Veterans returning from Iraq and Afghanistan are plagued with both traditional (e.g., psychological trauma) and less traditional (e.g., blast injuries) psychiatric concerns, some of which are understudied (1). Limited literature is available concerning existing U.S. Department of Veterans Affairs (VA) educational curricula in psychiatry and psychology and the array of treatment settings in which this training occurs. In this article, we describe the medical education program in psychiatry and the internship program in psychology at the Syracuse VA Medical Center and the State University of New York (SUNY) Upstate Medical University as an exemplar of academic collaboration in clinical training and the opportunities and challenges that abound for interns and residents.

In 1946, clinical psychologists were initially placed in five different kinds of treatment settings within the VA: mental hygiene clinics, neuropsychiatric convalescent centers, neuropsychiatric hospitals, paraplegia centers in general hospitals, and aphasia centers in general hospitals (2). Currently, VA mental health treatment programs approach nearly two dozen different types of treatment settings (3), including inpatient and outpatient drug and alcohol and specialized posttraumatic stress disorder (PTSD) programs, day treatment centers, day hospitals, vocational assessment and counseling, biofeedback programs, neuropsychology evaluation clinics, pain clinics, sexual dysfunction clinics, and sleep disorder clinics.

In their 1996 article, Lambert and Fowler (4) described the mechanisms by which a small Veterans Affairs Medical Center (VAMC) was transformed over a 6-year period into an active and well-functioning educational program for medical students and psychiatric residents. These methods included the recruitment and support for an educationally oriented staff, efforts to integrate the educational mission into the VA’s clinical and research programs, and new emphasis on the combining contemporary trends in the field of psychiatry with VA training. At the time that article was written, both the private and public sectors expected future practitioners to efficiently treat the sickest and most complicated patients, an expectation that was consistent with the greater part of the VA patient population. The residents completed their training believing that it had prepared them well for the future. Current trends within psychiatry and the VA in the new millennium include rediscovering the importance of psychological trauma as a cornerstone of the field, integrating behavioral health treatments within the primary care setting, and using telepsychiatry in clinical care.

Dean’s Committee

Since the end of World War II, the VA has had a prominent history in the training of psychiatrists and psychologists (2). Historically, teaching VAMCs have been distinguished from nonteaching VAMCs by the term “Dean’s Committee” medical center. A Dean’s Committee facility is fully affiliated with an accredited medical school and has a formalized commitment to train future clinicians as one of its primary missions. Psychiatry and psychology staff typically hold faculty appointments in the medical school. In addition, research relevant to the VA’s patient population is frequently conducted. The Dean’s Committee is the administrative entity for the development, direction, and assessment of educational programs at the affiliated VAMCs and is composed of representatives from both institutions.

Syracuse VAMC and SUNY Upstate Medical University

The Medical Education Program in Psychiatry

The Syracuse VAMC is one of the major training sites for SUNY Upstate Medical University. For undergraduates, it offers the required third-year medical school 6-week psychiatry rotations supervised by an attending psychiatrist. Electives can also be arranged for fourth-year students, and many of the attending psychiatrists teach first- and second-year medical school courses.

All first-year psychiatry residents are assigned 2 months of acute inpatient psychiatry at the VA. Some may do rotations on internal medicine and neurology. Emergency night call coverage is also included. During the second year, residents are assigned a 2-month rotation for daytime emergency call duty, and nighttime call coverage continues as well. All residents work on the psychiatric consultation-liaison service for 2 months. During the entire third and fourth years, residents are assigned to the psychopharmacology clinic for 3 hours per week under attending faculty supervision and take night call duty. During the fourth year, electives, such as opportunities for research, are available.

The VA Psychology Internship Program

The yearlong psychology internship program in clinical and counseling psychology at the Syracuse VAMC is predicated upon the Boulder scientist-practitioner model of training (5, 6), which calls for an equal emphasis on scientific research and clinical practice. It encompasses multiple theoretical orientations and empirically informed treatments that are well suited for a teaching hospital and academic curriculum. Psychology interns gain exposure to treatments in a variety of clinical settings, which includes the Behavioral Health Outpatient Clinic, with traditional psychotherapeutic and psychopharmacologic services. Interns also see a more contemporary approach to mental health services in the primary care clinics, where brief treatment is provided onsite for patients as appropriate (7). Rotations are offered in psychological testing and assessment, outpatient chemical dependency treatment, neuropsychology, geropsychology, and PTSD specialty care. Psychological testing and consultation are also provided to the acute care inpatient psychiatry unit. Since the war in Iraq, from which blast injuries are frequent (8), a new polytrauma rehabilitation program has been implemented to treat the combined physical and psychological traumas of combat (9). Psychology interns attend and participate in the psychiatry Grand Rounds presentations at the medical school. Research opportunities are available through a separately funded Center for Integrated Health Care, a collaborative effort among the VA, the medical school psychiatry department, and the psychology department at Syracuse University.

