The Veterans Administration, once the largest employer of psychologists, had begun undergoing a massive transformation as The National Psychologist reported in an article in our July/Aug. 1996 issue. How is the VA faring now that the changes have been completed? Where and how do psychologists fit into the total picture? We revisited our original source, Thomas Horvath, M.D., recently. Here is what he had to say:
The “Psychology Service,” long a staple in the Department of Veterans Affairs, is no more. Psychology has become a part of the mental health units in a massive organization that now prides itself on “health care” replacing “hospital care.”
In the new VA, there is a place for psychologists, assures Thomas Horvath, M.D.
“But we no longer have departments,” he said. With the reorganization, the VA’s medical administration department is gone, and there is also no physical, engineering, medical or psychology department. The VA has shifted its focus from 172 hospitals to regional organizations, called VISNs that administer this vast federal empire.
The larger picture is not whether psychology will merge with another department but “where do psychologists fit.” And they will, and they do fit, Horvath believes.
It means the needs of mentally ill patients are being served by a multidisciplinary team comprised of psychologists, psychiatrists, nurses, social workers, chaplains and medical administration people. The leadership will come from “the best qualified individual regardless of professional background.”
Nonetheless, the professional identities of the different professionals will be maintained for such purposes as training. A “lead professional” will be responsible for professional development of the specific profession.
In a lengthy interview, Horvath continually stressed the importance of “team” in the new-look VA.
Could a psychologist be a primary care provider within this setting? he was asked. Horvath answered that as an individual, the psychologist would not be a primary care provider, but as part of a team–composed of a psychologist, psychiatrist, a nurse, and possibly, a nurse practitioner–professionals complementing one another’s skills–he can be a primary care team member. Horvath said that Kenneth Kizer, M.D., the VA chief, supports the concept that a mental health team can be the provider of primary care for a group of patients.
A significant change has moved the VA from emphasis on inpatient services in its 172 hospitals to outpatient service. After World War II, the emphasis was on building facilities in the Northeast and the so-called Rust Belt. Overlooked was commensurate construction in the Southwest and now, during reorganizations, more attention is being shifted to states with high population growth, such as Arizona.
On the issue of internship training, Horvath said today’s VAMC wants to train people in areas with the greatest clinical loads. The VA, he said, needs professionals who are able to directly serve the need of veterans.
Asked to discuss the type of person the VA hires today by comparison with 20 years ago, Horvath replied that today’s psychologist would have to be even better qualified than an individual hired in the 1970s.
“We would expect that person to be scientifically up-to-date with the latest changes in cognitive and social psychology and neuroscience,” Horvath said. “We expect the person to be cognizant of behavioral health issues, and we would want to be sure that people we hire look more like the patient we treat… that is, I would look for more people of color and a reasonable proportion of women, particularly in leadership positions.” Horvath noted that the VA continues to be a “white male, upper echelon hierarchy.”
Additionally, he said individuals now being hired have worked on multidisciplinary teams which have become fundamental in the VA’s. They must be able to work comfortably within teams of providers, able to take part in the give-and-take, and understand the medical and nursing mentality.
On research, Horvath declared, the focus is also shifting. “It won’t be so much the psychology service doing the research, but the mental health program doing it. The research training of the average psychologist is a major positive within the multidisciplinary team, and individuals should be able to rise in accordance with their abilities and skills.”
Overall, the medical-oriented system with chiefs of staff has become outdated. The “good old days” in the VA, said Horvath, “were not necessarily good old days for the mentally ill. The VA was often not sufficiently sensitive to their needs. Access and quality of care were very much on the agenda when we were pushing for healthcare reform.”