VA psychologists work to influence their future

By Russ Newman, PhD, JD
Executive Director for Practice

Psychology has traditionally held a very important place within the health-care system of the U.S. Department of Veterans Affairs, formerly the Veterans Administration (VA). Indeed, VA psychology has been instrumental in the development and growth of our profession, both for training and practice.

In the last few years, however, psychology?s stability has been threatened as a health-care reorganization within the VA has sought to reduce the number of psychologists and eliminate formally designated Psychology Services (departments).

Many psychologists in the VA system have been working aggressively to preserve psychological services in the wake of changes driven by the reorganization. The recent meeting in Dallas sponsored by the Association of VA Psychologist Leaders and APA?s Practice Directorate is one example of this activity.

The Dallas meeting brought together close to 100 psychologists from more than 50 different VA hospitals around the country. The goal was to begin developing a coordinated action plan to ensure psychology?s viability within the changing VA system.

Such coordination has become increasingly difficult due to the decentralization of the VA health-care system. What used to be controlled and directed out of the VA Central Office pursuant to national policy is now diffused into 22 separately run Veterans Integrated Service Networks (VISNs). Each regionally based VISN has the authority to organize those hospitals and services within its jurisdiction.

While this theoretically could result in completely different structures for every region, many of the VISNs have common characteristics. Perhaps the most significant reorganization feature common to many VISNs is the elimination of discipline-based services (e.g., psychology, social work, psychiatry) and creation of interprofessional ?product lines,? such as mental health, rehabilitation or primary care. Loosely speaking, this change parallels the integration and consolidation process that is spawning integrated delivery systems in the health-care system at large. Administrative efficiency and cost economy are purportedly the positive outcomes expected of this new structure within the VA.

However, for psychologists and perhaps some other disciplines as well, a significant downside of the creation of product lines is apparent. In particular, eliminating designated Psychology Services threatens to diffuse psychology?s professional identity within the VA and potentially void psychologists? professional autonomy by ?replaying an old song? and putting psychiatrists in charge of the mental health product line.

In some VISNs, however, heading the mental health product line is said to be as likely for a psychologist as for a psychiatrist. Also, efforts are being made to preserve professional identity by continuing discipline-specific credentialing, privileging and training activities in a number of VISNs. Psychology then can retain control over these activities for psychologists in the VISN, despite the elimination of the discrete Psychology Service.

Although the transition away from discipline-specific services to product lines is by no means the only significant change, it is a good example of the type of change VA psychologists face. The Dallas meeting was a major effort to strategize and plan for psychology?s future in the evolving VA health-care system. Initially, there was discussion pitting the strengths of the old version of VA health-care against the perceived weaknesses of the reorganized system. Soon, however, the focus became how to meld useful innovative aspects of the new system with the core values inherent in the traditional form of psychological services delivery.

The need to move beyond the narrow role of mental health provider to the provision of comprehensive health-care services was identified as a priority by most participants. That is, VA psychologists working with a range of physical health problems should not replace mental health services but rather supplement them. To accomplish this goal, meeting participants recognized that psychologists in the VA need to do more to develop, maintain and enhance interprofessional partnerships within the system. Success cannot occur in isolation. It was also deemed critical to involve psychology in administrative, management and governance committee activities within the system. On a related note, training for psychologists in the VA needs to include management and administration skills, in addition to traditional clinical and research skills.

In the end, it is probably safe to say that few, if any, of the conferees were happy about the upheaval taking place within VA health care. Some were feeling downright embattled and abused by the process, and rightfully so. Yet with the forward-looking energy and creativity so obvious throughout the day-and-a-half meeting, it is easy to see why VA psychology has been such a central part of our profession?s development.