You’re home. Now what?

Local veterans counselors are few and far between in the region

Published June 25, 2008
By Casey Farrar
Sentinel Staff
The 15 people who gather weekly at Granite Hills Behavioral Consultants paint a complex picture.

A Vietnam veteran in his 60s who has been divorced three times and said sometimes he drinks his problems away.

An Iraq veteran and reservist who has applied for 63 jobs since he returned, but has never heard back from any employer after telling them he might be called back to war.

A veteran of the Gulf War who says he sought help for depression when he saw his children suffering from his mood swings.

All of them have seen the face of combat, and each has a very different story to tell.

But when they are in this conference room in Keene every Thursday among other veterans, they say they feel understood.

A 24-year-old veteran of Iraq from Keene, who asked that his name not be used, says it took a suicide attempt several months after his return to recognize the magnitude of his depression.

He said talking to the other veterans in the group has helped him understand that what he feels is normal.

Leading the group is Anthony “A.J.” Paige, a veterans readjustment counselor for Monadnock Family Services in Keene who is himself a veteran of the U.S. Army.

During his 23 years in the Army, Paige saw his share of combat in Somalia, Central America and the Persian Gulf.

In the nearly three years since Paige began counseling veterans at Granite Hills, a branch of Monadnock Family Services, the number of veterans walking through his door has increased seven-fold.

In 2006, Paige worked with eight veterans who had been referred from regional veterans centers. In 2007, 23 veterans sought treatment at Monadnock Family Services, and this year that number has jumped to 58.

All of the veterans Paige sees are men. He said a female veteran has also sought treatment with him, but because he counsels her husband, who also is a veteran, Paige is unable to see her. She is forced to travel to Manchester for treatment.

Nearly a quarter of the veterans he sees have returned from Iraq and Afghanistan. He also counsels 26 Vietnam veterans, nine veterans who served in the Gulf War, two veterans of Bosnia and Kosovo, two veterans of Somalia, three veterans of conflict in Central America, one veteran of World War II and a veteran of Grenada.

“(Veterans) are very proud people,” Paige said. “They have an enormously tough time talking because they come from our society, which tells people big boys don’t cry.”

That mentality is enforced in the military, Paige said, where losing focus for only a second can be the difference between life and death.

“You suck it up. You drive on. You accomplish the mission,” Paige said.

Most of the veterans Paige sees have symptoms of post-traumatic stress disorder including depression, trouble sleeping, anger, and isolation. Some battle substance abuse and several have been homeless. All said they’d considered suicide at one time or another.

The veterans at the group meeting said they are sometimes asked difficult questions about combat or feel people don’t believe their stories, making it hard to relate to those they were once close to.

“Sometimes people will ask, ‘Did you ever shoot anyone?’” said a recently returned Iraq veteran. “And you know they just don’t understand, but it makes you wonder how someone can ask something like that.”

Post-traumatic stress disorder was first recognized by the American Psychological Association in 1980. It is caused by exposure to a life-threatening situation and feelings of helplessness and can result in flashbacks of a traumatic incident months or years later.

Recent reports showing an increasing suicide rate among soldiers, combined with a rising number of diagnoses of post-traumatic stress disorder and traumatic brain injury, are leading Paige and others in the mental health field to say long-term care for veterans needs to improve.

“Unfortunately, we live in a nation that has a bad tendency to be a throw-away society,” Paige said. “Once we’re done using you, once you’ve served your purpose and the rounds are done going down-range and the bullets are done flying, ‘it’s have a nice life.’ ”

The U.S. Army recently reported 115 confirmed soldier suicides in 2007, both stateside and abroad — the highest number recorded since the Army began keeping such records.

In 2006, 102 suicides were reported. Neither of those figures includes suicides among veterans no longer in the service, which are not tracked.

Rates of post-traumatic stress disorder diagnosed by the Army also jumped in 2007, increasing by 50 percent.

A recent study by the RAND Corp., a health and government policy research program, showed one in five returning veterans from Iraq and Afghanistan report symptoms of post-traumatic stress disorder or major depression.

Of the nearly 1.6 million troops deployed to Iraq and Afghanistan, 300,000 have reported symptoms, yet only 53 percent of those sought help from a medical provider over the last year, according to the RAND study.

The U.S. Department of Veterans Affairs recently announced an effort to ramp up suicide prevention with the creation of an advisory panel.

The Department of Defense also announced it will expand the network of mental health care providers who accept the military’s TRICARE health plan and teach civilian providers how to screen for traumatic brain injury.

In New Hampshire, nearly 125,000 veterans have returned from Iraq and Afghanistan and 28,000 are registered for medical coverage with the Manchester Veterans Administration Medical Center, according to Debra N. Krinsky, a spokeswoman for the center.

