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A prime reason for such an approach is avoid communicating the covert message to the VA mental health system that only an elite group of experts have the corner on knowledge about PTSD. The numbers of patients currently in treatment, and the overwhelming demand for such services demand that the existing expertise of VA professional be enhanced and not

demeaned by the creation of PTSD centers.

Given such an arrangment, the Center would function best by :

1. Establishing a residency program which enabled researchers and clinicians from various medical centers to come concentrated periods of time for training and collaborative

for work.

2. Dispatching trained staff from the center or other PTSD experts to medical centers OT clinics to work for concentrated periods of time with health professionals there in diagnosis, case consultation, and treatment.

regular expert

3. Participation and organization of conferences, more intensive 2-3-4 day workshops with hands-on involvement in particular interventions, diagnosis or research.

4. Providing a site and staff for the development evaluation of innovative unit structures, treatments collaborations that might create models for future programs.

and and

5. Developing assessment and evaluation techniques for diverse PTSD patient populations and treatments.

Question 4. In your view, where does PTSD treatment and research currently fall as far as other VA priorities are concerned?

Answer 4.

Priority of VA PTSD Research

The Administrator's Advisory Committee on The Readjustment of Vietnam Veterans, on which I serve as Chairman, has had a continuing dialogue with the VA research office on this subject. As you are aware, the question of PTSD has always been controversial. The inclusion of PTSD in the latest diagnostic manual of the American Psychiatric Association has precipitaed precisely the type of ferment and discussion in the professional

community which those of us who worked on the entry wanted in order to advance the scientific inquiry and promote examination of treatment. That ferment over PTSD as noted in a series of papers being presented this month at the American Psychological Association meetings reflects both the professional concerns and the personal biases long associated with the discussion of war

reactions.

As discussions and questions about PTSD has become more of an issue, requests for funds for research to address those questions have increased. These requests have, as noted by Dr. Hollis Boren, Chief of the VA Research Office, in his discussions with the Advisory Committee last.fall, have conflicted with existing research priorities aimed at the recruitment and retention of basic science researchers. In addition, a closer focus on the dialogue over PTSD, treatment and its relation to other psychiatric problems has more sharply defined some of the glaring questions, difficulties and unsupported assumptions in the scientific community in general, and in the VA review committees and the VA Research Office in particular. More rigorous attention to emerging design and diagnostic questions is being demanded of PTSD researchers.

As might be expected in a burgeoning new field, PTSD researchers and clinicians are demanding a greater level of sophistication and expertise in PTSD on the review committees. This healthy debate has precipitated fruitful discussions. These dialogues are leading to more rigorous and detailed research proposals to the Research Office. The dialogue is also promoting a reexamination of the review committees and the priority of PTSD in funding VA research. The forthcoming October VA research conference on PTSD in Nashville is a concrete example of this increased attention on the part of the VA Research Office. The review and reexamination of the Peer Review Committee on PTSD is a further example. In response the Advisory Committee is awaiting the outcome of these initiatives.

expertise

With regard to treatment, there is an increased attention to PTSD and related problems. Encouragement attention to PTSD treatment has increased at Central Office level.

in

However, the basic problems stem from conflicting messages received at local medical centers. PTSD units, the Readjustment Counseling Service and sympahetic professionals encourage further attention to our priority of PTSD units and programs. Other professionals and demanding PTSD patients on admissions and acute treatment wards, encounter a degree of obstreperousness, patients diagnostic uncertainty and reaction in staff members that fuels a different view. This view focuses on the antilack of patient behavior and their frequent coorperation with staff. Recognition in the face of inability to treat these patients as successfully as the staff might like, fear and anger fueled by difficulties managing patient behavior foster a frequent impulse to dismiss or be rid of them.

social

aspects

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Therefore, efforts to enhance the priority of PTSD treatment often serve to heighten resistance and negative reaction. Only when a dialogue is promoted, and serious and widespread efforts at educations bring changes and insights to the daily problems of these staffs can the priority of PTSD be truely augmented.

Question 5. What broad guidance can be issued to the field which would enable the individual medical centers to continue to develop their own treatment programs for PTSD and yet ensure that care is coordinated and knowledge is disseminated among Districts or Regions nationwide?

Answer 5.

VA Guidance on PTSD

Broad guidance is already taking place on the question of PTSD in the VA. Actions by the Congress in establishing and extending the Vet Center program, encouraging the National Needs Assessment Study undertaken by the VA, and proposed support for PTSD inpatient initiatives have demonstrated that Congress has considerable investment in this issue. Support by the Department of Medicine and Surgery (DM&S) has increased for those medical centers which have allocated their own resources to establish PTSD programs. RMEC PTSD training conferences and film development is also notably enhanced. All of these efforts are having profound reverberations in the system by demonstrating the priority of PTSD. The forthcoming research meeting and planned enhancement of PTSD expertise in the research review committees adds significantly to this broad guidance.

to

The more immediate problem is what to do growth of knowledge and effective PTSD treatment. reflect how one views the problems.

