Episode 80 Transcription

Welcome to Episode 80 of Behind The Mission, a show that sparks conversations with PsychArmor trusted partners and educational experts. My name is Duane France, and each week I'll be having conversations with podcasts guests that will equip you with tools and resources to effectively engage with and support military service members, Veterans, and their families. You can find the show on your podcast player of choice or by going to www.psycharmor.org/podcast.

Thanks again for joining us on Behind The Mission, our work and mission are supported by generous partnerships and sponsors who also believe that education changes lives. This show is brought to you by PsychArmor, the premier education and learning ecosystem, specializing in military culture content. PsychArmor offers an online e-learning laboratory. That's free to individual learners as well as custom training options for organizations. 

On today's episode, I'm having a conversation with Dr. Umar Latif, a board certified psychiatrist in general psychiatry, geriatric psychiatry and addiction medicine. Dr. Latif serves as the National Medical Director of Help For Heroes, a multi-site specialty program he helped design his co-founder to meet the clinical needs of active duty service members, Veterans, and first responders who are dealing with mental health and substance abuse issues. He also works as the Medical Director of Carrollton Springs Hospital and has a private practice at the Noesis Clinic. You can find out more about Dr. Latif by checking out his bio in our show notes. Let's get into my conversation with him and come back afterwards to talk about some of the key points.

DUANE: Umar as a medical professional, you have supported service members and Veterans in a number of positions over your career from an early start in the department of Veterans affairs. I'm curious to hear how you came to work with the military affiliated population and what it was like for you in the beginning and where it has gone for you now.

UMAR: No, thank you so much for allowing me to be here and having this important conversation. It's an interesting journey. I had the privilege of being trained with some very good mentors in my fellowship at the Dallas VA Medical Center. So right after my residency training and fellowship training. In 2004, I stayed on at the Dallas VA medical center as a VA doctor. And during that time, again, it wasn't just direct patient care. It was program development. You know, I was given the opportunity to work with increasing access to care between 2004 and 2007 through telemedicine in some of the C box, when the concepts were really new, we didn't have these nimble video conferencing, equipments, you had those big cathode rate TVs and how do we help the patients where they're at in an accessible manner. So that was a really good learning experience. And then in 2007, I shifted into private practice and I had colleagues, psychiatrists at Darnell Army Medical Center in Fort Hood. And we were having conversations that they would have a need for their service members to seek treatment, but they had a capacity issue at this point.And so they would for acute crisis stabilization or specialty care, send the service members to outside entities in the community. And there would be incredible variances in outcomes. Some of those patients were coming back with excellent treatment, excellent outcomes, and some of them were coming back so out of sync what the mission was, what the original reason for the referral was that, patients were suffering not only because of that, but command was struggling that, our goal for mission readiness versus now we've gone completely in a different. So you know, I was working at a small,busy hospital up in Denton, Texas at that time. And in a collaborative fashion with one military base and providers,we said, how do we create something where we can learn from each other? What do we, as civilian psychiatrists need to know when we're receiving care for an active duty service member? What do you want to see as a provider when that patient is going back to you? It was from that collaboration, a program called Freedom Care arose, where we consulted with DOD guidelines, consulted with colleagues, programmatically at Walter Reed. We consulted with clinicians who were training cognitive processing therapy, evidence based treatment and in a collaborative fashion,we created that program.

And from 2007 till, I left in 2016, over a period of nine years a very dedicated team of clinicians. And again, every one or two years, we would evolve the program based on feedback. Not only now from service members, but also from Veterans coming from local VAs, the program expanded nationally.

And almost over that decade, we had the privilege of serving several thousand, not only active duty service members, but Veterans. And then towards the end, we started learning that there's a huge need in first responders, too. So that's how the program grew. That's how I grew as a clinician learning.

And it was a very professionally rewarding thing for that growth. It's that opportunity to in a very tangible way, serve those who've served. This was my way of giving back. And this collecting surrounding yourself with a team of people who are very compassionate in the same place, because once you earned that trust of your patient, you walked through their journey of healing when they came to you in a state of an absence of imagination. At that point, the patient could not imagine there's going to be help or there's going to be hope.

Or their experiences were so disjointed there wasn't a uniformity experience that they struggled through that. And that's where we saw bad outcomes. So I think, and one of the things we teach our medical students is that after you finish your degrees and your License insurance stuff, don't stop learning. Your biggest teachers are your patients.  And if you approach that from a place of humbleness, that I don't know everything, I need to be able to be sensitive to what is this patient's lived experience that is different from what textbooks tell us. And that's, then they're allowing you to be in that space, that place of being vulnerable, where then together you can help them work towards.

