Vet center changes ‘a stab in the back’ as delays, counselor shortages grow
Blaine Bart knew he needed help. The edges formed by active duty wouldn’t round out. During his time in the Army, from 1999 to 2006, he was wounded in the second battle of Fallujah and “blown up countless times” – twice by grenades and once by a shotgun, he says.
As he transitioned back to civilian life about 17 years ago, he swung between explosive rage and feeling entirely numb.
“I was drinking as a religion and just isolating,” he said.
Bart first landed at a Veterans Affairs inpatient post-traumatic stress facility in Palo Alto, California, for about four months. One of his doctors told him something along the lines of, “You guys are a dime a dozen,” he remembers. “I know exactly what’s going on with you guys because I’ve seen 1,000 of you.”
Bart felt dismissed, even belittled.
The classic symptoms of post-traumatic stress – hypervigilance, replaying difficult situations, or even anger – are formed while in combat zones, Bart says. Some veterans have a difficult time coming back down.
“I would argue the symptoms of post-traumatic stress that I’ve seen in myself and other returning combat veterans are adaptive behaviors that assisted them hugely in their ability to survive in a war zone,” he said. “And that recognition is rarely given in VA circles.”
About 15 years ago, he decided to give the Spokane Vet Center a try. He found counselors – many of them combat vets themselves – who helped him rein back behaviors causing chaos in his life, “but not in a way that would say that there’s something wrong with you,” he said. Eventually, he became a counselor himself and was featured in a 2018 “Today” show segment highlighting the center’s positive impact on veterans.
“I’m floored every day I get to come to the vet center and give back and help veterans,” he said during the interview.
But a few years later, in March 2021, the job that felt like a calling radically changed. In a memo sent to vet center management, the Veterans Health Administration announced that readjustment counseling therapists, such as Bart and an estimated 250 other counselors across all vet centers, were not to perform clinical therapy anymore. Bart wasn’t sure what to think. He had a master’s in clinical psychology, all the proper licensure, and he was an especially thoughtful, compassionate counselor, his vet center director told the War Horse.
This wasn’t the first major change the Veterans Health Administration’s Readjustment Counseling Service, which oversees all vet centers, had made. In 2016, counselors were required to meet productivity standards, and some longtime employees and clients say directives rolled out over the last seven years have damaged the peer-to-peer, relationship-focused model that Vietnam veterans envisioned more than 40 years ago when vet centers were conceived.
As of early fall, an estimated 17% to 19% of vet center positions were empty. Mental and behavioral health shortages plague veteran and civilian health care systems alike, but frustrated vet center counselors and clients say the Readjustment Counseling Service is pushing seasoned counselors out, rather than encouraging them to stay. This comes as onboarding new VA counselors can drag on for months, leaving clients who need clinical therapy facing longer wait times.
For decades, vet centers had a fairly loose leash, allowing a wide range in the programming, quality of services, and patient monitoring at each center. In a 2022 House committee hearing, Michael Fisher, chief readjustment counseling officer, said new policies at vet centers were long overdue.
“RCS is getting in line with VA policy,” he said.
Some counselors and veterans told the War Horse that’s exactly the problem.
‘It’s about living as a veteran’
In the late 1970s, Vietnam veterans struggled to readjust to life at home, and they often didn’t get the support and mental health care they needed. A heavy distrust of government – including what was then called the Veterans Administration – was partly to blame.
In 1979, after congressional hearings, VHA established a system of nationwide community-based centers that operated like distant cousins to VA medical centers: They were in the same family but housed in different buildings from VA hospitals. Vet centers have even kept their own confidential client records, though they coordinate with VHA for clients who have a high suicide risk or complex needs. Over the years, the program has grown to include 80 mobile centers and locations in Puerto Rico, Guam, and American Samoa. In 2021, 73% of vet center clients received care for post-traumatic stress symptoms, according to Readjustment Counseling Service data.
Since their inception, vet centers have sought out veterans as staff, knowing the power of shared experience. In 2021, 300 vet centers provided counseling services to 107,367 clients and conducted 32,415 outreach activities, according to VHA. But vet center usage has declined during the last 20 years, and the pandemic only exacerbated that trend.
