Orange and Agent Blue afflicted.
Steven Coughlin, a former epidemiologist for the Department of Veterans Affairs was quoted in an article
written by Bryant Jordan March 14, 2013 of the Military. Com stated, "On the rare occasions when embarrassing
study results are released, data are manipulated to make them unintelligible, he told the House Subcommittee
on Oversight and Investigations. Coughlin said his former office never released findings of a $10 million study
that produced data on 60,000 Iraq and Afghan war vets of which up to 30 percent were Gulf War vets that
revealed exposures to pesticides, oil well fires and more.
With these realities in mind, there is an important piece of research done on the progress within the Department
of Veterans Affairs. Not to be understated the achievement of the researchers the project itself is titled, Why are
Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? by Richard
J. McNally Department of Psychology, Harvard University William James Hall 33 Kirkland Street, Cambridge,
MA 2138 is no small accomplishment. Interpreting the research from an organizational perspective, it says volumes
about the capability of the Department of Veterans Affairs to cope with internal factors that militate against quality
clinical services during the most important criminal and ethical investigation period of its existence:
Argument Two
The Department of Veterans Affairs (DVA) data is only as good as its collection and those willing to carefully
record an accurate visit. Visitors to the DVA have not felt confident they can leave it to the DVA to tell their story.
There is a slow fading loyalty veteran service organizations show in their support for DVA. Here are some reasons
why and what implications it has for researchers that want to report their stories accurately and over time.
The Department of Veterans Affairs has held the defensive research position, being protective of its data at least
since the 1980s. Their data reporting has been used not only for measuring internal trends, but to defend itself
against congressional budget cut hawks. Strangely enough, although proven several times to be repeatedly wrong
the data were also used by Congress to request a facility be opened in their district, so long as the data justified
the need. Medical necessity among the veteran population as a whole is as changing as the rest of health care and
requires flexible treatment approaches. These considerations are both the limitations of research and the hope of
it could be a deciding factor for policy makers when pointing the national agenda in the right direction. That is,
if medical necessity guides their judgment.
Congress acts on the Departments data on face value creating policy and programming as well as for spending
allotments for special population intervention. Instead of Congress correlating the data with (ready) available data
at the state level, such as suicide incidence and health demographics, Congress has relied solely on DVA. In other
words, there seems a total absence of the vital importance of epidemiological study and deliberation, capable,
intelligent intervention that is absent of power brokering by Congress and the street influence by constituents.
These factors reduce the hopes of good judgment by Congress to the street level. It also adds a level of complication
for outside researchers who might find DVA has released a set of data contradicting their findings. Lets find the
history of the DVA defensive character found in many of their outcomes data.
Ostensibly data took on a nonscientific application during the President Reagan administration when it initiated
the first deep staff cuts of an estimated 160,000. Presidents Clinton and Bush matched those cuts and destroyed
the DVA psychiatric clinical program thru understaffing. Thus, it created the first nursing crisis in America. Later
this led to a demise of the DVA domiciliary homeless and the incarcerated veterans program, then comprising a
majority census of non-combat veterans in its special population programs. In truth combat veterans stopped
swarming to the DVA as it relied on non-combat veteran programs for its defense to remain in existence. When
the Presidency decided to allow state and local government entitlement programs to take over the non-combat
veteran assistance role the productivity numbers were strikingly low for combat veteran participation.
But social forces were underway to bring these special populations back. Partially to restore what program cuts
removed. In doing this, coincidentally non-combat veteran votes may also have returned to Congress; for those
that had street credibility for having such DVA entitlement facilities in their district. Wait times for combat veterans
competing against special population vacancy rates were a byproduct. DVA has never reported the unique visit
data count of each combat veteran eligibility criteria on its website. Meanwhile, in the Department, productivity
numbers once again became a total defense against fiscal austerity and thats where the war lines have been drawn
for quite some time.
