Ways the VA Healthcare Program is Hurting Local Veterans

            Prior to moving to the Durango, Colorado area, I had been enrolled in what is called the Choice Program, which provides military veterans, as well as their dependents, to obtain care from community resources that are not provided through the VA system. This is the system I used to receive services such as rheumatology, gastroenterology, and dermatology. For the most part, this system helped to provide me with the resources I require to tend to my health needs. Sure, the physicians and specialists could have just as well been military doctors, as I received the same quality of care from them...and that is not saying much, considering my previous experience with military doctors, but I digress.

            When I had my initial appointment with my new primary care provider, I was told something that just came across as blatantly wrong. See, my doctor told me that my only options to see these types of specialists would be to drive nearly 4 hours each way to the large VA facility in Albuquerque, which is insane to suggest, or not see any specialists. Sure, they have a courtesy shuttle van that takes patients to the larger facility, but you must plan your day around the appointments of others, so you would either leave early, or must stay late, depending on the schedule for that day. The other option just was not feasible either, as I have a family history of colon and bone cancer, as well as having been diagnosed with a myriad of chronic pain conditions.

I live at a Level E on a daily basis, just for reference

            You know the saying “if it sounds too good to be true, it probably is?” Well, that is applicable to my situation, but rather replace “good” with “wrong” and you see where I am going with this, right? Well, when I met with the social worker at my local VA clinic, she repeated the same incorrect information regarding the Choice Program. She told me that, while there are services in town, such as support groups, there is little in the way of community resources that address symptoms. I can’t really go to a support group for my colonoscopy or endoscopy now, can I?

            My social worker also told me that I am my own advocate for my health, which is a phrase that she might be wishing she didn’t say. See, I thought that the information I was provided by not just one, but two medical professionals at my local VA clinic, sounded incorrect. Just in case though, I called the Choice Program directly, and boy, am I glad. The representative that I spoke with was just as befuddled by what I was told as I was when I heard it. It helped to put my mind at ease, knowing that I was correct about this program, as well as the fact that I would (hopefully) be able to see a provider here in the community, as my symptoms have increased since my last visit to the shoddy rheumatologist who reprimanded me for crying out in pain when he took a biopsy from my thigh at 5:30 in the morning, before I was fully numb. But again, I digress and that, along with the other numerous experiences I have had with military health officials and those covered by the Choice Program.

            So, here is my conundrum. Yes, I am my strongest advocate for both my mental and physical health. The soonest they could schedule me with a mental health professional (to address my depression, anxiety, PTSD, and MST) is the end of February, and even then, it would be only via tele-health. That falls outside of the 30 days or 30-mile rule that applies to the Choice Program (maybe not the distance, but certainly the time-frame). In the past, I have conveniently fallen through the VA health cracks, as it had taken me 18 months to even get an appointment with a rheumatologist, as the original request somehow got lost. I know that I am in the right and have a whole organization and website that provides me with the answers to help to support my position. I know that I am most likely not the only veteran in the area who has been fed this lie. However, I may be the only one to raise a little hell over the incorrect information that could have potentially affected the lives of a significant number of veterans living in the area.

            I have been known to let my emotions get the best of me, particularly when I know that I am in the right. This isn’t just relegated to my health, but also where we used to live, I have been physically threatened when I spoke up for the poor treatment of the dogs I would witness running in the street. As if it were my fault that I recognized this behavior as wrong and dangerous. I am not kidding. I wish I were. So, I need to come up with a game plan of sorts, as I know that I need to go into the clinic and let them know that they are wrong, that I qualify to see community providers that honor the Choice Program in the area. I know that other veterans have experienced this same type of treatment. The sooner the better, but, dude, I am not looking forward to it. I just need to keep my cool, and remember why I am doing this...for the health of not only myself, but the countless veterans who have received the same misinformation. Sadly, I know that this not only applies to my local clinic, but the Portland, Oregon one too, as that is who contacted me to set up my appointment for the tele-health mental health sessions...I was told that since they can provide me with the tele-health services, then I don’t qualify for community care. Well, that is not true either.

