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July/August 2019

Psychiatric Breakdown at West LA VA

The closure of long-running mental health and transitional housing programs, combined with an exodus of experienced clinicians amid allegations of toxic leadership, is disrupting care at VA Greater Los Angeles Healthcare System (VAGLAHS), according to some former VA doctors, a social worker, and local veterans.

In a letter sent last November to Sen. Johnny Isakson (R-Ga.), Chair of the Senate Committee on Veterans’ Affairs, four recently retired VAGLAHS clinicians alleged “mismanagement of resources and abuse of power by current VAGLAHS leadership” that “strongly derail the crucial needs of our veterans.”

VAGLAHS is the largest integrated health care organization in the Department of Veterans Affairs, serving 1.4 million veterans in five counties. So any upheaval in its mental health programs—such as lowered staff morale or high clinician turnover—could have a negative impact on countless former service members.

“My concern with Mental Health services has been with the defections of many of the senior psychiatrists and a general sense of fear and, more generally, lack of collegiality,” said Dr. Robert Rubin, a co-signatory to the Isakson letter. Rubin was VAGLAHS Chief of Psychiatry and Mental Health from 2005-13, and remained as a staff psychiatrist there until last year.

Most of the clinicians and veterans interviewed for this article noted the importance of continuity of care—that is, sustained relationships between veterans and their doctors or social workers (and between a veteran and other veterans on a centralized VA campus)—to the treatment of mental health conditions. Yet, according to Dr. Rubin, more than fifty psychiatrists (as well as other specialists and social workers) have left VAGLAHS since the appointment of Dr. Barry Guze as Associate Chief of Staff for Mental Health and Chief of Psychiatry at West LA VA in November 2014.

“If you’re going to have a constant turnover of staff, you have no continuity of care,” said Dr. Shoba Sreenivasan, a psychologist who retired from a 28-year VAGLAHS career in September. “Particularly for combat vets, I think that that kind of continuity and the environment at the VA was like the base. They weren’t outside the wire without anybody—they’re outside the wire reconnecting to that sense of platoon.”

The VA’s 2016 Draft Master Plan for its West LA campus, drawn up in the wake of an ACLU class-action lawsuit alleging mismanagement of that property, proposed “Expanded Mental Health and Addiction Services.” Yet the co-signatories to the Isakson letter—two psychiatrists, a psychologist, and a social worker with decades of combined VA experience—paint a picture of mental health programs instead being disbanded or dispersed.

“There are a lot of things that’re perplexing—that don’t seem to go in the direction of what would be the mission of the VA,” Sreenivasan said. “Certainly a PTSD and a combat PTSD clinic ought to be a central mission, but that’s all closed down. Dual-diagnosis treatment is incredibly important, but that was shut down.”

Citing the federal Privacy Act of 1974, VA spokeswoman Nikki T. Baker, in a written response to questions for this article, said that the department could not comment on specific complaints from current or former employees without them filling out a Request for and Consent to Release of Information from Individual’s Records form. Former VA clinicians interviewed for this article declined to do so.

Axing the West LA PTSD Program

Perhaps most concerning of the recent VAGLAHS reforms has been the axing by Dr. Guze last year of the comprehensive PTSD Outpatient Services Team (POST) clinical program at West LA VA. Co-founded by social workers Leslie Martin (another co-signatory to the Isakson letter) and Jim Dwyer, the program served thousands of war veterans on the VA’s vast West LA campus over the past twenty years, offering group therapy, various individual therapies, couples therapy, and spouses’ therapy.

James Fox/Lima Charlie news (limacharlienews.com)“The heartbreak for me is that these guys are not going to continue to get those services,” said Martin, who retired from the VA last October after nearly thirty years of working with veterans. “And I try not to even imagine the group [of PTSD patients] who are going to be coming in, who will never have had these services.”

While an average of twenty veterans die by suicide daily in this country, POST, which treated many thousands of PTSD patients over its two decades, had only one veteran take his own life, according to Martin. She also claimed a recidivism rate of inpatient stays of less than one percent per year.

