Former therapist: VA is hurting mental health care for combat veterans at its Vet Centers

A former VA therapist says productivity pressure on counselors who treat veterans for mental health issues like PTSD is hurting the quality of care.

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By Courtney Kube and Rich Gardella

SMITHFIELD, R.I. — From his small home office, former Lt. Col. Ted Blickwedel is conducting a self-appointed mission: to call attention to what he claims is a serious problem inside a little-known Department of Veterans Affairs program that provides free mental health care to combat veterans.

From 2009 until retiring last year, Blickwedel, a former Marine Corps logistics officer, worked as a counselor and therapist at a VA facility in Rhode Island called a "Vet Center."

That facility is one of 300 that VA operates across the U.S. through its "Vet Centers" program. The program includes 80 mobile Vet Centers, 20 vet venter "outstations" and almost 1,000 community access points.

The program began after the Vietnam War as the Readjustment Counseling Service. Its purpose was and is to help combat veterans "readjust" to civilian life at home after returning from deployments.

The centers provide cognitive behavioral "talk therapy" and organize social activities and events designed to get vets out of the house and connected with other vets. All services are free.

Blickwedel, himself a combat veteran, said he got a master's in social work so he could help veterans as a therapist. He told NBC News he found working at a Vet Center to be a "wonderful" experience.

"We witnessed huge changes in veterans. Some of them, their lives completely did a 180," Blickwedel said. "I've personally had veterans tell me that I've saved their lives. That I made a difference for them."

Lt. Col. Ted Blickwedel working at his computer in his home office in Rhode Island.NBC News

But Blickwedel quit his job, after he said management upped counselors' workloads by requiring more counseling visits at a level that interfered with the quality of care they could provide to their clients. The VA's effort to make its counselors see more clients each week is another sign of a veterans' health care system that has trouble coping with an increased demand for services for millions of veterans.

A need for help

Government data shows a growing demand for mental health treatment by veterans. In 2011, more than 1.3 million veterans received specialized mental health treatment from the VA. Six years later, the annual number was 400,000 higher.

According to the VA, its Vet Centers had 307,737 unique clients in FY2019, a 3 percent increase from FY2018, and 1,890,853 visits in FY2019, a 1.5 percent decrease from FY2018.

In 2015, an internal VA report prepared by a volunteer group of Vet Center leaders and counselors analyzed the "clinical capacity" workload for Vet Centers and found that "many of our Vet Centers have exceeded their real capacity."

The report, obtained by NBC News, recommended that the productivity standards for counselors be set at 18 visits (clinical hours) from clients per workweek — two fewer visits than the 20 visit per week standard at that time.

The U.S. Department of Veterans Affairs' Providence Vet Center in Warwick, Rhode Island.NBC News

According to a VA employee with knowledge of the report and its conclusions, Vet Center national management disregarded the report and its findings. "It was dead on arrival," the source said, speaking on condition of anonymity, because its findings didn't support increasing the number of minimum visits.

Instead, a year later the VA significantly raised the number of required visits.

A VA official issued a memorandum in March 2016 to all Vet Center managers, notifying them of new productivity and performance standards for counselors and setting "minimum expectations" for the number of counseling sessions they had to conduct each week.

The memo specified that the minimum for counselors would be 30 readjustment counseling visits each week — six per day, based on a five-day workweek. That number represented a 50 percent increase from the previous expectation of 20 per week.

When Blickwedel learned about the new minimum target, he felt it was too high, and thought it would create an ethical dilemma for counselors.

"The dilemma is, choosing between, 'I'm going to do what I need to do to meet these metrics,' or actually do [what's] best for the veterans," he said.

After raising his concerns to his local and regional managers, Blickwedel wrote an email to Mike Fisher, who heads the Vet Center program as the VA's chief readjustment counseling officer.

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Blickwedel told Fisher the new higher minimums had made him decide to retire early.

"The bureaucracy has degraded the ability of clinicians to properly perform their duties as counselors and therapists," Blickwedel wrote. "Ultimately, the veterans suffer since they cannot be given the best care they deserve under these circumstances."

He cc'd his local managers and colleagues and others.

After a week without a response, Blickwedel forwarded the email to all 1,300 VA Vet Center counselors, and their managers, encouraging them to "express any concerns and provide any constructive solutions you might have."

Fisher replied all to that email, thanking Blickwedel for his message.

"You bring up an important point in that we all need to find more ways to talk to each other, bring up and discuss issues, and most importantly find solutions," he wrote.

Fisher wrote that "this conversation must continue," but pointed Vet Center staff to do so through submissions to a VA website and not through email.

Blickwedel wasn't satisfied with the response and expressed stronger criticisms in a second mass email.

"Whoever is coming up with these production standards is seriously out of touch with what is happening in the field and how it is adversely impacting those of us who are doing the day-to-day therapeutic work," he wrote.

"I strongly encourage everyone to speak up and respond 'reply all' with your comments so your voices are heard."

Three days after that, Blickwedel said, VA cut off his computer access. But before it did, Blickwedel said, he received supportive feedback from Vet Center counselors across the country.

