Harold Kudler is chief consultant for Mental Health Services for the Veterans Health Administration, a part of the Department of Veterans Affairs.
What is the scope of your responsibilities?
As chief consultant, I am responsible for mental health policy throughout the entire VA system, which means 150 major medical centers and 819 community based outpatient clinics, each with an outpatient mental health component. In addition, we work in coordination with the 300 Vet Centers.
What kinds of issues are crossing your desk now?
The hottest issues right now are focused on suicide prevention. I have been involved in two congressional hearings, one on the House side, one in the Senate, and they were both pretty much focused on what VA is doing to reduce the rate of suicide among veterans. And often, the focal point for that conversation has been the statistic that 22 American veterans die by suicide every day. That is a staggering number. It is roughly twice the rate of the average American man, and suicide rates among women veterans are very high, higher than they used to be and higher compared to other American women.
What drives this current interest in the VA in suicide prevention?
It was actually in the military that people began to notice. Traditionally suicide rates in the military were lower than in the general public. Then, over the last several years, it was found that those rates were going up and up. It probably is a reflection of the stress of the deployment cycle (and not just of combat), but it is also a reflection of the fact that you have young people coming home from war, even if they are still in the military, facing some significant economic challenges. Often they have married young, they are having children young. When they get home their roles have changed entirely, they often feel less connected, so they may feel like strangers in their own lives.
Let me change directions for just a second. You are a psychoanalyst.
Yes. But, I cannot say I am a card carrying psychoanalyst, I am an advanced candidate in adult and child psychoanalysis.
What does psychoanalysis have to offer a large bureaucracy like the VA?
The VA is large and national and thinks in huge terms. It has to in order to accomplish its mission. When I was interviewed for this job, I was asked what I would bring to VA that would make it better? After all, the VA had built this really gigantic evidence-based therapy program. It had hired thousands of new clinicians and trained them to deliver these manualized therapies and had even done a good deal of the original research for development of these treatments. What I said was, yes, the VA has accomplished everything you say in response to an industrial-sized, national mental health need but the problem was you cannot industrialize mental health. Mental health is always a human story, always an individual story, and it has to be addressed in human terms according to individual needs. This is what I wanted to bring to VA and this springs directly from my analytic experience and point of view.
How do you do that?
The VA, partly in response to its critics, had created a system to ensure it was seeing people within a certain number of hours and bringing people back within a certain number of days and that, within that time frame, it was making accurate diagnoses and documenting certain things and putting people on specific tracks for different interventions. But at no point, as policy, did it emphasize making a profound connection with that person. The vital link needed to make our programs maximally effective is to help the individual who comes to us with a very personal problem to articulate that problem in personal terms and be heard in the way he or she was hoping to be heard. That was not our top priority in the VA even though, as an institution, we were just realizing the critical importance of being veteran-centered and veteran-driven.
Can you change the training or the framework within which clinicians in the VA operate?
I think it would be difficult for me to wade in and say, “I have a different way of looking at things and, since I am in charge, everyone should look at things my way.” It would create friction and, ultimately, battle lines. What I have found in my 31 years in the VA is that when I can offer insights that help clinicians do their jobs, even without labeling it as psychoanalytic (or anything else), people say, “I can use that. That is helpful. Thank you.”
I have put this into action over the past five years in a group supervision I have run for VA health professionals working with trauma survivors. I started doing this just at my own medical center in Durham, North Carolina, and, before I knew it, people in our outlying community-based outpatient clinics many miles away were saying, “We heard about this; we need it too. Could we join you?” So we started teleconferencing them. Other hospitals in our region joined us. Once we realized how much our colleagues liked this, we reached out to a listserv of VA clinicians east of Mississippi and, ultimately, across the entire nation. We got to where we were having over a hundred clinicians from across the country calling in for a given session. Each month a clinician somewhere in the U.S. would present the case of a trauma survivor whose story the clinician found him/herself taking home at the end of the workday. That was our inclusion criteria for presenting.
A very common theme emerged in the course of these monthly presentations: A veteran was trying to deal with a memory, an emotion or an idea that was so overwhelming it was literally unspeakable. The presenting symptoms were ways of expressing what could not be put into words—and which may not even have been available to consciousness. These veterans inevitably brought these concerns into therapy and, since the patient was not able to articulate them or even to become aware of their power, it was the therapist who had to carry the discomfort even though he or she was only dimly aware of what the content was. Therapists reported a variety of feelings including helplessness, sadness, depression, fear, rage, shame and/or futility. Often, the therapist would say, “I cannot do this work because I am too afraid,” or “I cannot do this work because I am becoming depressed,” or “I cannot do this work because I feel so incompetent and overwhelmed.”