The Contemporary Health Care Environment: Opportunities and Challenges

The VA has evolved into the nation’s largest provider of mental health services (10). The size of the VA treatment system and bureaucracy, and the attendant escalating demands for patient care, form not only advantages but also challenges.

The VA has a unique mission to treat a very important subset of society—the veterans of U.S. armed forces. This mission is especially important during times of war. However, the health care struggles the VA faces are, in many ways, a microcosm of similar pressures that the health care system also confronts in the nation at large. Its lessons are instructive and have broad applicability. Because the VA’s primary mental health mission involves treatment for the emotional wounds of combat and military deployment, the VA stands at the forefront of treatment and research on PTSD. Two other developments also provide a wealth of learning experiences: the integration of mental health services within the primary care setting and the advent of telepsychiatry.

Psychological Trauma and PTSD: Advances in Assessment and Treatment

Psychological trauma has been a cornerstone in the etiology of psychiatric disorders, beginning with Freud’s (11) work relating to childhood trauma through the delineation of PTSD as part of the official psychiatric nomenclature in DSM-III after the Vietnam War (12). While the most frequent cause of PTSD in civilian populations is from automobile crashes (13), combat experience is the greatest cause in military populations.

The complexity of combat also involves added existential features: intentional aggression and, at times, cruelty from human-inflicted trauma. Veterans’ exposure to multiple traumatic stressors over time through prolonged periods of combat (14) or captivity stress (15) provides an opportunity for clinicians in training to observe and treat complex psychological trauma (16) and disorders of extreme stress not otherwise specified (17, 18). Historically, combat veterans have emerged from these powerful emotional experiences with little psychological debriefing from the military (19). When they arrive at the VA, a broad range of psychotherapeutic modalities (e.g., individual, group, and marital/family interventions) are employed to address multiple concerns (20).

In addition, the ability to work with such veteran cohorts from a broad range of military conflicts (e.g., World War II, the Korean War, the Vietnam War, Gulf War I, Iraq, and Afghanistan) provides an opportunity to treat the longstanding impact of trauma across the life cycle (21). The treatment conforms to the latest practice guidelines outlined by the International Society for Traumatic Stress Studies (22). Profound clinical dilemmas are at the foundation of instructive case formulation conferences (23). Further, clinical work in psychological trauma is supported and supplemented by up-to-date information provided by the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder.

The prospect of integrating pharmacotherapy and psychotherapy provides a substantial training opportunity for psychiatric residents (24). As fundamentals of the psychobiology of trauma become increasingly elucidated (25), resident psychiatrists are learning more sophisticated ways to help alleviate or decrease some of the most severe PSTD symptomatology with psychopharmacological interventions (26). In this way, many patients who previously could not or would not tolerate the emotional intensity of psychotherapeutic interventions have more access to the various available therapies (27–29). A significant part of residents’ experience at the Syracuse VAMC involves the inpatient, outpatient, and emergency treatment of patients with PTSD, both chronic and acute. There is also an exceptional opportunity for residents to work collaboratively with psychology interns and staff to integrate biological and psychosocial treatment approaches.

Military Women and the VA

Ever since American military women piloted helicopters in air assault missions within the battles zones of Kuwait and Iraq during Operation Desert Storm in the first Gulf War, combat trauma has become a reality that knows no gender specificity (21). To meet the overall health care needs of women veterans, a congressional appropriation from the Veterans Health Care Act of 1992 has allowed the VA to expand and improve services for women veterans through the Women Veterans Health Program (30). In addition to the trauma of combat, women in the military are also significantly more at risk for sexual trauma (31). The prevalence of military sexual assault among women veterans has been estimated to be as high as 41% (32, 33). Thus, women in the military often suffer not only from fear of assault by the enemy but also their male comrades in arms.