Rhubarb Applesauce: The VA Choice Program

Imagine the following scenario and assess what you would do in the situation…

“I’d love to make some homemade applesauce. I think I will go down to the fruit stand to pick up some apples” you say to your dog as you head out the door to the fruit stand. After making your way into town, the green grocer greeted you with a warm and friendly “Good morning! What can I get for you today?”

“I need some apples, so I can make some applesauce. Homemade always tastes better and there’s often fewer ingredients too.”

“Gee, I am so sorry. We have some lovely bananas, but we’re all out of apples. Can I interest you in some rhubarb?”

“No, I don’t think those will do, as I am making applesauce.”

“What about some pomegranates? They are chock packed with nutrition.”

“No, I am sorry, but those won’t work either. I really need apples.”

“Well, you can drive four hours south and I think they might have some apples for you. You could try that.”

“Thanks for the idea, but I am not sure that it will be worth the travel.”

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Okay, after you have read that scenario, what are your thoughts towards the fruit stand employee? What would you do in that situation? Maybe change your mind and not make applesauce after all? What if all of the stores within a 30-mile radius were also sold out of apples? Would you make the trek?

            In the example scenario, it outlines something I learned today from my visit with a social worker at my local VA outpatient clinic. See, there is this program called Choice, which is supposed to be a safety net for veterans if they need care, specialized or routine. In my previous clinic location, I was placed on community care via the Choice program for dermatology, rheumatology, and gastroenterology. Since the clinic where I received care in the past did not have these specialists on hand, this system worked for me, for the most part.

However, at my new clinic location, I was told that if you are within a 30-mile radius of a VA health clinic, the veteran would not be eligible for the Choice program. I even inquired if this would still be the same answer if the clinic did not have certain specialists on hand, such as a rheumatologist, gastroenterologist, or dermatologist. Sadly, I was informed that it would still apply. Seriously. If I want to receive care from these specialists, I will have to drive nearly 4 hours (each way, so 8 hours round-trip). With my hips seizing up after sitting in a car for less than an hour, it does not look like I will be receiving any care from these types of specialists. I have been diagnosed with fibromyalgia and irritable bowel syndrome, along with a familial history of colon and bone cancers. This system is broken.

What would you do in this situation?

Funky Mon(k)ey

            Do you ever start a day and it goes well for a few minutes, then it all, just, changes? Yeah, that was me yesterday morning. My allergies have progressively gotten worse, now both at night and during the day. Postnasal drip. That feeling that you just need to either continuously clear your throat or sacrifice a virgin to the allergy overlords. I was able to take three of our dogs for their walks and strip the bed to wash the linens. However, the annoyance level increased when it came time to walk the last dog. She just did not want to budge. Her dad was off today, so his car was in the driveway. Princess, who most certainly lives up to her name, loves riding in the car more than walks. However, she (and I) needs to exercise. We tried four times to go for her walk, but as soon as we walked past her dad’s car, she just put the brakes on and just would not move.

            I do not know why that annoys me so much, but it just puts me in a mood. A funk. Well, that, combined with my allergies make me a right cunt sometimes. So, what’s the remedy if I can’t go to bed and call a do-over on my morning? Put some treats in a large Kong toy and watch my OG Peggy Sue try to get the treats out. I picked up this toy yesterday at a thrift store and it turns out to be the best $3 that I have ever spent on a dog toy. So far, my OG, who is the oldest out of our dogs, is the best at figuring it out. It’s fun to watch.

            See, you don’t need to spend a lot of money to find some happiness, it can be found in watching a dog gleefully explore a new toy from the thrift store! Too often we try to buy things in an attempt at finding happiness, when, in reality, the saying, money can’t buy happiness, carries much weight. Why not look inside to identify what is the real underlying issue, rather than shelling out money in an expensive, and often fruitless, attempt at finding happiness? Yes, it takes motivation, dedication, and perseverance. However, the outcome is, well, happiness (duh!) and a cut back in unnecessary spending. Which would you prefer?

