Teaching veterans to be mental health workers
A program at Newton’s Massachusetts School of Professional Psychology looks to train military men and women to become therapists who can help other vets.
THE DRILL SERGEANT flipped on a television at the front of the warehouse-like room that was home to Trey Tippens and dozens of other Army recruits during basic training in March 2003. The news footage showed a shower of bombs over Baghdad at the start of the US invasion. Many in the room would be headed there after training, the drill sergeant told them. "We just kind of sat there in silence," Tippens remembers. In the days that followed, a group of soldiers gathered occasionally in a back stairwell to read Scripture. Often the group asked Tippens, the son of a Methodist minister from Virginia, to end the meeting with a prayer. Channeling his father, Tippens became an unofficial chaplain. "When you join the service, you don't think you're going to be leading prayer groups," he says. "It seems that's what everyone wanted. Everybody kind of needed that."
Tippens deployed to Korea for most of his three-year enlistment. As friends from those first days in the Army returned from tours in Iraq, Tippens saw changes in some — nightmares and anxiety, signs of stress, things that couldn't be fixed by a prayer group. "I saw there was a need that wasn't being met, and I couldn't fill it," he says. Tippens left active duty in 2006 for school. Now the 33-year-old Marlborough resident is a fourth-year doctoral candidate at the Massachusetts School of Professional Psychology and coordinator of a program aimed at encouraging more people like him — those who know the structure, culture, and potential consequences of military service from personal experience — to choose a mental health career. "Veterans treating veterans. I may be biased," Tippens says, sitting in the lunchroom of the school's new building in Newton, "but that's probably the ideal situation."
The Train Vets to Treat Vets program, funded over two years by the state with $250,000, pays Tippens and other Massachusetts School of Professional Psychology students with a military history to visit veteran groups on college campuses around the state to promote mental health professions. With input from Tippens and others in the program, the school is developing a military psychology track that organizers hope to launch this fall for people who want to work with veterans and their families, joining just a few private and state schools nationwide that have developed similar offerings. The effort reflects a national focus on bolstering what could prove to be one of the most critical resources in meeting the needs of people returning from Iraq and Afghanistan: other veterans.
In the past decade, less than a half percent of Americans were serving on active duty at any given time, according to a 2011 Pew Research Center report. That has left many returning veterans feeling isolated, says state Secretary of Veterans' Services Coleman Nee. While the research around the effectiveness of peer support for veterans is limited and somewhat unclear — some randomized studies have found no benefit compared with support from people who are not veterans — it's no mystery to Nee. "Veterans just feel more comfortable talking to fellow veterans," he says. "If we want to acclimate people back to civilian culture, you're going to have to use veterans to do that. You're going to have to use veterans who have the skills and the training and the background to counsel these folks."
WHEN TIPPENS FIRST got to the Massachusetts School of Professional Psychology, he was reluctant to talk about his military experience, unsure how classmates would respond. Eventually he met three other veterans there. They began swapping stories of active duty and the often
difficult transition to school. Administrators at the school learned of their impromptu discussion group and began planning a more formal program, eventually getting funding earmarked in the state budget.
President Nick Covino says the idea came, in part, from the school's approach to serving another group sometimes isolated in mental health care. Latinos make up about 17 percent of the US population, but as of 2005, they accounted for about 3 percent of psychologists, according to a report published in the journal Health Affairs. The Massachusetts School of Professional Psychology began to develop a specialized track in Latino mental health in 2003. Even if they are fluent in English, native Spanish speakers often describe their experiences in more detail in their first language. And they may use metaphors or cultural references that a Latino therapist could more readily understand. "All we have is our words to do our job," Covino says. "If [patients] don't feel understood, they're not going to come back."
Of course, not all Latinos would need to see a Latino psychologist, just as women or men may not have a preference in their therapist's gender. Someone who is gay can receive beneficial treatment from a good therapist no matter that person's sexuality. But for a subset of patients, a psychologist's ability to relate through firsthand experience — their likeness — does matter.
