Bridging the Gap: The Evolution of Behavioral Health in the Veteran Community

A Conversation with Amanda Spray, Ph.D., Program Director at Steven A. Cohen Military Family Center at NYU Langone Health

Bridging the Gap is a series of conversations designed to spotlight the challenges of accessing and practicing behavioral health in diverse communities. Through open and honest dialogue, we aim to address barriers and specific needs with expert recommendations and online resources in the hopes of increasing awareness, improving accessibility to behavioral health care, and inspiring further conversation that can bring us together.

In this interview, we speak with clinical psychologist Amanda Spray, Ph.D. Dr. Spray is the Program and Training Director at the Steven A Cohen Military Family Center at NYU Langone Health and a Clinical Associate Professor of Psychiatry at NYU’s Grossman School of Medicine.

Dr. Spray has helped further the Steven A Cohen Military Family Center’s mission of providing free, compassionate care for Veterans and military families who are experiencing the long-term effects of all phases of military service, in addition to other life stresses like relationship difficulties, addiction, anxiety, and unemployment and relocation issues.

Founded in 2012, the Steven A. Cohen Military Family Center at NYU Langone, provides free mental health services for Veterans and their families regardless of discharge status. Starting in 2015, the Center became part of the Cohen Veterans Network, a philanthropically supported network of similar clinics across the country.

How has the COVID-19 pandemic altered or changed mental health support in the Veteran community?

The biggest way in which mental health service delivery has changed in the past five months is that it’s almost exclusively being conducted via telehealth, and I think that’s really exciting. Had this occurred ten or even five years ago, we may have not had a way to reach our Veterans and their family members.

Taking a page from the VA, our Center has tried to be a real leader in telehealth mental services for the past decade. In 2015, our Center was actually the first clinic within NYU Langone Health to roll

Staff members at a Veterans Day parade

out telehealth in a substantial way, so it led to a greater familiarity with technology for our providers as well our patients. When we all went remote around the middle of March, our patients were already accustomed to a certain amount of remote treatments from the get-go.

When the stay at home order went into effect, we had a full caseload of patients scheduled for their in-person treatment the following Monday. We pretty much transitioned all of our patients from in-person psychotherapy and medication management to remote through a HIPAA-secure video platform over the course of a weekend. It was exciting to see that we didn’t miss a beat in terms of being able to continue the treatment that our Veterans and family members have become accustomed to at NYU.

Do you get a sense that telehealth will be the new standard of care post-pandemic whenever a ‘return to normal’ happens?

I’d say that telehealth is a great addition to our menu of options to treat Veterans and family members. For a subset of people who really have insurmountable barriers to care, I think it’s a wonderful way to really break down those barriers and reach them. However, I wouldn’t say that telehealth can be a replacement for in-person care in every case.

About 23 to 30 percent of Veterans struggle with PTSD

For example, one condition that we treat a fair amount of at the Military Family Center is PTSD, and one of the hallmark symptoms of PTSD is avoidance. And so we want to be very careful that whenever this pandemic ends, we are very cautious when evaluating someone’s desire to engage in care via telehealth. We want to make sure we aren’t inadvertently colluding with their avoidance by providing services remotely. For certain patients, it could still be preferable or clinically indicated to see them in person.

What are the biggest misconceptions among the general public about behavioral health within the Veteran community?

The biggest misconception is that all Veterans have PTSD. While many Veterans are exposed to traumatic events, they don’t all develop PTSD as a result, and I think that is very important to understand.

The rates of PTSD in Veterans have varied over different conflicts, and research shows that Vietnam Veterans might have a slightly higher rate of PTSD than Veterans from Operation Enduring Freedom and Operation Iraqi Freedom. But they hover around about 23 to 30 percent of Veterans struggling with PTSD. That leaves 70 to 75 percent or more of Veterans that have been exposed to potentially traumatic events who don’t develop PTSD. In the civilian world there’s a related misconception that Veterans are broken in some way. And I think it’s really important not to fall into that trap.

Clinical psychologist Amanda Spray, Ph.D.

Have you seen the stigma around mental health change or evolve during your time as a clinician and a practitioner?

Historically, there’s been a really negative stigma within the Veteran community towards engaging in mental health care. I’ve certainly heard a lot of deeply held beliefs associating the development of a mental health condition or engaging in treatment for it with weakness. That was sort of the pervading mindset for a long time. However, I think there has been a movement in the community, and I’m seeing a change with an increased appreciation for the importance of mental health and the willingness to engage in care over time. The stigma still exists, but I think we’re finally making some progress towards validating people’s experiences and engaging them into care.

I’ve been very impressed with how the media is normalizing how difficult the pandemic has been on our mental health and that it’s okay to not be okay. This can be very helpful in terms of hopefully making a dent in the negative stigma associated with receiving mental health treatment in general and that it will also trickle into the Veteran community.

What type of treatments or therapies are potentially more effective for the Veteran community than the civilian community?

Most of the research that has been conducted is aiming to establish that treatments are also effective in the Veteran community or to be as effective as they are in the civilian community. I don’t think the benchmark has been set for better.

Most of the treatments we have, have been developed and studied in civilians and then modified and adapted for use in Veterans, and we’ve found that many of the treatments for trauma are also effective in Veterans, with varying degrees.. es. Like I said, not every Veteran is struggling with PTSD, but usually when I’m asked about treatments and therapies with Veterans, I’m being asked about PTSD treatments. There are some leading treatments for PTSD in both the civilian and Veteran populations.

Two of the leading psychotherapies treatments we have for PTSD are called cognitive processing therapy and prolonged exposure therapy. They were developed in civilian populations and shown to be quite effective for the treatment of PTSD in civilians. When they were brought over to the Veteran population they also showed efficacy, however some research suggests that they may not be as effective as in civilian populations.

With that said, these treatments are still effective, and these are the treatments that we offer at NYU and that I offer to my patients every day because they really are the most evidence-based treatments we have at this point in time.

In the civilian world there’s a related misconception that Veterans are broken in some way. And I think it’s really important not to fall into that trap.

One thing that we are increasingly aware of is that we likely do not need to develop new psychotherapies for PTSD, rather we are starting to gain a greater appreciation for the match between the Veteran, their clinical presentation, and the Veterans’ preferences. There’s ongoing research to determine which treatments work for which Veterans because the match is so essential.

How about outside a clinical setting? What seems to work well?

I’ve heard from the Veterans I’ve been working with for the past 10 years now, that many of them have expressed to me the importance of maintaining the camaraderie that they experienced in the service. So many of them have found that by engaging in activities with other Veterans. Whether it’s through formal therapy like support groups to help process their experiences with other Veterans with a mental health provider as a facilitator or through Veteran organizations that organize group athletics or participating in creating and sharing art of various different kinds or helping others.

Having that social support back in their life can have a buffering effect. There are going to be other Veterans that also need to engage in mental health treatments. And again, it’s sort of about the personalized medicine aspect of working with Veterans that I think is really important.