Krinsky said many veterans in the state go to the White River Junction Veterans Administration Medical Center in Vermont, and with veterans traveling out of state for treatment, it’s impossible to pin down exactly how many of the state’s veterans are being treated for service-related injuries.

Statistics on the number of veterans in the state diagnosed with post-traumatic stress disorder are not available.

Nine of 14 research studies at the Manchester medical center this year focus on post-traumatic stress disorder, according to center officials. The research is funded through grants from the Veterans Administration, the National Institute of Mental Health, the U.S. Army and the American Society of Addiction Medicine.

Paige says many soldiers returning from war are discouraged from seeking help because of the stigma attached to a mental health diagnosis.

They also face mountains of paperwork and frequent office visits to file claims with the Veterans Administration, Paige said.

Many are referred to Granite Hills by the veterans center in White River Junction, Vt. Others come after being treated at area emergency rooms or walk in from the streets.

For some veterans, getting counseling in Keene is easier than traveling to White River Junction or Manchester, which are each about 60 miles away.

The centers are also overloaded, meaning the average counseling session lasts about 20 minutes there, Paige said.

In contrast, at Granite Hills veterans are scheduled for hourly sessions, and sometimes stay longer if they need extra time, he said. They usually begin group therapy weeks or months after their counseling begins.

Since he is the only counselor at the center working full-time with veterans, the number of veterans who can receive treatment locally is limited, Paige said.

But funding at Monadnock Family Services and other counseling services around the state is tight, making it difficult to beef up veterans counseling staff.

“The Easter Seals, the Veterans Administration, the federal government and the Army all have a lot of money they want to shift toward the vets,” Paige said. “The problem is they haven’t quite figured out how to shift it down here to the trenches.”

In the meantime, several veterans gathered at the group counseling meeting in Keene last week say they have to wait months, and in some cases years, to get treatment for medical and mental health problems related to their time in the service.

For the Veterans Administration to cover the cost of treatment, veterans have to file claims that take an average of nine months to receive approval. Denied claims can be held up in the appeal process for more than two years, Paige said.

But the veterans who take part in the Keene group meetings say in the end, not coming in for help would be worse than jumping through the federal hoops.

“The more and more you wait around, the more and more isolated you feel and the worse all those feelings become,” said one veteran of the Gulf War at a weekly group meeting. “At least here we can talk to each other about it and feel like someone understands.”

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

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War-related brain injuries usually treated elsewhere

Published June 25, 2008 in the Keene Sentinel
By Casey Farrar
Sentinel Staff
Traumatic brain injury is gaining a reputation among military and civilian doctors as the signature injury of veterans returning from Iraq and Afghanistan.

Caused by the blast waves from an explosion or a blow to the head, the injury can result in short-term memory loss, headaches, ringing in the ears, mood changes and depression.

However, the way brain injuries from blasts differ from those typically suffered by civilians is a growing topic of study among experts in the field, according to Dr. Rocco A. Chiappini, director of brain injury services at Crotched Mountain Rehabilitation Center, a treatment center in Greenfield.

The Department of Defense estimates there are more than 22,000 soldiers who have survived blasts, about 25 percent of whom are probably affected by traumatic brain injury.

This month, officials from the department broke ground in Bethesda, Md., on a $70 million clinical research and education facility for the treatment of traumatic brain injury and psychological health.

In New Hampshire, moves are being made to meet the need for treatment at the local level.

The Manchester Veterans Administration Medical Center has opened three clinics for brain injury and neurological assessments for veterans since March, according to Debra N. Krinsky, a spokeswoman for the medical center. The third, a neuropsychiatric clinic, opened on Tuesday.

In the year since all soldiers returning to New Hampshire have been required to undergo assessment for traumatic brain injury, 131 have tested positive for traumatic brain injury at the Manchester medical center, according to a press release from the center.

Until the Manchester clinics began in March, those who tested positive for this injury were sent to Veterans Health Administration medical centers in Boston and White River Junction, Vt., for further treatment.

Since March, 70 veterans have been treated for traumatic brain injury in Manchester; another 13 are scheduled for assessments at the new clinic, according to officials at the medical center.

Federal officials are also considering using Crotched Mountain as a place to treat wounded veterans.

The rehabilitation center has been certified as meeting military requirements to treat veterans, said Michael D. Redmond, vice president of advancement for the Crotched Mountain Foundation.

Officials at Crotched Mountain have discussed with the Veterans Administration the possibility of treating one local injured veteran who may stabilize enough to begin rehabilitation, Redmond said.

Chiappini, who is a physiatrist, or doctor specializing in rehabilitation, said while the center hasn’t seen any veterans yet, he sees demand for local treatment services increasing in the near future.