These historical austerity reductions in force (RIFs) also reduced DVA substance abuse and conjoint inpatient
post-traumatic stress staff for combat veterans.
x
Presidential administrations rightfully believed the facilities and
staff were aging in and included them among those slated for RIF. Persistent in finding ways to parry down the
DVA productivity it married high productivity requirement with clinical care, but did not define the core as a
solely combat veteran eligible care requirement. These demands resulted in a justification to cut even more
positions. That is why today DVA actually is a patchwork of contracted out nonprofit services of special programs
previously performed solely by federal employees. This is in many respects a strange sort of sub-organizational
DVA comprised of a ready so-called dispensable staff volunteer force that can easily be dismissed at the proper
time when the Presidential downsizing acceptability goal is met. Congress seems to abide with this strategy as
perhaps they see no interference in keeping hold of the non-combat and the combat veteran vote. These are the
services MITRE hopes to study.
While these myriad of DVA services exist, it does so primarily for the non-combat veteran. Combat veterans
continue to have difficulty accessing care due to serious clinical staffing problems. Namely, there is no central
clinical coordination for continuity of care. For researchers this is seriously the important story of how the DVA
national health care system works hiding data among each little DVA entity across the US. Central data do not
exist at least not visible, nor ready for public digestion or criticism. Therefore, since there is little if any devalue
in pursuing the real picture of whats being done in the DVA system institutional researchers may need to
examine DVA from an entirely different point of view. Likely the previous research may offer insight into the
DVA research program by examining Dohrenwend, B.P., et.al. January 2007. Science Vol. 315, 185 p. "The
psychological risks of Vietnam for U.S. veterans. A revisit with new data and methods." and Centers for Disease
Control July 22, 2011 / 60 (28); 955-958. "Severe Hearing Impairment Among Military Veterans --- United
States, 2010."
What we do not know helps us draw a portrait of how the DVA system accumulated knowledge about it and what
it does with it. The mechanism it uses to hide the data is more important than the data itself, because it reveals so
much more to the extent DVA takes in justification to request its expenditures. There seems no end to the amount
of money it receives from Congress while its major stated priority of reducing suicide omits written state and local
collaboration.
In order to understand how wrong the post traumatic stress disorder program data was and is we must discuss the
relationship between the DVA medical center and DVA Readjustment Counseling Service Vet Center program.
Specifically the productivity data on the treatment of post-traumatic stress disorder were not clean. DVA Chads
were inaccurate based on the following reasons:
Since the PTSD data reporting of the 1990s had to be compiled not just for the DVA post traumatic stress
disorder inpatient program, but was incoming and correlated with the Readjustment Counseling Service Vet
Center program. Warning signs existed of inaccuracy and incapability during the 1990s when the DVA Office
of The Inspector General gave reports warnings {Veterans Health Care System Office of the Inspector General.
September 20, 1999. Report Number 9R5-A19-161. "Accuracy of data used to count the number of unique
patients."}, report of the serious inaccurate counting of visits, virtually no clinical oversight existed coupled
with no credible reportage and no referral exchange to and from DVA inpatient PTSD units. This DVA OIG
report did not need to say that the clinical condition of the Readjustment Counseling Service Vet Center
Program had not changed since the General Accounting Office inspection in
xi
1987.
In other words, no one secondarily saw the Vet Center visitor other than Vet Center program staff due to an
aversion to collaboration. Even in the face of current deficiency in PTSD continuity of care no amount of
pressure has led to a togetherness, not even to reduce suicide numbers. This is the new DVA archetype of self-
interest. The standard response by either DVA and Vet Center was We dont want to lose our autonomy
(productivity numbers).
What went wrong in the reporting of post traumatic stress disorder visits? Once Readjustment Counseling
Service refused to consider an on-site psychiatrist the community validity of their program suffered.
