Therapeutic Measures Required

To Ensure Millions of Veterans and Their Families Get High-Quality Care, Community Mental Health Providers Need More Training, Support, Resources

by Terri Tanielian, Coreen Farris, Caroline Batka, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael Robbins, Lisa H. Jaycox

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Research Brief
The face of a soldier as he hugs a woman.

Photo by US Army

To Ensure Millions of Veterans and Their Families Get High-Quality Care, Community Mental Health Providers Need More Training, Support, and Resources

With policies shifting to permit millions of veterans and their families to seek mental health services in the private sector, the civilian providers they turn to in communities across the country will need more training, support, and resources so they can deliver culturally competent, high-quality care, RAND research has found. The study found very few community providers surveyed met key thresholds for military cultural competency and use of evidence-based care, indicating few are ready overall to assist this important group of patients.

Training alone does not ensure delivery of high-quality care

Getting to effective care

Building on RAND's extensive portfolio of studies on veterans, their families, and their physical and mental health needs, the researchers expanded their focus beyond access to services to also include how care for veterans and their families might be most effective and whether community providers have the capacity to deliver it. Are they comfortable working with this unique group of patients? What do they know about the military and the lives and experiences of veterans and their families? Have they treated veterans or their families before? Are they trained in, and do they regularly practice, evidence-based therapies for prominent conditions affecting veterans and their families, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD)?

Building cultural competence

Licensed counselors, clinical social workers, psychologists, and psychiatrists in the sample varied in their knowledge and cultural competence to treat veterans and their families, the survey-based RAND study showed. Providers were asked, for example, what they knew about military ranks, slang, deployments, services, and other information and experiences common to veterans and their families. Only 1 in 4 (or 25 percent) of those responding to the online questionnaire reported being very familiar with general and deployment-related stressors for service members and veterans; only about one-third had prior training in military culture; and fewer than one-fifth had high military cultural competence. Not surprisingly, providers who work for or had experience with the Department of Defense (DoD) or the Department of Veterans Affairs (VA) reported the greatest cultural competence to work with veterans or their families as patients.

Applying evidence-based therapies

While veterans and their families benefit from evidence-based treatments for PTSD and MDD, and DoD and VA recommend them, 65 percent of psychotherapists sampled had not received training or supervision in these therapies. Even among those with training, only 41 percent reported delivering evidence-based therapies to most of their patients; training alone does not ensure delivery of high-quality care. Newer psychotherapists were more likely to report providing evidence-based therapies, perhaps reflecting both the more recent emphasis on these treatments in graduate schools and a gap that policymakers may seek to address more systematically for all providers, particularly those already in the field.

Four Steps for Policy and Program Officials

Based on an assessment of this survey's data and RAND's existing work in this field, researchers identified steps policymakers may wish to consider to ensure veterans and their families receive high-quality care in the private, civilian sector.

  1. Improve assessments of the workforce providing mental health care

    Assess

    As the VA presses to hire more and expand access to civilian providers to treat veterans and their families, policymakers and personnel experts would benefit from having sound data on the size and characteristics of the U.S. mental health workforce, and, in particular, whether the civilian sector can meet expectations for the quality of care. Professional groups and organizations that maintain provider registries are in a position to assess the knowledge, skills, and practice patterns within memberships, focusing on access and quality of care provided. Data on the provider workforce is important so policymakers not only know if the pipeline will provide an adequate supply of providers, in number and quality, but also to address gaps, for example, affecting rural and remote areas.

  2. Determine the impact of cultural-competence training for providers

    Impact

    Federal officials have pledged to step up programs to train community providers about the unique needs of service personnel, veterans, and their families. But training by itself will not necessarily increase providers' cultural competency or expand access or quality of care for veterans, and it does not replace provider experience in treating these patients. And while initial interest in training programs can be high, sustained and rigorous evaluation is needed to assess their effectiveness in changing and influencing provider competency and capacity.

  3. Expand access to effective training in evidence-based PTSD and MDD therapies

    Access

    This study points to the need for more training on evidence-based approaches for community-based mental health providers, particularly if they underwent formal professional training some time ago. The current training programs in military culture and evidence-based approaches for PTSD and MDD varies greatly and includes short, online courses to longer, in-person programs. While participation in continuing education may help to expand their skills and capacities, providers may need incentives and motivation to obtain training and to apply their learning in routine practice, particularly because this effort can cost them time and money. Policymakers may need to find ways to keep course costs low, and they must ensure the programs' quality and effectiveness, especially through rigorous evaluation.

  4. Facilitate providers' use of evidence-based therapies

    Motivate

    Even when providers have been trained in evidence-based approaches, they may not use these therapies in their routine practices. So, motivation and incentives may be called for to ensure the therapies are adopted: In larger, managed practices, these might include system- or practice-level monitoring and quality improvement efforts; in smaller or lone practitioner settings, payers may supply the impetus, with quality-of-care monitoring and adjustments to reimbursements and referrals. Research shows that there is a business case for these steps: Improved care for veterans and their families has been cost-saving and cost-effective.

When researchers combined responses for cultural competence and use of evidence-based approaches, they found just 13 percent of those surveyed had an overall readiness to deliver culturally competent, evidence-based mental health care to veterans and their families.

While this exploratory work produced key information on the knowledge, behaviors, practice settings, and backgrounds of mental health providers, the researchers said more study is needed and cautioned about over-generalizing from this specific survey to the general population of providers nationally.

Geography Matters

While RAND survey responses came from providers nationwide, this map shows military treatment sites and VA clinics, plus the density of populations of veterans and their families. Survey respondents reported the greatest familiarity and cultural competence in caring for this unique group of patients if they had treated them before, especially if the practitioner currently worked in the DoD or VA.

A map shows military treatment sites and VA clinics, plus the density of populations of veterans and their families
  • This research was sponsored by the United Health Foundation, which partnered with the Military Officers Association of America (MOAA), in commissioning this study.

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