Dr. Harold Kudler, a Duke University associate consulting professor in the department of psychiatry and behavioral sciences and a retired VA psychiatrist, calls vet centers “the best idea the VA had in many years.” Largely, that’s because of how they approach post-traumatic stress, he said.
When post-traumatic stress became a recognized disorder in 1980, VA medical centers responded with a highly medicalized approach, focusing on the best way to make an accurate diagnosis and reduce the severity of symptoms.
But vet centers have always focused on talking veterans through daily challenges.
“How are you sleeping? How’s your family doing? Did you ever use those benefits?” Kudler said. “It’s about living as a veteran, rather than a person with a disorder.”
Veterans seem to respond well, as vet centers have historically received high satisfaction and trust ratings from clients.
In 2006, Scot Frazer finished a 15-month deployment with the U.S. Army training Afghan soldiers. The following year, he downshifted into civilian life in Spokane Valley, Washington, but his temper flared when people complained about little annoyances, like the cost of milk. And he craved combat’s steady trickle of adrenaline. Without it, depression filled the void. His marriage suffered. He was terse, with everyone.
Frazer grew to avoid Mann-Grandstaff VA Medical Center in northwest Spokane. Visiting it felt like a “zombie walk,” with patients appearing dull-eyed and trudging to appointments, he said. And he was bothered by the “amount of pills they were throwing at my dudes,” he said, referring to what he saw of VA care and the medication prescribed to his fellow soldiers struggling with their mental health.
So he turned to the Spokane Vet Center, a facility 16 miles from Mann-Grandstaff along a bend of the Spokane River. It offered psychological counseling, support groups, classes – all for free – and a noticeably nonzombie vibe: warm, relaxed. Sometimes, overwhelmed clients walked along a wooded trail with their counselor or caseworker to recalibrate. Other times, veterans stopped by just for coffee because, not only were clients veterans, so were most members of the staff.
“You feel like you’re back in the unit,” Frazer said.
More than 10 years ago, Frazer connected with Andrew Rowley, a licensed mental health counselor on staff. Rowley was an Army veteran who had served in Bosnia and Iraq, and who later earned his master’s in clinical psychology. He struck Frazer as a “rock solid” straight-talker, and, around the vet center, he was the guy to help veterans in crisis.
Frazer, a reservist with the 455th Engineer Company based in North Idaho, decided that whenever one of his fellow soldiers wrestled with the trauma stemming from their deployment spent “constantly looking for bombs,” he’d point them to the vet center.
But after Readjustment Counseling Services introduced changes starting in 2016, Frazer noticed counselors becoming buried under caseloads.
Then, roughly two years ago, Rowley, along with other vet center counselors, had to stop providing clinical, evidence-based therapies to clients. No longer could they dig through the roots of mental health struggles, or talk about suicidal ideation.
“I had at least five patients where suicide was a huge part of our discussion,” Rowley recalled. “We were told, ‘You have to transfer them.’ ”
Earlier this year, Rowley left the vet center. And this fall, the center’s director, a 21-year Navy veteran, transferred into another position within the Veterans Health Administration. Both loved working with veterans at the vet center, they say. They left out of frustration – a feeling shared by staff at some of the other 300 vet centers scattered across the country and U.S. territories.
“When all this took place, it was like a stab in the back,” said John Hopson, a vet center counselor and Army veteran based in Missouri who holds a master’s degree in counseling and wrote his thesis on eye movement desensitization and reprocessing therapy for combat veterans. “Telling me I can’t help my fellow veterans – fellow combat veterans.”
‘We should be grateful to have a job’
The 2021 directive aimed to standardize job descriptions across all vet centers, said Fisher, the Readjustment Counseling Service’s chief officer. For years, vet centers across the country borrowed human resource management services from nearby VA medical centers, creating more than 120 disjointed human resources offices that resulted in inconsistencies in policy and job descriptions, he told the War Horse. Shortly after he started his role as chief officer, in 2016, he started consolidating human resources into one central office.