“In my case, the program was a life changer and a life saver. The same can be said for so many of the guys,” said Steven Goldstein, who served as an infantry officer in Vietnam in 1969-70. “The West LA administration turned blind eyes and deaf ears to our repeated attempts to meet and talk with them regarding the discontinuation of certain POST groups.” 

Dr. Guze has replaced the open-ended, long-term group therapy offered by POST with twelve-week “evidence-based” individual counseling programs. These consist, in essence, of short-term treatments such as Prolonged Exposure and Cognitive Processing Therapy. Such therapies can be distressing to veterans who have often spent decades trying to forget the experiences these types of programs require them to re-live. Completion rates can be as low as 50 percent.

“You can’t do something in twelve weeks that needs to be released over a lifetime,” said one Vietnam War pilot, who said he’s attended both group and twelve-week individual PTSD therapy sessions at the West LA VA.

“Because you’re looking at psychiatry running this [new VAGLAHS PTSD program], they see the world through medical model glasses,” Martin explained. “They treat the disease. We are a social work-driven program—we treat the person.”

VA spokeswoman Baker characterized recent changes in PTSD therapy at the West Los Angeles VA as “co-locating all of GLA’s acute care services including mental health to the south side of the campus and moving permanent supportive housing services to the north side of the campus. The move offers veterans the opportunity to have collaborative care that is coordinated across programs.”

James Fox/Lima Charlie news (limacharlienews.com)

POST 2.0

Some of former POST patients from its war veterans PTSD group, including Goldstein, have continued gathering on their traditional Tuesday evenings, with each chipping in three dollars weekly to rent a room at a Santa Monica community center close to the West LA VA campus. Since last October they’ve been congregating at what Goldstein dubs “POST 2.0” meetings, with Martin continuing pro bono as the group’s facilitator.

POST meetings “were great, because they forged the camaraderie that we have right now, which is why this group is still together,” said a former Ranger company commander who served along the Vietnam-Cambodia border in 1969-70 but requested anonymity, relaxing before one such meeting in March. “We had these weekly meetings, which was the ‘glue,’ but most of us also took various evidence-based courses. We had the best of both worlds.”

Today, the former Ranger combines attendance at the off-campus meetings with biweekly visits with a VA psychiatrist, of whom he speaks very highly.

“There’s no cure for PTSD. You learn how to manage it, but that’s basically it,” said a former Army artillery officer who fought in the Mekong Delta in 1966-67 and also wished to remain anonymous. “You can go for psychiatry and the help that it gives you, [then] it’s a natural flow into maintenance. And these groups are maintenance.”

He further pointed out that ongoing group support was crucial in dealing with re-occurring life issues resulting from PTSD, which can be triggered by an array of everyday circumstances. The artilleryman expressed “anger, sadness, and a feeling of abandonment” upon learning of POST’s disbanding by the VA.

“I feel like I got ripped off,” the former pilot said. “After forty-seven years of bouncing off imaginary walls, so to speak, and finally being given a potential antidote, I’m told that they’re discontinuing our group.”

Homeless Vets Not Welcome

The Isakson letter also alleges that homeless veterans who seek help at West LA VA are being sent to Skid Row or other dangerous areas of Los Angeles, and that the promised renovation of some of the West LA property’s many derelict buildings into veteran housing has proceeded at “a glacial pace.”

“Homeless veterans are not welcome on VA grounds,” the letter said. “Even though there are approximately 4,800 homeless veterans in Los Angeles County, a 57 percent increase since 2016, VAGLAHS has shut down most of its on-campus transitional housing.”

According to the VA’s own numbers, up to 80 percent of homeless veterans nationwide suffer from mental health or substance abuse disorders. So any crisis within GLA VA mental health and homeless veteran services is doubly harmful to thousands of area veterans.

James Fox/Lima Charlie news (limacharlienews.com)

“We’ve had elderly veterans in wheelchairs sent to Skid Row, and some of them have been physically assaulted. It’s just a dangerous environment,” said Sreenivasan, whose forensic outreach services program—which helped veterans safely transition from state prisons and mental hospitals back into the community—was recently terminated by Dr. Guze. “The housing program is very limited and in very marginal areas, by and large. And yet, if you go onto the grounds, there are all these empty buildings.”

