2013 APA Silver Award: On-Campus VA Mental Health and Social Work Services for Student Veterans: SFVAMC’s Veterans Outreach Program at City College of San Francisco

Since 2008, unprecedented numbers of former military service members have enrolled in college by taking advantage of greatly expanded educational benefits provided by the post−9/11 GI Bill. Many of these returning veterans, however, find adjustment to college life difficult. In fact, up to one-quarter have a diagnosis of posttraumatic stress disorder (PTSD) or depression, and a significant number have cognitive impairment or difficulties with attention and concentration that are due to traumatic brain injury.

At the City College of San Francisco (CCSF), enrollment of student veterans was increasing dramatically each semester, but the veterans had no opportunity to meet each other on campus. They were also having difficulty getting across the city in time to attend crucial mental and general medical health appointments at the San Francisco VA Medical Center (SFVAMC). In 2010, a veterans task force, including a group of students, was formed. It enlisted the help of the school’s football coach, George Rush, who in turn contacted Keith Armstrong, L.C.S.W., the director of mental health social work at the SFVAMC.

Mr. Rush, Mr. Armstrong, and student veteran leaders recognized the clear need to support the growing population of student veterans on campus, and they began to garner support at CCSF and the VA to provide an on-campus center where veterans could feel a sense of community and receive social, educational, and emotional support. Mr. Armstrong envisioned the development of a VA mental health program on the CCSF campus. This idea triggered an outpouring of help from VA mental health and social work clinicians, who worked with their supervisors to obtain time away from their usual clinical duties to launch the program. Staff psychiatrist Ellen Herbst, M.D., arranged training for staff to allow them to work off site in a non-VA setting and collaborated with CCSF and SFVAMC to ensure that the office complied with Joint Commission standards and SFVAMC priorities. Coach Rush obtained the support of over 30 unions, local businesses, and donors to convert a group of old classrooms into a modern, spacious lounge and private offices. CCSF provided necessary amenities, such as office equipment, parking, and a computer.

Now in its third year, the SFVAMC’s Veterans Outreach Program at CCSF has become a veritable student health center for veterans. It has provided outreach services to over 1,000 student veterans, nearly half of whom were deployed to Iraq or Afghanistan. In recognition of its innovative program that serves a vital national purpose by providing accessible mental health treatment for student veterans, the Veterans Outreach Program at CCSF was selected to receive the APA’s 2013 Silver Achievement Award. The award will be presented on October 10, 2013, at the opening session of the Institute on Psychiatric Services in Philadelphia.

Veterans, and particularly combat veterans, may experience difficulty transitioning back to the civilian context and into a college setting. Military culture, which emphasizes structure, discipline, and order, differs vastly from typical college student life. Moreover, a high percentage of returning combat veterans have faced exposure to life-threatening events, death and dying, and other stressful deployment experiences while serving in Iraq and Afghanistan and may return with psychiatric and psychosocial conditions such as PTSD, depression, or a cognitive disorder related to traumatic brain injury. These conditions can impair attention and concentration and place veterans at risk for academic problems. In addition, their unique military and life experiences may cause student veterans to feel different from their civilian counterparts, and other students may not be understanding or sensitive to the cultural experience of military veterans.

Our young veterans need to be reintegrated into our society,” according to Richard A. Shadoan, M.D., and Lawrence B. Lurie, M.D., who visited the program on behalf of the Psychiatric Services Achievement Awards Committee. “We messed up this process with the veterans of the Vietnam War. Hopefully, we can get it right this time.”

The SFVAMC’s Veterans Outreach Program is the first in the nation to deliver comprehensive VA specialty mental health care, including psychiatric medication management, on a college campus. The program provides a “one-stop shopping” experience where veterans can access information, enroll in VA health care on site, and receive comprehensive, evidence-based mental health services and assistance in navigating both VA and college services. Services include psychiatric evaluation, medication management, smoking cessation therapy, social work case management, addiction treatment, and psychotherapies, including motivational interviewing, cognitive-behavioral therapy, prolonged exposure therapy, cognitive processing therapy, and emotionally focused couples therapy.