VHA then realized a group of counselors, known as readjustment counselor therapists, or Title 5 counselors, had a variety of educational backgrounds and duties. This created a liability because some counselors within this group were undertrained. Others had the proper state licensure and had been trained to administer evidence-based therapies, including cognitive behavioral therapy or EMDR, but their job descriptions may not have permitted them to fully engage in clinical work.
“It’s really about making sure that we are ensuring the best possible quality for veterans and service members in a consistent way across our enterprise,” Fisher said.
In March 2021, counselors like Bart were told that while their pay would remain the same, they could only provide low-level counseling, such as financial coaching, stress management, and employment assistance. One counselor likened these scaled-back duties to “the McDonald’s level” of therapeutic work.
“You are reducing me to the most simplistic version of what people might think a counselor is,” Bart said.
At the time, around 75% of his caseload were veterans with “stacked military trauma, whether it was sexual trauma, combat trauma, leadership trauma,” Bart says. For some clients and counselors, separating from one another felt similar to abandonment – an act that’s especially looked down upon by those who’ve served.
Layering frustration on the situation, Bart and some other Title 5 readjustment counselor therapists affected by the policy change had comparable educational backgrounds and skills to the psychologists, social workers, and mental health counselors who were now the only ones allowed to do clinical work.
Bart had never heard the term Title 5 until a few months before the transition, he said.
“It was just irrelevant,” he said. “We were all treated the same. And we all did the same work.”
Pushback erupted, particularly from counselors who’d invested heavily in their educations and training to assist fellow veterans through dark times. Many urged Readjustment Counseling Service to grandfather them into roles that allowed them to perform clinical duties, only to get held back by a VA policy that requires all mental health counselors to have obtained their degrees from a program that met the standards of the Council for Accreditation of Counseling and Related Education Program.
Dave Baird, a former director of the Spokane Vet Center, left in September for another position within VHA. He says Title 5 counselors felt demoralized, particularly when seasoned counselors had to hand off some of their most high-needs clients to staff members with much less experience “because they went to a particular college or particular university that has the right accreditation.”
The number of council-accredited public and private institutions has almost doubled in the last 10 years, but programs were less common when some of the longtime counselors obtained their degrees.
For impacted counselors, it amounted to a one-two punch. Not only were their job descriptions downgraded, but their educations, in the eyes of the Veterans Health Administration, didn’t cut it.
Some vet center staff say there was little guidance from Readjustment Counseling Service on how to transfer longtime clients and little empathy for the plight of counselors suddenly stuck in the grinder of a bureaucracy.
“We were told, in no uncertain terms, that we should be grateful to have a job,” Bart said. “We were told, in no uncertain terms, that they would not put any directions in writing about how to accomplish this.”
Bart and others say a deputy district director within Readjustment Counseling Service’s Pacific division told them to “operate as if nothing has changed.”
This created a murky ethical dilemma and liability risk for Title 5 counselors should one of their clients harm themselves or others.
Hopson, the Missouri vet center counselor and a retired Army lieutenant colonel and disabled combat veteran, remains one of the most vocal employees about his anger at Readjustment Counseling Service’s decision.
In 2021, Hopson sent letters to 88 veterans in Congress and to VA Secretary Denis McDonough urging them to waive the council-accreditation requirement for Title 5 counselors who have the right skills, certifications, and experience. Limiting his ability to continue meaningful therapy to high-needs veterans is “a blatant disservice to me as a fully trained and capable clinician,” Hopson argued.
Fisher says they have encouraged eligible Title 5 counselors to reapply for positions that can provide clinical therapy – about 100 Title 5 counselors have successfully transferred into clinical counseling roles.
Hopson tried but was denied because his graduate degree lacked council certification, and he says he was told he’d have to re-earn his degree.
VA also created an Employee Incentive Scholarship Program that will help pay for counselors to return to school and complete the appropriately certified degree.
About six counselors have taken advantage of this, according to Readjustment Counseling Service.
You don’t want them to feel not heard
Vet center counselors first sensed a seismic shift in their jobs back in 2016, the year Readjustment Counseling Service set productivity and performance standards for counselors, increasing their total sessions per week to 30, up from 20, with a mandatory improvement plan process for those who missed the target. Baird, the former Spokane Vet Center director, says his superiors pitched this change as “entering the age of accountability,” which sounded like a good thing.