And we would suggest that the therapist, was in fact, experiencing a very appropriate awakening to the patient's own core concerns. We would point out that, rather than giving up on their patient or on their own ability to do good therapy, they might want to consider that their responses demonstrated they were actually well attuned to their patient's most personal issues: They simply had to grasp where those concerns were coming from and help the veteran begin to own them and then understand and resolve them. Thus it was the therapist's response, as uncomfortable as it might be, that enabled them to help their patients articulate the unspeakable and to find ways to live their own lives and own their own histories, thoughts and feelings without falling into symptoms and, sometimes, serious loss of function.
This simply reflects a concept Freud discovered a very long time ago: Countertransference provides a means of understanding the patient, even when the patient cannot understand him/herself. But this was a principle many people in the VA did not know because psychoanalytic ideas are no longer being taught in their graduate programs and their residencies. Once clinicians realized the sometimes painfully difficult thoughts and feelings they experienced in their efforts to help veterans might actually be the means by which they could provide that help, they found it liberating. And only an analytic perspective could have accomplished this.
I believe psychoanalytic perspectives can help a new generation of VA clinicians in the VA become more effective, more satisfied, and more resilient as therapists.
That's a tremendous number of people.
We have worked with more than 400 clinicians across the country in our group supervision program.
Are you talking about psychiatrists, social workers, psychologists?
All of those, as well as nurses, physical therapists, specialists in traumatic brain injury, primary care staff, nurses of all stripes and peer support specialists among others. That's because, in the VA, literally all of us are working with people who have lived through war and have carried the war home with them in visible and invisible wounds.
Clarify for me the treatments the VA offers.
One of my responsibilities is to advance and advocate for the evidence-based therapies (EBTs) the VA has helped develop and field for the treatment of veterans. These include such interventions as prolonged exposure therapy (PE) and cognitive processing therapy (CPT). Some of my analytic colleagues might wonder how I could be an effective advocate for theories and practices that often seem at odds with those of psychoanalysis. I have had to deal with that same question through most of my career. My answer is these theories are more alike than they are dissimilar. The proponents of exposure therapy, cognitive therapy and psychoanalysis all agree that the signs and symptoms that may follow a psychological trauma stem from and are maintained by avoidance of thoughts and feelings related to that traumatic event. These therapies primarily differ in how they attempt to overcome that avoidance in order to promote healing and open the path for future growth.
These brief treatments can significantly reduce the symptoms of PTSD and a sizable proportion of people will no longer meet DSM-5 criteria for PTSD after treatment. While many veterans who complete a course of therapy will continue to suffer symptoms and quite a few will still have diagnosable PTSD, many will, nonetheless, be more able to adapt and cope. Some will be inclined to see what the next steps might be. One mistake we cannot afford would be to say, “You have had a course of therapy, therefore you are done and we will go on to the next veteran.” Based on all we have learned up to the present (including psychoanalytic experience), we are in the process of redefining the continuum of PTSD care and considering what works for whom, how different kinds of people might best engage in treatment, and what a rational “stepped” treatment sequence might be.
From my perspective, there will be some trauma survivors who will do best by beginning in a psychodynamic treatment and others who will find psychodynamic treatment most helpful at a later point. Throughout my career, I've found the psychoanalytic lens the most helpful in understanding what psychological trauma is and how it is overcome, but I have also come to appreciate that there are many ways to heal. What is, I believe, universal among all trauma survivors is the need to develop a strong therapeutic relationship as the foundation of any psychotherapy. Equally important is the therapist's need to cultivate and maintain a disciplined use of him/herself in the service of the patient. These are lessons I've learned from psychoanalysis and they are among the most important principles we, as psychoanalytic clinicians, can share with VA clinicians of all disciplines and conceptual views.
What are some programs that have been put into effect?
It turns out there are many next steps. There are some pre-steps we are patching into the process as we build and refine it. For example, one of the things we have learned (maybe “re-discovered” is the better term) from these recent wars is the public health perspective. We can train the best clinicians in the world but that does not mean people want to see a clinician at all. Marines have come to call mental health professionals “the wizards.” This is not because they have such respect for our powers but rather because they fear, if they see one, they will be made to disappear. Given the stigma of having a mental illness or of simply not being self-sufficient (both of which are strong in American culture but greatly magnified in military culture), most service members and veterans do not want to talk to a mental health professional. Service members, veterans and their families actually have better access to mental health services than most of their fellow citizens yet, paradoxically, they simply will not go to see a clinician because of this cultural dimension.