Psychological Disorders: Neural Components of PTSD, Cultural Influence, and Treatment

Abstract

There are a number of psychiatric conditions that can affect the lives of military veterans and active duty members. One such condition is posttraumatic stress disorder, which can be accompanied by symptoms that can make life challenging. However, there are a number of underlying biological and neural causes that may contribute to the development of some of the symptoms. This recognition has helped to shape some of the treatment options and therapeutic interventions that are commonly used to address the symptoms of posttraumatic stress disorder.

Keywords: PTSD, veterans, neuroscience, mental health

Psychological Disorders: Neural Components of PTSD, Cultural Influence, and Treatment

            The body has a number of reactions to various stimuli, which are designed to alert and warn individuals of potential danger, leading to an increase in the likelihood of survival. However, in some instances, the reaction to these stimuli can lead to the development of various psychiatric conditions. One such reaction occurs to the exposure to one or multiple stressful events, which can trigger the onset of symptoms that are associated with a condition called posttraumatic stress disorder, or PTSD.

It has been shown that up to 15% of military members, both active duty and those who are veterans of the military experience symptoms that are associated with PTSD, with a significant percentage of these military members becoming debilitated and unable to participate fully in life (Dursa, Reinhard, Barth, & Schneiderman, 2014). As such, understanding the various influences on the development of symptoms that are associated with PTSD, along with the level of exposure and knowledge a mental health professional has on the topic of PTSD, can help to provide patients with the highest quality of care to adequately address his or her symptoms.

PTSD and Behavior

            It should be expected that following the exposure to a traumatic event, or even reading or watching media that details traumatic events, could lead to a change in one’s behavior. Traumatic experiences can lead to changes in a number of neural areas that can influence one’s behavior. For example, three of the brain regions that are often cited as being affected by the stress response that often occurs in the wake of a traumatic experience include the amygdala, hippocampus, and the prefrontal cortex (Bremner, 2006). Changes in these brain regions can bring about changes in behavior, including the symptoms that are commonly associated with PTSD such as hyperarousal, nightmares, difficulty in memory and concentration tasks, and a heightened startle response (Bremner, 2006).

Influences on PTSD

            Humans do not exist in a specimen jar, and as such, they are vulnerable to a number of internal and external stimuli and influences that can affect the behavior and experience of symptoms associated with various psychiatric conditions, including PTSD. These influences include structural, anatomical, physiological, and cultural factors. Through providing a foundation for the cultivation of a deeper understanding of the role these influences have on a person experiencing symptoms of PTSD, psychologists, therapists, and other mental health professionals can be prepared to treat patients in the most effective manner.

Structural

            There are a number of neurobiological changes that have been observed in the brains of individuals who have been diagnosed with PTSD. This includes neuroendocrine and neurochemical components (Sherin & Nemeroff, 2011). Changes in the volume of various neural structures, such as the left hippocampal section of the brain as well as gray matter volume have been found to be reduced in the brains of individuals who have been diagnosed with PTSD (Zandieh et al., 2016).

Anatomical

            As mentioned in an earlier section, the hippocampus, amygdala, and cortex are the neuroanatomical areas that are often affected in the wake of a traumatic experience. More specifically, a reduction in the volume of the hippocampus is thought to be responsible for altered stress responses (increased startle response); increased activity within the amygdala can also play a role in hypervigilance and threat appraisal issues (Sherin & Nemeroff, 2011). Additionally, when the cortex is affected, namely reduced volume and activation in the prefrontal, anterior cingulate, and medial prefrontal areas of the brain, can lead to cluttered thinking and fear appraisal (Sherin & Nemeroff, 2011).

