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How VA Health Care outdoes private sector6 February 5, 2016
by Suzanne Gordon
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Because the nation’s media has been
focused almost exclusively on the prob-
lems of America’s largest, and only
publicly funded, fully integrated health-
care system – the Veterans Health Ad-
ministration — we barely hear anything
about the successes of VHA healthcare.
Pioneering treatments for Post-Trau-
matic Stress Disorder (PTSD) (from
which anywhere from 18-30% of veter-
ans suffer) is one of the most significant
of those successes. Recent studies have
documented that the VHA’s mobile
phone app PTSD coach is highly valued
by veterans and that the VHA performs
better on the delivery of medication
treatment for mental health needs than
the private sector.
Many innovations in health care are
being pioneered at the San Francisco
VA Medical Center (SFVAMC) at Fort
Miley, where I have spent over a year
observing caregivers and their patients
for my forthcoming book on the VHA.
One of the research projects I will be
writing about explores the impact of
killing on veterans who have been in
combat and how it influences their re-
sponse to PTSD treatment. The project
‘s lead investigator is clinical psycholo-
gist Shira Maguen — Mental Health
Director of the OEF/OIF Integrated
Care Clinic and Staff Psychologist on
the Posttraumatic Stress Disorder Clini-
cal Team (PCT).
Maguen began her research when
she worked as an intern and then a post-
doctoral fellow at the VHA’s National
Center for PTSD at the Boston VA
Medical Center. She was impressed by
the fact that a number of her patients
who had undergone treatment weren’t
doing as well as she had hoped. The
usual focus of PTSD therapy was on the
deprivation or threats the patient had
experienced, on what had been done to
him. Was this approach missing some-
thing, Maguen wanted to know?
Maguen and a team of other men-
tal health clinicians held focus groups
with veterans from many different eras.
“Many of the people we talked with
were suffering tremendously not just
because of what was done to them but
because of what they did in war.”
Veterans who had been in therapy for
years, told researchers they had never
talked about these things and felt terrible
guilt, shame and contamination because
of these experiences. “They felt they
didn’t deserve a family or to have children
or to have successful relationships or even
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be successful in life,” said Maguen.
Members of the military were experi-
encing what is now called moral injury,
which happens when people violate mor-
al rules or beliefs. “In war,” Maguen elab-
orates, “people have to make quick deci-
sions.” When those wars occur in urban
environments like Iraq, this may mean
killing a child or civilian who someone
thinks may be carrying a gun or who gets
caught in cross fire or explosions.
Maguen and her colleagues began to
measure the impact of killing in three
different eras – Vietnam, the Gulf War,
and Iraq – and consistently found that
killing was associated with PTSD and
significant emotional problems that
often made it hard for people to func-
tion in civilian life. At the SFVAMC
the research team held seven focus
groups with 26 veterans. They used the
information and insights they gained
to construct a specific measure, called
the Killing Cognition Scale (KCS). The
KCS captures the various ways that vet-
erans may think about or perceive their
past actions. In particular, the KCS
tracks the guilt or shame they may ex-
perience, as well as their ability to for-
give themselves, or ask for forgiveness
from others.
“The KCS helps us get a sense of
where are veterans most stuck. Is their
problem guilt? Is it shame, or a sense of
having been contaminated by their ex-
perience? If we understand the distinc-
tions we can better craft treatments.”
Guilt, Maguen explains, may lead
people to reach out to others to make
facebook.com/TeamMarch
amends, while shame has been linked
with reckless risk-taking, social with-
drawal, and even decreased empathy
for others.
Maguen and her team developed a
special treatment, that can supplement
others, to deal with killing and moral
injury. In a randomized control trial
jointly funded by the University of Cali- are doing would be possible if veterans
fornia at San Francisco (UCSF) and the
VHA, one group of veterans, some of
whom were already in PTSD treatment,
began by filling out the Killing Cogni-
tion Scale so therapists could gain a
nuanced understanding of their symp-
toms. This was followed by individual
therapy sessions, after which a process
of amends is implemented where pa-
tient and therapist create a forgiveness
and an amends plan for the future, thus
assuring that the therapeutic experience
is not only present but sustainable over
the long term.
After this trial, Maguen and her
colleagues found that those who par-
ticipated in the treatment had reduced
mental health and PTSD symptoms.
Depression, and anxiety symptoms
were reduced. Veterans were also able
to be more intimate with a partner, ru-
minated less on bad experiences, and
engaged in more community events. As
they forgave themselves, they were able
to be more compassionate and accept-
ing of others.
The researchers are publishing a pa-
per on this innovative therapy and hope
to roll it out at multiple VHA facilities yondchron.org/31264-2.
across the country.
In the debate about VHA privatiza-
tion, which is now taking place in Con-
gress and through a Congressionally
mandated Commission on Care which
is considering the future of the system,
there has been a great deal of discussion
of shifting more mental health services to
the private sector. One must ask whether
the kind of research Maguen and others
were seen by private sector profession-
als who only had a scattering of former
service members in their practices and
little experience with the nuances of
military related PTSD? Or is this kind
of work dependent on the VHA’s large,
national community of clinicians and
researchers who deliver healthcare to a
very particular population of patients?
When I asked Maguen these questions,
she told me that, “This work would not
be possible in the private sector because
the majority of psychologists, psychia-
trists, social workers, psychiatric NPs,
whomever, would probably not special-
ize in a veteran population. Even those
who treat PTSD might have some veter-
ans scattered among his or her patients.
This would not provide the kind of vol-
ume that leads to the kind of question-
ing that goes on in an institution where
everyone treated is a veteran and has
shared a certain set or at least subset of
experiences.”
Hopefully, Congress will heed this
kind of logic as it considers the fate of
the VHA
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