But in 2019, Ted Blickwedel, a former combat vet and vet center counselor, publicly chided the new quotas, saying they damaged mental health care for clients. Appointments were often shortened to accommodate the new demand, a reality Rowley and other counselors bristled at. Combat veterans often need extra time to talk, not less – particularly if they’re unpacking a painful, traumatic event, Rowley said.
“You don’t want to make them feel like they’re not heard in the session,” he said.
Blickwedel told the War Horse the quota issue he raised in 2019 kick-started a “high turnover rate” at vet centers. But the decision to downgrade the responsibilities of Title 5 readjustment counselors is making things worse, he says.
In a February 2022 House congressional hearing, Tom Hall, national chair of the Vietnam Veterans of America PTSD and Substance Abuse Committee, said the VVA has found Readjustment Counseling Service’s approach to Title 5 counselors “confusing,” given how difficult it can be to find and retain good mental health professionals. Counselors at vet centers across the country have reported caseloads as high as 100 people – more than triple what counselors in private practice typically carry – leaving some burned out.
As of early September, vet centers had 393 positions open – more than double the open positions at the end of the year in 2020, but fewer than the 486 open positions at the end of 2018, a few years after the new quotas were enforced.
Fisher said Readjustment Counseling Service is responding to short staffing and burnout. A VA vet center scholarship program announced last spring helps pay for graduate studies with the agreement that recipients will serve six years at a vet center. As of this fall, VA has awarded about 47 scholarships, with at least 17 veterans included in that number. The STRONG Veterans Act of 2022 added 50 clinical positions to vet centers with the greatest need, including centers in rural Arkansas and West Virginia.
Kudler, the retired VA psychologist, is unfamiliar with recent changes at vet centers, but he said Readjustment Counseling Service is in a difficult position. Reducing suicide rates is VA’s top clinical priority. Death-by-suicide rates climbed in the 12 months following separation from the military, from about 36 veterans per 100,000 in 2010 to nearly 48 veterans in 2020, according to the most recent report. Increasing the number of veterans accessing vet center counselors could help. But more clients may hinder a personal touch.
“You get into an interesting problem: What’s best for veterans?” Kudler said. “For you to tap each one on the head for half an hour or for you to have that open door? ‘Hey, guys, you can drop in. Come in and let’s have a cup of coffee and hang out.’ ”
When Frazer experienced a swell of stress and helplessness in 2021 during the Afghanistan pullout, he turned to Rowley. Afghan soldiers Frazer had befriended called him, tearfully pleading to get them out of the country. For more than a decade, “depending what crisis landed on my table,” Frazer said, Rowley and others at the vet center stepped up.
Rowley left the Spokane Vet Center earlier this year after seeing incentives showered upon clinical staff to stay – incentives for which he was no longer eligible since those duties were stripped from his Title 5 position.
In March, Rowley started his own private practice.
It’s maddening to Rowley that while his educational background was viewed as unacceptable by Readjustment Counseling Service, the local VA medical center occasionally refers clients to him as a private practitioner as part of their community care program, he says. His services – once free at the vet center – are now billed to TRIWEST, the health care program for active-duty service members and veterans in the western United States.
Frazer recently stopped by the vet center to try to get an appointment for a soldier who had lost his mom. He said he was told it could be a two-month wait for a counselor, maybe longer.
“It’s like a gut punch,” he said.
Bart also left this past spring. His caseload had ballooned to 70 people.
“It wore on me,” he said.
On March 10, he shredded documents and packed his desk, heading for his next chapter as a counselor in private practice.
“Knowing the decisions that are being made to change that organization into whatever it’s going to become is hard,” he said. “That’s a betrayal as someone who both received support from (vet centers) and also worked there for the better part of a decade.”
This War Horse investigation was reported by Anne Marshall-Chalmers, edited by Kelly Kennedy, fact-checked by Jess Rohan and copy-edited by Mitchell Hansen-Dewar. Abbie Bennett wrote the headlines.