Physiological

            The exaggerated startle response is one symptom that is often associated with PTSD and is a topic that has been explored in the body of literature in order to conceptualize this condition. According to a study conducted by Butler et al. (1990), individuals who have been diagnosed with or experience symptoms of PTSD, specifically the increased startle reactivity, can be observed via a lowered startle threshold when stimuli are presented. This may help to explain the ability for certain sounds, such as the backfire of a car and other auditory stimuli, to startle individuals who have been diagnosed with PTSD, while the same sounds do not have the same effect on other individuals who have not developed symptoms of PTSD.

            More recent research has identified the disconnect that is present between physiological state and the psychological and/or behavioral processes that are involved in daily activities. The rapid oscillation between the body’s fight or flight response and dissociation or emotional withdrawal has been found to be an identified risk factor for the development of a number of comorbid disorders (Williamson, Porges, Lamb, & Porges, 2014). Additionally, with the constant back and forth between fight or flight and dissociation can lead to premature aging of the brain, resulting in changes in the immune, autonomic, and endocrine systems of the body (Williamson et al., 2014).

Cultural Factors

            Within the military, it is often thought of as a culture within a culture, as the traditions and regulations or rules that people follow are akin to the traditions and values that are held by various ethnic cultures. However, in this paper, only the ethnic background will be identified as a cultural factor for the sake of time and space. Research that involved veterans from various eras of conflicts has revealed that certain ethnic minority groups were exposed to a greater number of traumatic events when compared to their Caucasian counterparts (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Additionally, veterans who fall within an ethnic minority category were found to be more likely to disclose symptoms, but only when they are paired with a counselor or therapist who came from the same ethnic background (Rosenheck, Fontana, & Cottol, 1995).

Influence of Culture and Experience on Mental Health Professionals Conception of PTSD

            Just as with the patients who do not exist in a bubble, free from internal and external influences, the same can be said for the counselors, psychologists, and other mental health professionals who work with diverse patients or client bases. As such, it is imperative that the individuals who are tasked with caring for patients put aside their own personal opinions and beliefs, in favor of evidence-based practices (American Psychological Association, 2016). Additionally, patient input can be beneficial in helping to foster not only a therapeutic relationship that is necessary

Treatments for PTSD

            Providing effective and ethical treatments for patients with PTSD is one of the most important aspects of mental health. The research that has been conducted in regards to the neurobiological changes that occur as a result of experiencing a traumatic event have helped to contribute to the development of a number of treatment options for individuals, military veterans and civilians alike, to regain their quality of life. However, it should be noted that not all patients will respond equally to treatments and a qualified mental health professional should be attuned to his or her patient’s needs and responses to treatment.

Efficacy

            The efficacy of the various types of treatments that have been used in addressing the symptoms of PTSD vary, depending on the type, as well as individual characteristics of the patient. Some research has found that, for example, cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are ineffective for 1:4 to 1:2 patients who receive these types of interventions (Zandieh et al., 2016). However, this efficacy rate can also be influenced through the type and location of any structural changes in the brain. Poor treatment outcomes for patients who received CBT for the treatment of their PTSD symptoms were associated with damage to the ventral anterior cingulate activation response and parts of the amygdala (Bryant et al., 2008); poor treatment outcomes with EMDR treatment were linked to a decrease in gray matter volume (Nardo et al., 2010).

Ethics

            When it comes to treatment for patients with PTSD, there can be ethical issues that should be addressed as they arise. For instance, it is important to make an accurate diagnosis and assessment of the patient in regards to the symptoms present, with treatment focused on the patient and his or her experience of the symptoms associated with PTSD (Cahill & Anderson, 2013). Additionally, it is imperative that the risk for suicide is conducted in order to reduce the access to lethal means, if warranted (Cahill & Anderson, 2013). Healthy therapist boundaries are also important and should be an ethical consideration that psychologists and other mental health professionals are cognizant of when working with any patient, not just those who may have PTSD.