James Fox/Lima Charlie news (limacharlienews.com)“After completing federally required environmental studies, renovation of Buildings 205 and 208, which will provide sixty-eight and fifty-four new units of housing, respectively, will begin in summer 2019, and renovation of Building 207, which will provide sixty-four new units, will begin in December 2019,” VA spokeswoman Baker said. “Building 209 has been fully operational since June 2017, providing fifty-four units of permanent supportive housing for chronically homeless veterans.” 

Salvation Army Terminated

Most befuddling to many observers has been the 2017 termination of the Salvation Army’s enhanced-use lease agreement with the West LA VA. Since 1994, it had operated multiple programs on that campus, including providing transitional housing for some two hundred homeless veterans. These programs have now been dispersed elsewhere in Los Angeles.

“The Salvation Army was one of the most reliable places we had to send homeless vets,” said Dr. Rubin, a Vietnam War veteran who served two years in the Naval Reserve as a medical officer. “And not just in mental health, but vets with medical illness.”

According to Baker, the VA terminated the Salvation Army’s agreements after the latter “failed to make necessary safety-related repairs in the buildings required by the contracts.”  The VA was able to place affected veterans in alternative community housing, Baker stated.

“All the transitional beds run by the Salvation Army that were really critical to housing and mental health stability were shut down,” Dr. Sreenivasan said. “Between that and shutting down the Domiciliary [Care for Homeless Veterans Program], it was almost, I think, three hundred beds.”

Homeless veterans are now offered bus tokens to Skid Row shelters or, in partnership with nonprofit Safe Parking L.A., given a place to sleep in their vehicles on the West LA campus.

Toxic Leadership

The co-signatories to the Isakson letter (including Dr. Thomas Garrick, a psychiatrist with more than thirty-seven years’ VA experience) point to what they describe as “toxic leadership” of VAGLAHS Mental Health and Homeless Veteran service as “destructive to veterans’ care.”

“The architects of the authoritarian and abusive management style are Barry Guze, M.D. (Associate Chief of Staff for Mental Health) and Heidi Marston, MPH (Chief of Community Engagement and Reintegration Services), aided and abetted by Ann Brown, FACHE (Director) and Scotte Hartronft, M.D. (Chief of Staff),” they wrote. (Marston left the VA in February.)

The letter’s co-signatories describe a management style characterized by “psychologically abusive behavior intended to intimidate their subordinates, including invoking administrative investigations, humiliation through demotions, and marginalization of clinicians who either voice concern or ‘whistleblow’ regarding clinic closures, housing issues, and veterans’ suicide.”

While all this might sound like the grumblings of disgruntled ex-employees, the strained professional relationships they describe could have a direct impact on Los Angeles-area veterans.

“All the clinicians who take care of veterans are human beings—they’re not automatons,” said Dr. Rubin. “And if people are disgruntled in their work [and] fearful about their job security, this does not allow them to focus their full attention on the veteran.”

James Fox/Lima Charlie news (limacharlienews.com)

Martin described a growing culture of fear at West LA VA, which has reached an alarming crescendo under its current administration. “The administration is afraid of the veteran population they’re put there to serve,” she said. “The perception is that if a veteran comes to this VA that they obviously have just crawled out of a dumpster. And the fact that we’ve got architects and lawyers and people who’ve been in business their whole lives [is] irrelevant.”

A feeling of disillusionment and disappointment with the VA over recent changes to its LA Mental Health programs was expressed by former clinicians and patients alike.

“Most of us who’ve left [VAGLAHS] had a lot of allegiance and found it a deep honor to be allowed to serve our nation’s veterans,” Dr. Sreenivasan said. “It was very meaningful for me, and I would not have left but for the toxic leadership.”

“We either volunteered or [were] called upon to put our lives on the line. I’ve buried people; I’ve got hurt myself,” said the former pilot, who was shot down and seriously injured in Vietnam. “We’re not asking for a gracious entry into la-la land—all we’re asking is take care of us; give us the medical treatment.”





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