For example, in trauma care, we have a concept of recovery from victim  to striver, to thriver. And oftentimes patients are stuck in the first two loops. So that was the journey originally. And then,as the program grew as we brought on some really excellent clinical partners, we shifted to Spring Stone, which is a network of mental health facility. Over 30 locations across the United States. And we found a home for a next version of that original program called Help for Heroes. And the leadership was very passionate. They saw the impact that we had done. They saw the evidence based curriculum that we had developed with our team and they saw the outcomes. And Spring Stone, which is a Veteran led organization. Our CEO is a US Army Veteran. Our Chief Medical Officer is a US Navy Veteran. We collaborated with them to Stand Up and Help For Heroes as a specialized uniform specific program within Spring Stone facilities and continue to evolve the program, learn from where there's room for improvement, and actively report and outcomes.

Since 2018 Help For Heroes has served several thousand heroes. And the demographic that we're very specifically engaging is uniform specific, active duty military service members, Veterans, first responders and frontline emergency workers. And so we've been partnering with about 90 plus military installations, both KONAS and OCONUS.

And I think one of the things that was very professionally rewarding was during COVID, how we were very intentional in staying ahead of the curve with colleagues who were in military basis. For example, in Italy, at the height of COVID, their providers were struggling, their patients were struggling. What could we do collaboratively to either get them stateside, use precautions for COVID or use telemedicine for improving access to care. So it's been a very professionally rewarding journey since 2007. Continuing to collaborate with both the DOD and the VA. And now in the first responder space.

DUANE: I'm thinking about that journey and some of the clients, even as you said earlier, where you started in 2004, global war on terror Veterans weren't in the VA at that time, right?  You were looking at Gulf War Veterans and likely Vietnam Veterans at that point, they were in their mid fifties or something like that. And so while I think some people in the VA may have seen the wave coming, at that point you didn't start seeing global terror Veterans from Iraq and Afghanistan until about 2006, 2007. And that was a seismic shift in the VA.

UMAR: Significant. And there was new learning for us as providers also because the theater was different. The impact of when we talk about the invisible wounds of war, there is now more learning about how does mild, moderate TBI impact clinical pictures of psychiatric illnesses. How does that change what we know a course of post-traumatic stress? How does that modify or evolve that?

And if you're not trained in that, you'll miss it. And that's where we started learning with this new cohort that dual diagnosis became a very different clinical picture. There was a more brittleness, for example, if you have someone with mild to moderate traumatic brain injury, they've got frontal lobe inhibition, poor impulse control. Oftentimes those clinical symptoms were misdiagnosed and they were lost down the path of care for too long. And then they would become disheartened that they were not seeing any outcomes and stuff. But there were other things that we learned,for this cohort of patients. For example, now the concept of moral injury and psychiatrically psychologically moral injury is not equal to PTSD is not equal to compassionate fatigue. It definitely is not when it's misconceived as moral injury means amoral, acts and stuff. No. 

So we started to see that not everyone who has PTSD, and who has attempted or completed suicide, they might have this adjacency, this other process going on that we need to train ourselves as providers on, how do we look at what is now being called as the invisible wound of the soul. So there's an evolution in learning as providers also, and that's where culture competence and clinical confidence I think is extremely important. One of the things in med school where we taught is being a compassionate physician, absolutely is beneficial, but being a competent one is not optional. Lack of competence will not save lives. And so one of the things that we're very invested in is that finding a group of passionate providers, passionate clinicians who find this as a clinical calling, but helping them level up with very structured trainings. Both on what is the latest science with DOD and natural center for PTSD telling us what are things that we need to know about new models of understanding suicide, understanding dual diagnosis. How do we cross train our providers? Because that's one of the things where we've been consulted on a lot from both the VAs and the active duty behavioral health space, and even first responder space is that someone might be struggling with alcohol and they've gone to some excellent treatments. They received a medical detox.

They even did a 28 day rehab. That provider who was an excellent provider in the lane of substance use was not trained. It wasn't their wheel house in seeing in plain sight trauma, driving the addiction model. And so we hear the story a lot from patients that a really good chemical dependence council will say, we're not going to talk about or touch your trauma process until you get sober. Or vice versa, a trauma therapist saying I can't get to the core of the stuff until you're sober and who's getting lost in that process? The patient is. And so that's one of the things over the course of, you know, almost now going a couple of decades that we learned that evidence informed care is the paradigm rather than being stuck in these silos of evidence based care.