Historical records show DVA and Readjustment Counseling Service overstated the incidence of PTSD as noted
by Professor Michael Kelley, Myths & Misconceptions:Vietnam War Folklore, July 1998.Dr. Kelley often
critical of the DVA myth of over rating and exaggeration of PTSD symptoms observed how well their data fit so
well into the DVA program justification. The street knew it, as many Vietnam veterans distanced themselves from
DVA and denied their service participation to avoid the DVA generated and congressional portrayal of the Vietnam
violent veteran as a ginned inaccurate data effort. Instead of validating their diagnostic label of PTSD (which they
could not do, because one DVA facility had no record of what another DVA location had diagnosed) it allowed
DVA to make a PTSD diagnoses as presumptive based, on stereotype behavior. This outraged many combat
veterans who were denied PTSD compensation, because one DVA facility diagnoses this and another that, and
were medicated sometimes contradictory prescriptions, it was unclear what the combat veteran was receiving, as
care and whether any of it was being professionally coordinated. By not unifying visit data a higher data count
was reported.
This did not stop the DVA from piling on high prevalence rates of PTSD without the generally accurate psychiatric
evaluation and assessment process of Medicare professionals. In fact, Vet Center had no mechanism to engage in
a psychiatric assessment of PTSD. Vet Center PTSD was essentially hypothetical by staff who had hypothetical
credentials compared with highly trained and licensed Medicare practitioners. Thus, the accuracy of any data
obtained must be written to be clear and definitive, if a combat veteran is to receive compensation. But to expect
claims reviewers to figure out the maze was beyond human capacity. Often, the DVA clinical staff had difficulty
deciphering what health care was delivered as combat veterans went through entirely different care departments.
In an effort to obtain accurate PTSD data President Clinton era policy makers tried to incorporate two elements;
telling DVA to treat combat veterans as its top priority and computerization of productivity and diagnostic data.
This would certainly tighten the screws? Perhaps not with definitive congressional support (although Congress
would be the one to have the greatest benefit to regaining its previous large non-combat DVA constituent numbers)
an underground internal DVA plan began to undermine President Clintons initiative. The veteran militancy is
long gone, but its tactics have been assumed by different internal political interests, not in obtaining health care
access and Agent Orange treatment, but financial gain. Decades later the resistance against Presidential reform
has been hardened and institutionalized even among some veteran service officers who are too quick to file
compensation claims when they know full well the looming problem may be socioeconomic. Instead of referring
for psychiatric evaluation they draw a claim.
Here is an example of the data gamesmanship. When the President Clinton data computerization effort threatened
to weed out false numbers DVA medical centers and Readjustment Counseling Service began to see data shortfalls.
The changes of eligibility left a negative mark on the productivity of Readjustment Counseling Service, so a plan
was developed to accept non-combat veterans under a little known and remotely used category of seen for
humanitarian reasons that soon came into vogue. This allowed for a substantial return of the non-combat veteran
productivity numbers. Migrating back as well was a reduction of time combat veterans were seen. Congress was
informed more staff was needed, but no amount of staff could cure the infiltration of non-combat veterans into
DVA and Vet Centers that were legislatively mandated to see combat veterans only.
There continues to be a strong message given by the Department of Veterans Affairs, Congress, and some
veterans service organizations for them to remain self-contained. What other government organization has
established its own non-profit (MITRE) for the express purpose of carrying out this mission. Surprising is
this organizational belief goes so deep that it is transmitted easily from one Presidential administration to
the next.
Instead of gaining time seeing just combat veterans, DVA and Vet Centers perpetuated the same eligibility criteria
as before the law. Under this formula no amount of staff can satisfy the requests for services as the program adjusts
its productivity numbers to conform to its survival needs and a wink-of-the-eye from parts of Congress that have
DVA and Vet Centers in their districts. This is what is called the culture of the DVA and it is worrisome because
there does not seem to be a juncture whereby data could be collected accurately for the development of health
care strategies that would reduce the daunting suicide numbers among veterans. Otherwise, the public would see
results. The nation just isnt prepared for the task and the hard work necessary. In fact, our greatest strength as a
nation seems to be watching while combat veterans decease and little if anything changes that data.