Services are provided by six part-time staff members who share one full-time-equivalent (FTE) position. Mr. Armstrong is program director, and Bridget Leach, L.C.S.W., is program coordinator. Dr. Herbst works at the program one day per week to provide medication management, consultation with staff on difficult cases, smoking cessation, and brief interventions for substance use disorders. Also on staff are program psychologist Shannon McCaslin, Ph.D., Bay Area College outreach coordinators Brandina Jersky, M.F.T, and Gerard Choucroun, L.C.S.W., who have clinical and research expertise in PTSD among military veterans. The team also has the administrative support of Isaac Ramos and Morris Karo.

A group of student veterans, the City College Veterans’ Alliance, works closely with the Veterans Outreach Program to provide feedback about the program and to ensure that veterans are receiving needed services. It also provides advocacy, support, and camaraderie for veterans on campus.

Located in Cloud Hall, the program is housed in a suite of offices shared by academic counselors and educational benefits officials. Next door is a modern lounge and resource center, where veterans can recreate the sense of cohesion and support characteristic of military culture. The design allows the students and staff to informally interact and allows veterans to seek out private conversations with the VA staff. Treatment can begin immediately, if necessary.

By locating services at the college, the program hopes to destigmatize mental health treatment, reduce barriers, and make it convenient to seek care. The veterans have an alternative to traveling across the city to mental health appointments at the VA Medical Center. “They are able to access treatment in a setting comfortable to young people, not the VA Hospital attended by old people, but rather in the halls of a college,” said Dr. Shadoan. That may be particularly important for the younger generation of veterans, who are less likely to seek out or continue treatment with traditional models of mental health.

The staff believe the model has the potential to dramatically improve retention rates and engagement in mental health care for a high-risk population of veterans, particularly combat veterans. Providing services on campus allows the staff to identify and treat mental health problems soon after military service or deployment. Early intervention, they believe, can help a younger generation of veterans avoid long-term disability and achieve better mental health and academic outcomes.

In an acknowledgment of the challenges facing student veterans, the VA has initiated a nationwide pilot project to connect the growing population of student veterans to their local VA medical centers. The project, called Veterans Integration to Academic Leadership (VITAL), helps student veterans get the care and counseling they need while still in school. In March 2011, the Veterans’ Outreach Program was selected as one of the five pilot programs funded by VITAL and has been serving as a model for the 16 additional VITAL sites across the country. The program’s staff has consulted with a number of other VITAL sites regarding the design and implementation of services throughout the new locations’ program development.

The VA’s national VITAL program provides $142,000 annually, and the SFVAMC has provided $60,000 annually; these funds are used for clinical staffing. The SFVAMC has recently committed to providing funding ($142,000) for one clinical staff member.

The results of the VITAL pilot programs have been very encouraging, according to VA Secretary Eric Shinseki, who spoke in December 2011 at the annual conference of the Student Veterans of America. “All of society’s efforts to provide opportunity to veterans count only if they cross that graduation stage and receive their diplomas,” he said. The Veterans Outreach Program, he said, has helped over 500 veterans enrolled at CCSF. “Without the program’s help,” he said, “there's a good chance those veterans would still be struggling on their own to get over the past and make it through school.”

“To convince the VA to go outside the walls of its hospital onto a college campus is truly extraordinary,” said Dr. Shadoan and Dr. Lurie. They credit the collaborative leadership of football coach Rush and the student veterans, unions, VA staff, and college administrators for developing a mental health outreach program that helps overcome the isolation that many veterans experience.

Working together, we can help veterans transition from the high-stress but highly structured operational environments they knew in the military to a largely unstructured and often isolated student life, according to Secretary Shinseki. “When troops run alone,” he said, “you know what happens: they don't run as far or as fast. But when troops run in formation, everybody keeps the pace, and everybody finishes.”