We don't have the luxury of waiting for two years outcomes study when there's a lot of good scientific literature already available to us as providers. It's the application of that. We don't have the luxury of waiting for a cohort of 12 patients to wait to sign up, to start a cognitive processing therapy group. When that seven day delay might create a crisis and a bad outcome. And if you go by the book, you're not supposed to start certain treatments until suicide is off the table, but we also know that, during good trauma work, there's an uptick in suicide risk and you have to be trained in how to walk the patient through that. So, clinical competence, cultural competence is something that is not optional when we're helping specialty patient populations.

DUANE: And I think this is one of the things that we've seen in conflicts in the 20th century. Certainly as each conflict we have greater medical advances than we learn more. In the 20 years of the global run terror, the conflict in Afghanistan and Iraq or no exception, especially when it comes to what you're talking about, the diagnosis and the treatment of mental health conditions.

And as you said, it's been cyclical because then the Veterans that came to you in 2012 and 13, they've now had three or four deployments, which the ones in 2007 necessarily didn't. So there's this constantly evolving learning as you're talking about. And we know more about the impact of combat and traumatic exposure in service members and Veterans now than we have ever.

UMAR: You’re absolutely right. I'm rereading right now, Rethinking Suicide by Craig Brian, and a lot of these things is these first order thinking that is it repeated deployments that are moving the needle? Is it a certain exposure that is moving the needle for suicide? And in a very elegant fashion, he's trying to inform us of that. He doesn’t give us the full picture. For example, joiner, who has his interpersonal psychological theory of suicidal behavior that he presented quite some time ago, we're starting to see the adjacency for the current combat, the current theater and the outcome of that which is a whole other topic on how COVID then just became a black swan event for mental health crisis, thwarted belonging.

You know this sense of social connectedness and the pandemic, then further magnified that, or the sense in the helping professionals of a sense of perceived burden as belief that my death is worth more than my life. And this concept that suicide is an acquired ability. That then is accelerated with desensitization to death or painful stimuli.

So death no longer holds fear for us. But again, what we tell new providers is just being exposed to combat is not synonymous with post traumatic stress. So you really have to be very precise in your understanding of that particular patient. And this is where then the broader construct comes in.We're having some really new research that's informing us about social determinants of mental health. It's not just what's happening with the patient. It's what is the context of their lived experience, either helping or hurting their path to recovery. So you're absolutely right.

DUANE: And not just what their current context is. But what their pre-military context is. We've started to see how adverse childhood experiences the military as much are running away from something as it was, and it predisposes people. So if you had unhelpful social determinants of health as a child, and then traumatic exposure, and you go back to unhealthy social determinants of health environment, post-military,  that can almost be a perfect storm.

UMAR: And you bring up such an important point and further extending that we're now we're learning with very good science what we knew intuitively is trauma has generational impacts. The epigenetics of chronic post-traumatic stress or certain psychiatric illnesses with your longevity and then your next generation, the impact of that. So, there needs to be as providers, an evolution in our understanding as new research informs us, but then also how do we customize that individualize that treatment to the patient in front of us. 

DUANE: Yeah, no, I absolutely agree. I mean, we know what works clinically, perhaps as you're talking about the evidence informed, but then it's the application of that can be very important. And you've mentioned the Help for Heroes program and that is a non VA non D O D. This is, as you mentioned, Spring Stone is a network of private clinics. But that's a program that can work in cooperation. You've mentioned earlier the collaboration of what you did with, the Freedom Care program. But that's an important aspect of supporting service members and Veterans that's outside both the department of Veterans Affairs and the Department of Defense.

UMAR: And it's critical. You know one of the things that I share with people about the Help For Heroes, the DNA what's baked in. If we look at our national leadership team, incredibly talented, incredibly passionate group of people that I've got a privilege to work with every day and they bring an incredible diversity of background and experience to it. So how do we model, what we're trying to do in health for years program is breaking down the barrier. Because nationally we do have both a capacity challenge in mental healthcare and a capability challenge in mental healthcare. RAMP corporation did a really excellent study in the word, the verbiage of high quality care. How do we define that everyone can have a pretty brochure and say we're providing high quality care. And they looked at certain frameworks is the care you're providing military and Veteran centered care. For example, the health for years, program two decades of combined experience, no one who's providing clinic care is allowed to be in front of that patient in that program until they've received cultural competency training.