So how do we develop a public health model (some would say a population health model) that allows us to improve mental health outcomes among this entire group of people whether they be on military bases in the U.S., deployed to a combat area, or re-immersed in civilian life? One outside the box idea we've developed is to train members of the clergy to recognize and support the service members, veterans and family members within their congregations. For the most part, clergy members do not want or need to become mental health professionals but, because we have found people are five times more likely to tell a congregational leader about a deployment-related mental health problem than they are to talk about it with a mental health professional, we need to make sure those members of the clergy can recognize a problem when they hear it and that they know something about how to provide effective support and to direct people to appropriate resources including those of the Department of Defense and the VA.
We have also created programs that work to reach family members instead of veterans because, even though family members often share many of the same military culture beliefs, they tend to be more likely to see the need for mental health services before the veteran realizes this. We have developed a program, Coaching Into Care (1-888-823-7458), which connects family members and loved ones with a life coach who shares approaches from motivational interviewing that can help them help their veterans come to face their problems and take positive action.
These are great examples of how to take therapeutic thinking beyond the consulting room.
During World War I, Freud worked with the Austrian government to plan for free psychoanalytic clinical services for veterans once the war ended. When the war was over there were going to be free clinics for veterans, and they were going to be analytically based clinics but Austria was in no position to follow through after the war. Still, he saw the need coming out of the suffering of those who had served and, as a family member and colleague of many in service, I suspect he understood the need was great across the entire community after the war.
And, even as that war was starting in Europe, the Mental Hygiene Movement (a partnership of American mental health leaders, mental health consumers, family members and policy leaders, which was funded by the brand new Rockefeller Foundation) came together to promote a national awakening to the idea that mental health was everyone's responsibility. You know, the saying, “War is too important to be left to generals”? The mental hygiene movement said mental health is too important and too big to be left to the mental health professionals. I think Freud saw this too and that it led to his efforts to work with government and policy makers in Europe at the same time. We send these people to war and they represent all of us. They serve all of us and are ready to die in that service whether or not we, as individual citizens are politically in favor of a particular war. The way I understand it, they are actually fighting for our right to disagree on issues like this. When the war ends, it is everyone's responsibility—this is not just a trite phrase—and it will take all of us to bring these people home. We have learned homecoming may take the rest of their lives.
What is the proper role of the VA?
A lot of people say, “ Less than one percent of the population has been in these wars so why are we getting so excited about veterans?” The truth is there are over 22 million living veterans in America and another 40 million who are their direct dependents, eligible for some kind of VA benefits. We are talking about roughly one in five Americans. So, yes, the VA is built, as per Lincoln's statement in his second inaugural address, to serve those veterans who have borne battle, their families and their survivors. In doing that, it represents the entire nation and serves the entire nation.
When was the VA started?
The VA has its roots in the Mayflower colony at Plymouth, which decided that those injured in its defense were their responsibility. It is a principle that is older than our nation and which goes to the roots of our identity and tradition.
Is there something that distinguishes the VA population from other Americans or is it a cross section that is really comparable to any community?
For many years, veterans were overwhelmingly men and overwhelmingly older. It is still true that half of all American men over the age of 65 are veterans. But the veteran population is more and more coming to resemble the American demographic in terms of gender, age and ethnicity. Many Hispanic immigrants have come to view military service as an important pathway to “becoming American.” And it should be noted the first Americans, American Indians, serve at the highest rate of any ethnicity. The military is where rural American meets urban and rich meet poor. It is also one of the most powerful engines of social change: Consider President Truman's order integrating American combat forces. Our military is an American melting pot and our veterans represent the broadest possible spectrum of American society.
Anything you want to add?
It is very hard to generalize about veterans, but it is essential to recognize they are all around us even if they are invisible to us without their uniforms. They are all sorts of people. As a group, they have their vulnerabilities but I believe they also have certain important advantages; they have been part of something bigger than themselves. They know what it means to be truly close to other people (even though they may be very different kinds of people) and to value other people above themselves. More than that, they know the importance of being ready to sacrifice for a cause and they stand ready to do that their entire lives. They bring tremendous strengths to society.
The greatest privilege (and there are many) of working for the VA is in working with people like these. So when people think about veterans, it is essential not to think about broken people and not to pity them; they neither want nor need our pity. But they would benefit from our attention and respect. I think if everyone in America was awake to the need to recognize and honor veterans and their families (and not just in the clinics, but in the workplaces, on campuses and across the community and not just on holidays but every day), that would comprise the single greatest benefit to their mental health and we would all have a much stronger nation.