The military has its own language, full of acronyms and slang, much of it passed through generations. Sandy Dixon, an Arlington psychologist, teaches a class at the Massachusetts School of Professional Psychology on veterans' mental health that would become the foundation of the broader military curriculum. She spends weeks talking with students about military rank and structure, the difference between someone who is enlisted and an officer, between active-duty Army and the National Guard. The class studies the effects on military families and how modern war compares with past conflicts. During Vietnam, there was a draft, and most who went to war had only just entered adulthood. Today: no draft, and many service members are closer to age 30. "What does that mean?" Dixon says. One of her goals is to make students comfortable with being curious about the military.
But there are some things that are harder to teach, says Evan Bick of Cambridge, a second-year doctoral student at the Massachusetts School of Professional Psychology who deployed to Iraq for about a year in September 2008. "Being deployed — it's just weird, from top to bottom," the 28-year-old says. "You go live in this strange place, and everybody's pushed together, and it's kind of like being at home but kind of very different from being at home. It's weird in a lot of ways, and some of those ways are pathological." Someone who has been through it, he says, might be able to sift through a patient's experiences at war to more readily separate "regular messed up from extra messed up."
More than that, Bick and Tippens say, putting veterans in the psychologist's seat can lower the stigma of mental health care overall. Bick understands about stigma. He went through a mental health screening, as everyone in his unit did, when he came home from Iraq. Bick decided to make a follow-up appointment. He wanted to talk through some of his experiences in combat and the effects on his relationships back home. No one he worked alongside at Fort Riley in Kansas, where he planned training operations, would have chided him for going to see a therapist, he says. But when the day of his appointment came, he lied. He was going to the dentist, he said. "Culturally," Bick says, "the hurdle is so high that anything you can do to lower that hurdle is probably useful."
A VETERAN GREETS EVERY PATIENT who visits Boston's Merrimac Street clinic run by the Home Base Program, a partnership between the Red Sox Foundation and Massachusetts General Hospital that supports service members and their families with mental health and medical care. If veterans get lost at North Station on the way to their appointment, a veteran on the outreach team will go find them. If they aren't sure whether to go through with the appointment after all, a veteran on staff can meet them at a coffee shop to talk it over. Treatment "is a completely foreign territory," says Dr. Rebecca Weintraub Brendel, a psychiatrist and clinical director of the veterans program. The chance to exchange stories with another veteran about when and where they served — and in a common language — can normalize the process some. Plus, she says, doctors and psychologists at the clinic, who are not veterans, call on the outreach team members several times a day for their perspective on cases.
Peer counseling, by people who have firsthand experience but may not have extensive clinical training, has been used for decades in other areas of mental health care. Alcoholics Anonymous may be the most familiar example. Vet-to-vet support was the hallmark of vet centers developed in the 1980s by people who served during Vietnam, when much of the country was eager to move on from the war. It remains the focus today as the leadership of those centers is being handed off to the newest generation of veterans. And in the past six years, VA hospitals have been training and employing veterans to provide peer-to-peer services. President Obama in August issued an executive order directing the Department of Veterans Affairs to hire 800 more peer specialists before the end of 2013.
Whether the perceived benefits of having veterans in those counseling and outreach roles also apply in a therapy room, where veterans may get individual care from a clinician, is unclear. But at a time when the country is struggling to figure out just what will work to help today's generation of veterans, Nee and others say training people like Tippens and Bick as psychologists could only help. The number of student veterans at the Massachusetts School of Professional Psychology since Tippens arrived nearly four years ago has grown from four to 18. In addition to the campus visits, students in the Train Vets program counsel veterans at homeless outreach centers and elsewhere and host training for community mental health workers. Tippens plans to return to active duty as a psychologist after school. He has committed to three more years in the Army but is thinking of making his career in the military. Bick says he may pursue a job with the VA or elsewhere in the community.
As many as 1 in 5 returning service members has symptoms of post-traumatic stress disorder or major depression, according to a 2008 RAND Corp. study. Some will use VA services, others will get care elsewhere. Many won't.
When the wars in Iraq and Afghanistan began, vet centers in Massachusetts saw a surge of Vietnam veterans coming in for help, some for the first time. We like to think — despite the alarming number of military suicides last year and countless stories of the toll two wars have taken — that we've done better this time, as a society, at acknowledging the sacrifice of service members and giving them what they need when they come home.
The real test could come in the decades ahead. When today's service members take the difficult step of showing up for an appointment with a psychologist, now or years from now, will it matter if the therapist sitting across from them can say, "I was there, too"?