Collaborative decision making. We provided consultation liaison models. So we're not just receiving the patient from a VA medical center or an active duty base and not actively communicating mid treatment. Every week we have conferences calls with the providers, accessibility, ease of access, barriers to care, making sure that we're in network with VA connected care and then a continuum of care. Both inpatient partial hospital, outpatient medical assistant treatment. But then when we look at the halo impact, the impact for our first responders in their mental health struggles in recovery is not happening in isolation. It's impacting their families, their children. So being aware of that, providing clinical services outside of Health For Heroes, but within the Spring Stone model, using the same evidence based care for child and family members. And then again, evidence based care where standing up certain clinical tracks that are specific for trauma or mental health or addiction. But what's really elegant, what's being developed with the team is how do we have a duality of that programming so that the patient is accelerating in that care.

We're very passionate about our trust and outcome. How quickly can we establish a level of trust based on cultural competency and clinical competency, and then backed by reported outcomes. And that has been what has earned us  like I mentioned, 90 plus military installations, and it keeps us going with our vision, which is saving the lives of our heroes and supporting those who've served. 

So one of the most important things that I'm passionate about is that how can we help break down these barriers, keeping the patient in the center of this? We've talked about the Bush Institute Veteran Leadership Program. And one of the most transformative kind of moments was when our cohort was asked this question, on whose behalf do you occupy this seat? So this program and the impact is bigger than any one of us. And if we lose sight of the patient who we're helping walk across their journey of healing, then there's no differentiator of care here. So how do we break the barrier with the local VA as a partner with them? Just like we've broken down the barrier. We were talking about OF and theater. I forget if it was, 2011 or 13, and we had an active duty service member down range who had an acute psychiatric crisis. He became suicidal. He was struggling with homicidal thought through a command. He was medivac launch tool, and his bay said, don't send them back to us, to our behavioral health. Put him on a flight and get him directly to that program. That was the level of trust. You had to look up our program on a map, but where is this place again? But those things only happen if you're sitting at the table and you're able to demonstrate that we've got the same mission here. We have to break down these institutional barriers within which the patient is falling. What I call the last mile gap. VA is doing a beautiful, phenomenal job in reducing the stigma, improving access to care. But what happens if your local VA doesn't have bed capacity in a community and you might have five VA connected or non-VA connected hospitals. The local ER  has no metric to know do I send that Veteran to a place that just out of bed available and happens to take Tricare or to a program that has demonstrated high quality care because the first 72 hours in that moment of crisis for that patient will make it or break it. If they're in front of a clinical team that is not able to create a space of trust and vulnerability. We all know as clinicians, the completed rate of suicide within 30 days of an inpatient, are extremely high. So that's the passion that not only helping the patients, but helping collaboratively in a consultation liaison model, work together, keeping the patient at the center of all of this.

DUANE: And I think that's the point that I hear that's emerging is the need to establish trust in a couple of different levels. Obviously us as mental health professionals have a whole way to go to establish trust with our clients. Regardless of whether my clients knew that I was a combat Veteran and a clinical mental health counselor, there was still a measure of distrust from me as a therapist that I had to overcome.

But you're talking about establishing organizational trust, being able to make sure that VA provider specifically, or that VA system generally trusts Help for Heroes or another community organization to meet the same level of care in the same with the DOD, as you were mentioning,

UMAR: And we do a disservice to our patients, our Veterans, our first responders, when that perceived lack of trust becomes a barrier to have conversations. How can we collaboratively support each other, for the common good of the patient?

DUANE: Yeah, I don't know them well enough. So I'm just gonna keep the Veteran in this system. I may not have something for a week or two, but it's still better than what I think is out there. And that's simply not true.

UMAR: Or I'll just send a Veteran to a local hospital until my bed opens up and then I'm going to yank them out of that care where they had started opening up. They had started developing a place of trust and it becomes about the system rather than the patient. So we're having some really good inroads in continuing these conversations. I'm an optimist and I think that if we all have value driven common missions that everyone can speak to and see, we can continue to evolve, in the right direction.