Closing Statement and Recap -Argument Two
While pursuing research locations with the Department of Veterans Affairs it is recommended that whenever
possible an eye on reducing stigma should be kept. Professor Michael Kellys legacy indeed is more cogent and
thought provoking than ever before. Due to the misunderstood definition of PTSD and its political utility of the
past in this Department care should be taken seriously by compensation claim representatives when informing the
veteran of unintended consequences. The concerns in this paper are not new. They are provocative and emotional.
Often thoughts critical of government policy have brought together, even the staunchest of Department of Veterans
Affairs reformers and advocates to question the
xii
validity and identity of the Department and its Readjustment
Counseling Service Vet Center data program.
Footnotes
i
Veterans Healthcare System Office of the Inspector General. September 20, 1999. Report Number 9R5-A19-
161. "Accuracy of data used to count the number of unique patients."
ii
United States General Accounting Office Wash. D.C. 20548. GAO Report B-227618August 26,1987. DVA
discontinued use of the programs data base in January 1986 becauseof a series of technical problems;
therefore, many new clients seen duringfiscal year 1985 were not documented in the data base. In addition,the
data on certain contacts reported by vet centers were not consistent.Thus, the data are of little use for decisions
about the need for particularcenters.
iii
A Supplemental Take-Home Module for the NAMI Family-to-Family Education Program: Understanding
and Coping with PTSD Prepared by Veterans Healthcare Administration, National Center for PTSD
www.ncptsd.DVA.gov Updated January 2011 "Adjusting back to life at work or school after experiencing a
trauma or being in a war zone can be a very difficult. For some people, going back to work is made harder by
changes that have happened on the job during deployment, or a lack of interest in their job or school work after
a more exciting time in the war zone. For others, who might have quit their job before deployment or who have
been in the military until returning, the difficulty might be in finding a new job or a career path. Still others find
that some of the symptoms of PTSD, such as feeling irritable or on edge or having a hard time sleeping or
relating to people, make going back to work or starting classes feel difficult or impossible. In addition, this may
be made worse by worries that an employer or future employer would react negatively to having somebody at
work that was dealing with PTSD or a stress reaction." Page 8:G.
iv
United States General Accounting Office Wash. D.C. 20548. GAO Report B-227618August 26,1987. The
committee recognized that although utilization of services in the vetcenters had not shown any significant
decrease, the current organizational structure of the program lends itself readily to downsizing at whatever
rate is indicated by a future decline in need for services. Page 18.
v
Veterans Healthcare System Office of the Inspector General. July 20, 2009Report No. 08-02589-171.
Healthcare Inspection. Readjustment Counseling Service. Vet Center Report.
vi
Taborga, Jorge. March 2013. "How Organizational Archetypes Manifest at Each Level of the Gravesian
DVAlue Systems" Learner Papers. Integral Leadership Review.
vii
DVA Publication. US Department of Veterans Affairs. DVA DVAnguard June-July 1999. Kizer Withdraws
Name from Consideration for Second Term as DVA Under Secretary for Health. Page 5.
viii
Centers for Disease Control July 22, 2011 / 60 (28); 955-958. "Severe Hearing Impairment Among Military Veterans
--- United States, 2010."
ix
Gesensway, Deborah. May 1996. ACP Observer publication of the American College of Physicians. "DVA
attempts to realize new 'vision' for survival Thinking the unthinkable: layoffs and hospital closures."
x
Author note: Nevertheless, though this austerity plan has been a satisfactory strategism we need to keep in
mind that governmental planning of the past was largely responsible for the unacceptably high deaths of
Vietnam combat veterans exposed to Agent Orange.
xi
United States General Accounting Office Wash. D.C. 20548. GAO Report B-227618August 26,1987. The
committee recognized that although utilization of services in the vetcenters had not shown any significant
decrease, the current organizational structure of the program lends itself readily to downsizing at whatever
rate is indicated by a future decline in need for services. Page 18.
xii
No. 716. ISSUE BRIEF. Restructuring the DVA Health Care System: Safety Net, Training, and Other
Considerations Wednesday, March 25, 1998. Washington, DC.