He showed NBC News emails from 57 counselors, from 45 Vet Centers in 25 states.

"I was distraught reading the responses," he said, "all saying the exact same thing that I was saying, 'Thank you for speaking up. These are things that needed to be said, but we were afraid to say things like you did because of what we have witnessed with retaliation by the management.'"

In the emails Blickwedel showed NBC News, counselors linked the higher minimum to a broader change in the Vet Center program's culture.

"There's been a clear shift to a business model that is not conducive to optimum care," said one.

"Our leadership has ruthlessly fixated on productivity numbers, using fear and intimidation to force compliance," said another.

NBC News spoke to current and former VA employees about Blickwedel's concerns — most, but not all, through referrals from Blickwedel. Almost all agreed with Blickwedel, and said problems are continuing.

One current Vet Center official and one current counselor, however, who spoke on the condition of anonymity said the standards were and are reasonable. The official suggested any discontent reflects poor local management at specific Vet Centers.

Fisher has run the Vet Center program since 2016, according to his official VA biography. A combat veteran, he served in the Pennsylvania National Guard infantry and was deployed to Iraq in 2005.

In an interview at VA headquarters in Washington, Fisher acknowledged hearing concerns from other counselors about the standards, but said Blickwedel's concerns were overblown and did not reflect the views of most.

"In the beginning," said Fisher, "the first question was: Where did this come from? Why are we doing this? What do the numbers mean? And I think after we explained that … I felt like there was a sense of, okay, I understand that. This makes sense. When we moved into this year's training over the summer, these questions weren't coming up."

Fisher denied that the 2016 document, sent before he began managing the program, had actually set a minimum standard of 30 visits for all counselors.

"That document was to talk about goals," he said. "That wasn't the actual performance standards."

In an email in response to an NBC News request, the VA's press secretary, Christina Mandreucci, stated that 30 visits a week is the goal, but 25 visits is the actual requirement. The VA, she wrote, "requires RCS counselors to aim for 30 visits per 40 hours to be exceptional and considers counselors fully successful if they achieve 85 percent of that goal (25 visits)."

Mandreucci said that in 2019 Vet Center counselors provided an average of 34.5 visits per week to clients.

Fisher said an individual's performance standards are written in a performance plan that every counselor signs. He defended the concept of setting productivity standards for counselors.

"A lot of it had to do with making sure that, as an organization, we were being consistent across the country, and really making sure that [we're] providing the right services within a community, the right balance," Fisher said. "And also looking at how we can ensure that we're increasing access to care or looking at those opportunities to bring more veterans and service members in to receive services."

Michael Fisher, chief readjustment counseling officer, U.S. Department of Veterans Affairs, Veterans Health Administration, ion Sept. 20, 2019 at VA headquarters in Washington, D.C.NBC News

Fisher said that most Vet Center counselors — 77 percent — have been meeting their standards, and that almost half are "far exceeding" them. He acknowledged that several factors have been adding pressure to the Vet Center system, including growing caseloads, as the program has increased outreach to veterans, and a national shortage of clinicians, including psychologists and social workers.

Mandreucci told NBC News that 81 percent of counselors' performance standards "include the expectation of 25 visits per 40 hours worked. The remaining are bargaining unit professionals whose performance standards were unable to be updated to include a visit expectation. This was due to an administrative error with union notification that we are working to correct."

Blickwedel said that one week after VA shut off his computer access he chose to go on extended leave. He officially retired from VA three months after that, on April 28, 2018, three years earlier than he'd planned.

He subsequently filed complaints about the standards and the VA's treatment of him with the VA Office of Inspector General, the U.S. Office of Special Counsel, and the VA's Office Of Employment Discrimination Complaint Adjudication. Blickwedel provided documentation to NBC News showing all three entities reviewed his allegations and dismissed his complaints.

But the letter from the VA's Office Of Employment Discrimination Complaint Adjudication in February, denying Blickwedel's Equal Employment Opportunity discrimination complaint, also buttressed the argument that 30 counseling sessions really was an actual standard, not just a "goal," and that counselors felt it was too high.

VA vet center "readjustment" counselors meeting with combat veteran clients in a group session at the U.S. Department of Veterans Affairs' Spokane Vet Center in Spokane, Washington, on Aug. 27, 2018.NBC News

"The record reflects that in March 2016, mandatory clinical visit counts for all RCS counselors [were] increased to 30 visits per 40-hour week. You and many RCS counselors, all of whom were subjected to the increased standards, believed that the standard was too difficult to accomplish."

Blickwedel has now taken his concerns to Congress. At the request of two senators he approached, Jack Reed, D-R.I., and Jon Tester, D-Mont., the Government Accountability Office (GAO) is now investigating how the standards are impacting Vet Centers counselors and their care for combat veterans.

Meanwhile, Blickwedel is continuing to speak out. He says he is motivated by a strong belief that the nation's combat veterans deserve better.

"They've given their lives … for this country, our freedoms," he said, his voice choking with emotion. "[V]eterans not potentially receiving the best care they can, because counselors are having to worry about these metrics, it's unfortunate. It's just not right. And, fundamentally, it needs to change."