enhance the The answer S

From my observation and perspective, PTSD clients of ten present a troublesome problem to our medical centers. Apart from the core symptoms of intrusive thoughts and imagery, the prime manifestation of PTSD in these patients is the reservoir of unresolved feelings so frequently galvanized as bitterness, frustration and anger. In some patients it is turned inward, as depression, self-destructive behavior or suicidal impulses. In others, it is projected outward in anger and rage, intolerance and irritability. Armed with these emotions, and energized by their general lack of psychosis, these patients often display a high level of activity that presents significant management problems to the hospital staffs. Responses in clinicians and professional staff include concern, compassion, fear, confusion, anger, tolerance, resentment, overidentification, and bafflement and therapeutic understanding. From a PTSD prospective, VA professional staff can be broadly characterized with respect to PTSD as falling into three classes - those knowledgeable and effective with PTSD, those interested and concerned but having reservations, reluctance or inexperience with effective PTSD treatment and patient management, and those somewhat skeptical, burned-out, or hostile to PTSD and PTSD patients.

:

In some respects, the establishment of the Vet Center program and the Readjustment Counseling Service was an attempt to circumvent these patient and staff problems by directly establishing readjustment services. The success of the Vet Centers is a tribute to that approach to counseling. However, this approach has subordinated the dialogue within the medical centers to an important but secondary role. One consequence in many quarters is a resentment over the lingering feeling that PTSD counselors and experts are viewed as the sole people knowledgeable about and effective with PTSD, with the unspoken implication that the hospital staffs are less competent.

or

No matter how well or how effective an individual PTSD unit ward at medical center is, the waiting lists and numbers of patients with PTSD related problems scattered throughout the hospitals attest to the improbability of any specialized staff to deal with all the PTSD patients in a medical center. Therefore it is imperative that we now move to enlist and ally ourselves with the professional staffs of the medical centers. We must acknowledge their expertise, their questions, and their problems. We can move to enlist them as colleagues empowered to surmount the problems and creatively meet the needs of the patients with multiple problems they are seeing independently of the formal PTSD programs.

My response then is to suggest that we now face an important choice as we decide how best to enhance knowledge treatment and understanding of PTSD in the system. We can continue to circumvent the problems as before or we can use the experience of the recent past to now promote creative solutions within the existing systems.

Therefore rather than suggest how the guidance should be implemented, I would prefer to be mandated to respond both to the patients and to the medical centers needs. Then I can be held accountable for results rather than instructed as to methods.

Mr. PRINCIPI. Dr. Martin Cohen and Sharron Dreyer. We welcome you. You may proceed.

TESTIMONY OF A PANEL CONSISTING OF MARTIN H. COHEN, M.D., CHIEF, ONCOLOGY SECTION, VETERANS' ADMINISTRATION MEDICAL CENTER, WASHINGTON, DC; AND SHARRON DREYER, B.S.N., ASSISTANT ADMINISTRATOR, PATIENT CARE SERVICES, HOSPICE OF NORTHERN VIRGINIA, INC., ARLINGTON, VA

Dr. COHEN. The goals of terminal care are to reduce or eliminate human suffering while allowing dying to occur. Suffering always accompanies a terminal illness. It results whenever the physical, emotional, social, and spiritual being that constitute a person is disrupted. Thus, overwhelming pain causes suffering. Knowing that one will never again be well causes suffering. Loss of hope is a major cause of suffering. The terminally ill patient is dying against his will. He will die before those he loves. The awareness of his aloneness and separateness, of his helplessness against the ravages of disease often cause almost unbearable suffering.

Society has recognized the needs of the terminally ill. It has initiated programs to meet these needs. While these programs may, with greater or lesser success, ameliorate patient suffering, more basic questions are still unanswered. As far as I am concerned, we still do not know the optimal way to control pain or other distressful symptoms to improve a patient's functional status and mobility, to improve the quality of a patient's social interactions, to increase life-satisfaction or to relieve feelings of isolation and helplessness. We do not know the psychological consequences of telling a patient that there is no more treatment available for him and that from now on we will only provide for his comfort. We do not know how best to manage the bereavement response of families after a patient's death. Further, we also do not know how to prevent burnout of the staff providing care for terminally ill patients.

I submit that answers to the above questions could greatly improve the format of the terminal care. I further strongly believe, for many reasons which are stated in my complete testimony, that Veterans' Administration medical centers are ideal places to conduct this research. I stress a research orientation to terminal care, because I firmly believe that research protocols constitute the best available treatment for the condition under study. Research studies are emotionally rewarding to both staff and patients because beneficial results are often clearly demonstrated. A strongly positive patient-staff interaction results which motivates both groups to maintain hope and to continue to seek even further improvements.

I would like to illustrate these points by describing some of the studies being conducted at the Washington, DC VA Medical Center that relate to the care of the terminally ill cancer patient. The most important problem that these patients face is pain control. We theorized that pain control could be best achieved by continuously infusing morphine so as to maintain a constant drug level in the bloodstream. We tried this in patients who had persistent pain despite large doses of potent narcotics taken by mouth and found that we could achieve complete pain relief by our method. More

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