Importantly, the study of sexual trauma among women in the military has led to increased awareness and research on sexual trauma among men in the military, confronting many of the myths about male rape and sexual assault (34). We have learned that reported in-service sexual assault among male combat veterans has been increasing substantially across wartime eras, from 1.7% of male World War II veterans to 13.3% of male Gulf War veterans (35).

As a result, a nationwide VA Military Sexual Trauma Program now provides counseling and treatment for the aftereffects of sexual trauma for both men and women veterans. The vast majority of traumatized male veterans suffer from the emotional wounds of combat. By contrast, the overwhelming majority of traumatized women veterans suffer from the emotional wounds of rape and sexual assault. As Herman (36) has cogently concluded, “Rape and combat … are the paradigmatic forms of trauma for women and men respectively.” Despite the fact that current wars are fought with sophisticated technological weapons, the emotional disruption from rape and combat are timeless.

Traumatic Brain injury and Polytrauma

In addition to women being more prevalent in America’s fighting force in Afghanistan and Iraq, another unique aspect of these wars is the enemies’ “weapon of choice”: improvised explosive devices, or IEDs. These devices result in multidimensional blast injuries (8) that include overpressure and barotrauma, fragmentation injuries, blunt trauma and crush injuries, thermal inhalation damage, and physical injuries requiring amputation (37). Such multiple injuries have been referred to as polytrauma, which the Veterans Health Administration defines as “two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability” (38).

Bodily injury constitutes a major risk factor for combat-related PTSD (39). Similarly, traumatic brain injury (TBI) and PTSD can be coexisting diagnoses, particularly if the patient remained conscious during the traumatic event (40). The substantial comorbidity between polytraumatic physical injury and PTSD should certainly surprise no one in the mental health field. The first diagnostic criterion (Criterion A) for PTSD in DSM-IV is for patients to have “been exposed to a traumatic event … that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” Any invasive event to an individual’s biological system has enormous potential for substantial psychological impact. As further articulated by Glasser (41), “Patients with physical disabilities that are the result of war-zone injuries clearly have the highest rates of PTSD… . The wounded are particularly vulnerable to unremitting PTSD … sounds and events similar to those connected with the original injuries, if reexperienced even years later, can trigger all of the original fears and anxieties.”

Dr. Steven Breckler, the American Psychological Association’s Executive Director for Science, testified before the U.S. Congress that TBI, polytrauma, and PTSD have become the combined “signature injuries” of the wars in Afghanistan and Iraq (42). Psychology interns who undertake training rotations within the polytrauma program are supervised by psychologists with expertise in rehabilitation psychology and neuropsychology. The opportunity for psychiatric residents or psychology interns to gain clinical experience regarding the interaction between the neurocognitive and social-emotional spheres in their patients is extraordinary with this population.

Integrated Primary Care Behavioral Health

The prevailing VA policy nationwide has been to advocate for more patient care and graduate medical education to take place within the primary care setting (43). Particularly with the influx of patients who are veterans from the wars in Iraq and Afghanistan, the embedding of behavioral health providers within primary care contributes greatly to efficient service delivery. A recent study showed that of 103,788 veterans from Operation Enduring Freedom and Operation Iraqi Freedom, 32,010 (31%) had co-occurring mental health diagnoses and/or psychosocial problems that were detected, and 60% of those diagnoses were made in nonmental health clinics, mostly in primary care (44).

In a tertiary care medical center such as the Syracuse VAMC, colocating and integrating behavioral health and primary care holds four distinct advantages. It facilitates rapid mental health assessment and consultation “on the spot” when patients attend their primary care appointments. It allows for the brief treatment of many such appropriate cases utilizing a combination of psychoeducational and behavioral medicine interventions. It enables screening for appropriate potential referrals for more involved specialty care to the Behavioral Health Outpatient Clinic. Finally, a psychiatrist colocated with primary care would make available immediate psychopharmacological consultation and intervention at the very first point of entry into the treatment system.

The first differential in the assessment of behavioral health cases screened in primary care is to determine which patients can be effectively treated within that setting and which are more suited for a specialty clinic. This decision largely involves assessing the appropriateness of brief versus longer-term treatment and psychotherapy (45). The choice is predicated in part upon the nature of treatments provided in each setting.