“There hasn’t been a lot of good research done in a methodical way to understand brain injury,” Chiappini said. “It has started and it’s increasing now because of the wars.”

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

Six to lose jobs at counseling center

MFS $500,000 short; more trouble expected

Published June 12, 2008 in the Keene Sentinel
By Casey Farrar
Nearly two months after announcing a $500,000 budget deficit, a Keene-based mental health organization has begun shifting its focus to cut costs.

The organization is shrinking its adult outpatient counseling services, which resulted in $190,000 in losses last year from unpaid fees, according to Jayme J. Collins, chief operating officer of the nonprofit organization.

The cuts mean long-term treatment for people who are not deemed at risk of harming themselves or others and can’t pay will no longer be available, Collins said.

Six full-time clinical therapists were notified last month that they will be let go on July 1, Collins said.

And by expanding services for severely mentally ill adults and children, who are eligible to receive state and federal funding, administrators at Monadnock Family Services hope to bring in more money for the organization, according to Jayme J. Collins, chief operating officer of the nonprofit organization.

The organization’s budget deficit came from unmet Medicaid deductibles, unmet deductibles from clients with commercial health insurance and people who couldn’t pay.

Meanwhile, a giant question mark looms over the 10 community mental health centers, including Monadnock Family Services, around the state as they wait to find out the possible financial impact of new federal Medicaid rules.

Then new rules, which would affect treatment plans and payment methods for patients covered by Medicaid, could lead to as much as a 40 percent reduction in reimbursement rates for the centers, according to Jay Couture, chair of the N.H. Community Behavioral Health Association.

The centers, which receive as much as 80 percent of their reimbursements from Medicaid, could see $20 million in losses next year, Couture wrote in a letter sent to health care advocates and legislators last week.

Monadnock Family Services is the first of the state’s centers to announce cutbacks. Last month, the organization’s 260 employees took a 7 percent pay cut when their work week was reduced by 2.5 hours.

Collins said nearly a third of the organization’s 3,300 adult clients will be affected by the cutbacks to the outpatient counseling services.

While the organization is required to treat severely mentally ill adults and children, it has been providing the same level of treatment to anyone who comes in, whether they can pay or not, Collins said.

By absorbing unpaid fees from people who are uninsured or can’t meet their insurance deductibles, the organization has been falling further behind, Collins said.

She said many of the outpatient clients receiving treatment are facing difficult situations like a recent divorce or move and are looking for help, but aren’t at risk of harming themselves or others.

“We have to use our resources efficiently so that we can provide services to those we’re mandated to treat by the state,” Collins said. “The thing that got (Monadnock Family Services) in the bind that they were in … is that they tried to treat everybody that same way.”

Collins said the organization will assess everyone who comes in, and offer short-term treatment for people who are not considered high-risk.

“We’ll try to give them a lot of tools to work with that they may have to do on their own or come back for a check-up a couple of months later,” Collins said. “We just can’t do traditional weekly kind of therapy in the same way.”

Collins said the organization is working to increase its group therapy offerings, which would cost about a third less than meeting individually with a therapist.

Up to eight people with similar diagnoses meet with one clinical therapist in typical group therapy, according to Collins.

It’s not a popular choice for many people, who don’t feel comfortable discussing personal issues with others, Collins said, but offers an option for people unable to afford individual therapy.

Emergency mental health services offered by the organization will not be affected by the cuts, Collins said.

Expanding services for severely mentally and emotionally ill adults and children will also help the organization financially, Collins said.

Because the organization is required to treat those clients, community, county, state and federal funding is available to cover unmet fees.

She said by broadening treatment options for severely mentally ill adults, including transportation to medical appointments, life skills training and career counseling when possible, the organization will be eligible to take in more Medicaid money.

The expansion of those services over the next year means the organization could offer jobs in other areas to the people it has had to let go from the outpatient counseling staff, Collins said.

“There will be new opportunities, but unfortunately they’re not happening simultaneously,” Collins said. “I’m afraid some of that talent will move on.”

Couture, who heads the state association of community mental health centers, warned in her letter that other centers in the state may face cut backs or even closure if the new rules are too costly.

“Clearly, the centers will not be able to operate if their reimbursement is cut by 40 percent,” Couture said in a press release.

With more than 41,000 people in the state turning to the state’s mental health centers for treatment in 2006, Couture said hospital emergency rooms, county and state correctional facilities and local police and welfare departments could be affected by the reduction of services in the centers.

The new rules, which were set to go into effect in March, have been delayed until August. Congress is considering a one-year moratorium, which was placed in the language of an Iraq war appropriations bill.

The bill passed in the Senate, but has been stalled in the House.

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.