DUANE:  I absolutely agree. Again, as I mentioned earlier, we are farther along now. We've nowhere near arrived, but we're farther along now than we were 10 years ago and we're gonna be farther along 10 years from now. Dr. Latif, it was so great to be able to have you as a guest on the show. If people wanted to hear more about Help for Heroes, how can they do that?

UMAR: So a couple of different ways. One is I would encourage them to look up our website. And then the other thing is for clinicians who want to refer specific, for example, if active duty members need to refer the clinicians, we've got a dedicated 1-800 line that they can call, or if there are any questions about first responders or Veterans, then they can call the local hospitals in the locations.

And they're trained in helping that patient seek to specialty care either in an inpatient program available in that location. Or in a specialty P H P I O P program. Because again, that's a whole other conversation. For example, our first responders, some of them have their own barriers where I might have a mental health police officer who does not want to be admitted himself into a hospital.

He was just bringing patients a week ago. So that's how we learn, what are the barriers, what are the internal issues and how can we collaboratively expand programming to meet you where you're at with the common goal of improved outcomes and saving lives. 

Absolutely we will definitely make sure all of those are in the show notes. Thank you so much for coming on the show today.

UMAR: Thank you. And I really appreciate what you're doing and continuing to have these conversations that are helping move the needle that ultimately I do believe strongly make an impact and where the patient sits seeking help and seeking hope. Thank you.

Once again, we would like to thank this week's sponsor PsychArmor. PsychArmor is the premier education and learning ecosystem specializing in military culture content. PsychArmor offers an online e-learning laboratory that is free to individual learners, as well as custom training options for organizations. 

Hopefully you enjoyed my conversation with Dr. Latif.  This is certainly an episode that focuses on supporting those who served and those who care for them with mental health concerns specifically, rather than social support or other unmet needs like other guests have.

 I really appreciated something that Dr. Latif mentioned early on in the conversation. He said that service members and Veterans come to mental health professionals suffering from an absence of imagination. That description is pretty striking. They find themselves in a situation where they can't think of a way out. Whatever they're dealing with addiction, traumatic stress, emotion, dysregulation, moral injury. It's so consuming that they can't imagine that life would be different then the way it is right now. I often describe acute suicidal distress as being stuck in the bottom of a well where you could see nothing, but the wall, a few feet away from your face. Your world shrinks to what's immediately happening. And what's immediately happening is really, really bad. Then life is really, really bad. 

A lot of the work of mental health and people in the Veteran support space in general is helping people develop the perspective that there is a way out. Dr. Latif doesn't suffer from an absence of imagination. He doesn't need to imagine a potential solution. He has seen the solutions work. He has seen the Veteran in the next well over, get out of the hole that they find themselves in. Get back to a place where they can see the whole sky. The horizon is miles in front of him and life is good again.That's the ultimate goal. 

The second point that I'd like to make is how Umar described the complexity of the psychological conditions that Veterans experience. If you're a longtime listener, you've heard me talk about this before, but I'm a firm believer in the interconnectedness of the mental health concerns that service members and Veterans experience. You have those that are common to all like PTSD, TBI addiction and things like depression and anxiety. Those are not uniquely Veteran conditions, sexual assault, vehicle accidents, and natural disasters are known causes of PTSD. And what I didn't know, when I started this work was that my home state of Colorado has done some of the leading research in the treatment of traumatic brain injuries not because of our wonderful military population out here but because of skiing injuries. You don't wear a helmet while sliding down the mountain. So Veterans experience these conditions again, common to all. But Umar also mentioned moral injury, which is a bit more tied specifically to the military experience or something that many guests have talked about, a lack of purpose and meaning that many Veterans feel after leaving the military. As he described, if you have a clinician who is skilled in addiction medicine, but not trauma or addressing existential concerns, then they're only treating part of the condition. Add on top of that homelessness or financial instability or relationship concerns. And you have a Veteran who is experiencing a complex set of conditions that require a multi-specialty approach. So it was great to hear Dr. Latif highlight the need for a collaborative approach to support Veteran mental health. 

So I hope you appreciated my conversation with Dr. Latif. If you did let us know by dropping us a review or shooting us an email at info@psycharmor.org. We'd appreciate knowing that you're listening, what you think and what you would like to hear about in future episodes. 

For this week's PsychArmor's resource of the week, I'd like to share the link to the PsychArmor’s course Barriers To Treatment. In this course, you'll learn how differences in military culture affect mental health and how to help service members or Veterans overcome barriers to seeking treatment. You can find a link to the resource in our show notes.