In primary care, psychotherapy is comprised of brief interventions which primarily involve psychoeducation or behavioral medicine approaches to treatment. Psychoeducation includes teaching patients about an illness, diagnosis, and commonly recommended interventions (46). Behavioral medicine interventions involve the treatment and prevention of medical and psychosomatic disorders, as well as unhealthy behaviors such as overeating and substance abuse (47). Brief treatment techniques usually include methods such as relaxation therapy for anxiety (48) and behavioral activation for depression (49). As a result, the structure of psychological treatment in primary care is technique-oriented, using good doctor-patient rapport rather than a deeper transference relationship. In addition, the duration of sessions tends to be 20–30 minutes with a shorter course of treatment (usually six sessions or fewer), periodic rather than frequent follow-up, and a focus on symptom management by both the therapist and medication prescriber.

By contrast, in the behavioral health outpatient clinic (i.e., specialty care), psychotherapeutic treatment tends to rely more on the nonspecific factors of the therapeutic relationship (50) and/or transference rather than on specific techniques. The duration of sessions tends to be longer (45–50 minutes), within a more extended course of treatment (preferably consisting of 12–16 weeks of weekly acute-phase therapy, followed by monthly maintenance-phase treatment). The therapeutic focus is on more complex interpersonal relationship problems, trauma resolution, and/or character difficulties rather than on symptom management alone. Thus, it is important to see psychotherapy patients with sufficient frequency to appropriately meet the complexity of the cases generally referred to this setting.

Even before the age of managed behavioral health care, some clinicians have noted that many patients do not always need or benefit from the frequency of weekly therapy sessions (51). However, more time between visits is often more applicable to patients who have been seen more frequently at the outset of treatment. The well-documented “dose-effect relationship” in psychotherapy has shown that about 8 sessions of therapy are needed for 50% of patients to measurably improve, and approximately 26 sessions are needed for improvement in 75% of the population (52). Similarly, in Klerman’s (53) interpersonal psychotherapy for depression, “acute phase” treatment generally has been found to last for about 12–16 sessions of weekly treatment (54). Ideally, this phase takes place before decelerating to a “maintenance phase” of monthly sessions (55). However, clinic staffing levels need to be of sufficient strength in order to provide a realistic “time-to-change” period of relatively frequent therapy sessions before treatment is deintensified (56).

To the extent that behavioral health care specialty clinics are unable to schedule patients frequently enough at the outset of treatment, providers may only be able to deliver a maintenance level of care to patients with acute difficulties. If this is the case, the treatment received in primary care behavioral health may be virtually indistinguishable from treatment received in specialty care behavioral health clinics, where a greater intensity and complexity of care is required. No doubt, this remains a challenge for many VAs that are currently being inundated with new patients with combat-related PTSD and other psychiatric problems who may require a weekly treatment during an acute phase of care. Fortunately, interns and students, whose primary task is learning, have remained relatively protected from the excessive service pressures to which the clinical staff remain vulnerable. This safeguard allows those in training to learn methods of treatment as they were intended by the clinicians and researchers who had designed and tested them. For an interpersonal form of treatment in which the therapeutic relationship has been repeatedly demonstrated to be the primary effective ingredient (57, 58), sufficient time spent with the psychotherapist and prescribing psychiatrist is both the most important as well as the most costly element of behavioral health care. Hiring a sufficient number of highly trained professional staff with adequate time available is an expensive proposition for any institution.

On the positive side, the recent influx of veterans to the VA system consists of patients who were socially and vocationally functional prior to deployment. However, it should be remembered that the VA still has a significant population of patients with chronic mental illness who require maintenance treatment in conjunction with more frequent treatment during periods of exacerbation. In addition to the new wave of veterans who need immediate attention, these existing patients continue to need care for an undetermined period of time.

Psychiatric and psychopharmacological management in the specialty care clinic are beleaguered by many of the same problems attributable to heavy caseload demands. A naive approach is to view the psychiatrist only as a “prescriber” who conducts a quick evaluation and writes prescriptions. This approach is generally unsatisfactory to the psychiatrist and does not result in optimal care for the patient (59). Neither is it a good model for medical students and psychiatry residents who are being taught more humanistic approaches to medicine in their early professional development (60–62). An essential ingredient to any effective pharmacologic treatment is the establishment of trust between the physician and the patient. The relationship is even more significant between the psychiatrist and patient, especially in patients with PTSD whose basic trust in the world has been shattered by their traumatic experiences (63).

Having psychiatric consultation located within the primary care setting is one way to create more time for psychiatrists in behavioral health specialty clinics to treat patients of greater complexity. Further, this arrangement in primary care aids the medical center’s ability to treat the patient influx from the wars in Iraq and Afghanistan in two additional ways (64): to retain and medicate patients with less complex conditions within the primary care setting, as appropriate, and to return stabilized patients for medication follow-up to primary care once sufficient psychiatric improvement has been achieved in the specialty care setting.

