If you're a veteran in International Falls and you need mental health counseling from the VA, you'll have to drive 100 miles to the nearest VA therapist in Hibbing. If you need a face-to-face visit with a psychiatrist, you may have to travel all the way to Superior, Wis., St. Cloud or the Twin Cities.
"It's just the distance, and the fact that we're so small. We just fall off the radar screen," said Dr. Jeff Hardwig.
Hardwig is the only psychiatrist in International Falls. For years, the Veterans Administration contracted with him to provide some mental health services to veterans. The VA ended its contract with Hardwig nearly two years ago.
"We want to be of assistance to our veterans. We want to help them," he said. "And they come here because they want to get some help and they want to get some help close to home. And so that's a frustrating situation."
Private mental health providers across the state share that frustration. It's part of a shift in strategy for the Veterans Administration. Rather than contracting with private providers, the VA wants to offer the service itself, even if it means a longer drive for veterans.
Tammy Jedlicka, a clinical social worker with the VA, said contracting with private providers was expensive for the agency.
" With budget cuts and the large number of veterans being served, they can't afford to do that anymore," Jedlicka said. " So one of the things they're doing is trying to provide more services in the communities."
NEW KINDS OF OUTREACH
More VA services in communities means more clinics. Since the 1990s, the VA has moved away from hospital-based care. There are now nearly 800 Community-based Outpatient Clinics in the U.S., with nine in Minnesota.
One of the newest clincs opened in 2007 in Bemidji, where Tammy Jedlicka works as a mental health therapist.
She said one of the clinic's big advantages is that it offers tele-medicine services which allow veterans to talk to psychiatrists or psychologists over a video connection, instead of driving hours to their nearest VA hospital.
Veterans can get mental health therapy at the Bemidji VA clinic. But Jedlicka said the resource is limited.
"I am the only one here at this time. Right now, I'm scheduling out about six weeks to see people, because it's that busy," she said. "We have a pretty high case load."
Veterans returning from Iraq or Afghanistan these days will find a far different Veterans Administration than the era of the last major conflict in Vietnam. Back then, the expectation for veterans was that you fought, you came home, and maybe you got a monthly disability check.
VA officials say their mission now includes far more outreach. Heidi Sanger is a VA veterans case manager based in Grand Forks, North Dakota. She works for a program that's only three years old. It focuses solely on veterans coming back from Iraq and Afghanistan. Sanger says the VA's efforts to reach rural veterans are evolving, but steadily improving.
"Times have changed. We've learned a lot about how to provide services to veterans," Sanger said.
One of the biggest changes is outreach. Sanger's job is to talk with veterans by phone or in person. In the past, Sanger said they only contacted those veterans they were more concerned about, but now they contact every single one.
In those conversations, Sanger said she asks service members how they're doing. She connects them with mental health or other services they might need.
Some say even more outreach is needed for veterans, especially in rural areas.
Dustin Oosten, a veterans case manager for St. Louis County in Duluth, said many returning vets have trouble adjusting to civilian life. But they're often reluctant to admit they have a problem and typically don't ask for help.
"Tracking these guys down and getting them to seek services is like pulling teeth," Oosten said. "Even though the military has taken great steps in trying to say it's okay to seek services, there's still that underlying military mindset that you're considered weak if you seek services."
Oosten said he believes the farther veterans live away from mental health services, the less likely they are to address their issues. Reliable transportation is a problem for some, and Oosten said hours of travel time getting to a counselor means time away from work and other obligations.
"A lot of them are going to school full time, and to drive and not go to school, they have to make a choice," Oosten said. "Sometimes they'll make a choice to go to school rather than seeking out services."
VIDEO AND MOBILE MENTAL HEALTH
The VA is working on new programs to bridge the gap for rural veterans.
Captain Edward Simmer, director of psychological health at the Defense Centers of Excellence in Washington, DC., said the agency is looking for ways to use technology to reach veterans.
"One of the things we now have is online counseling. If you have a computer with an internet connection and a Web cam, you can set up counseling across the Web from the comfort of your own home," Simmer said. "And we're very excited about that."
VA outreach also includes bringing services directly to the places that need them. In the fall of 2008, the VA put the first fleet of 50 mobile counseling centers into service. The units resemble a recreational vehicle from the outside. Captain Simmer says they're equipped to offer mental health services.
"People can go there and anonymously talk to a counselor in a private place, and that makes help much more accessible, because the greatest help in the world is only useful if people can get to it," Simmer said.
The mobile program is a work in progress. Minnesota has only one of the vehicles. It's been in the state for about a year, but isn't fully staffed yet, and it's based not in rural Minnesota, but in the Twin Cities.
Program officials say they hope to eventually schedule regular visits to see veterans in small, rural towns.