Telepsychiatry

Telepsychiatry is the practice of psychiatry at a distance through videoconferencing. Because many VAs serve large and rural catchment areas, many are also on the forefront of telepsychiatry with government-funded, cutting-edge technology.

In a study on depression (65), VA investigators were the first to demonstrate that symptom improvement and remission of depression due to telepsychiatry was essentially comparable to improvement found with face-to-face treatment with an equivalent degree of adherence and patient satisfaction. Telepsychiatry proved to be more expensive per treatment session, but this difference disappeared when the costs of psychiatrists’ travel to satellite clinics exceeded 22 miles from the medical center. It should be noted that telepsychiatry patients in this study were seen at community-based outpatient clinics where staff members in allied mental health professions were able to assist patients with the technology and acute distress. Ruskin et al. (65) did not feel that the findings were generalizable enough to safely permit the remote in-home treatment of psychiatric patients. Many professionals, even those who advance more modern notions of telepsychiatric care, have concerns about the degree to which an inherently interpersonal form of treatment (66) can be safely adapted to a video-based viewing of the care provider. In particular, there is concern about whether telepsychiatry could be used to sufficiently engage severely traumatized patients without a face-to-face interaction between doctor and patient (67).

The psychiatrists who participated in this study (65) also expressed significantly higher levels of satisfaction with in-person sessions than with telepsychiatry interviews. Most contemporary psychiatrists believe that talking is effective because it serves to create a coherent narrative among symptoms, life events, memories, and thoughts within the context of a safe relationship with an attentive and compassionate human being (68). An increasing amount of collaborative research by psychiatrists and neuroscientists also suggests that these face-to-face verbal processes may bring about verifiable changes at a neurological level (69). Thus, for many clinicians, looking directly into the eyes of his or her patient during the clinical interview is an element of care that is particularly gratifying. Despite these caveats, telepsychiatry represents a promising means to increase the access to certain levels of psychiatric care to rural communities throughout the country (70).

Historically, the affiliation of major VAMCs with outstanding medical schools across the nation has been a mutually beneficial arrangement. The academic knowledge base that medical schools bring to the VA has helped bring cutting-edge technology and methods of treatment to the forefront of national health care and to those who have fought for our national freedom. Reciprocally, the VA has played a major role in the education and training of medical students, residents, fellows, and interns. In some areas of medicine (e.g., surgery), it has been shown that teaching hospitals attend to a sicker and more complex population of veteran patients than nonteaching hospitals, with a comparable outcome rate (71). Likewise, in psychiatry and psychology in particular, the vast exposure of patients to psychological trauma has not only offered a complexity of psychopathology for treatment and education but has also kept training relevant to fundamental aspects of the field (36). Such learning opportunities are possible now with the multiple traumas and acute-phase stress disorders experienced by veterans from Iraq and Afghanistan.

Education at the VA also exposes students, residents, and interns to the contemporary means by which modern psychiatry and psychology address problems posed by the needs of large numbers of patients. The demands of service delivery are not only acutely faced by the VA but by health care providers in both private and other public health care systems; thus, the enhanced collaboration that has been a rich part of the Dean’s Committee VAMCs and some of the finest medical schools in the United States is important for meeting this need.

We would like to end this optimistic endorsement of these contemporary trends with an important cautionary note. In the interest of efficiency, we have developed a technology to assist in reaching more patients more quickly (telepsychiatry) and in offering faster symptom relief (psychopharmacology and the briefer psychotherapies). However, in our opinion, the clinical wisdom of the past (i.e., developing a durable therapeutic alliance, understanding the complete history and patient, working through conflict, and providing corrective emotional experience) must be integrated with the newer approaches to care. Not only does this require a critical mass of time spent with the patient, but also a critical mass of time spent by trainees with supervisors. A disturbing trend in psychiatry and psychology which concerns us as both clinicians and supervisors is the apparent overemphasis on streamlining various aspects of care at the expense of spending sufficient time required for a higher quality of treatment and education. Of all the medical professions, psychiatry and psychology should be at the vanguard of protecting this precious commodity.

The opinions expressed in this article are those of the authors and do not necessarily reflect those of the VA.

At the time of submission, the authors disclosed no competing interests.