Twenty veterans take their own lives every day. That number is smaller than it used to be, but still a clear sign of the brutality of war and the way veterans are treated after they return home.

The Central Arkansas Veterans Healthcare System has a program that is regarded as one of the best in the country at saving veterans from the brink of suicide. That program is being altered, for better or worse.

“Several people told me when I got back that I had PTSD,” Jason Crawford recalled about the end of his military service. “I wasn’t ready to accept it. So, I accepted the bottle and started drinking. Started losing touch with people, my kids, family. I started losing the ability to hold down all my responsibilities. Turned to drugs, and then eventually got to a point where I attempted to commit suicide.”

But Crawford survived, and a military friend took him to CAVHS. Crawford was admitted into the inpatient dual diagnosis program at the Fort Roots campus in North Little Rock. Dual diagnosis programs attempt to simultaneously treat mental illness, including PTSD, and addiction at the same time.

Crawford, who served in Iraq during a 16-year tenure with the Arkansas National Guard, knew he would face a different kind of fight to overcome PTSD.

“It just kept compounding and I kept running from it,” he said. “I didn’t want to face the stigma of having it, and I had too much pride, so I kept running, I kept hiding, and I kept trying everything I could to not be that way, and by doing that I just let it compound and get worse.”

And that program saved my life.

The dual diagnosis program houses up to 20 veterans at a time, and CAVHS officials say it is usually full. It is one of the only programs of its kind in the country, so veterans come from across the South and Midwest for treatment. They live in Ward 3H at the Towbin Healthcare Center for seven weeks. They receive individual counseling, classes, and group therapy. The unit also has a medical staff to manage any prescriptions the veterans might need.

Crawford said the treatment was well-structured; the counselors would often lock the door when a meeting was scheduled to begin, so anyone who tried to show up late would be kept out. He said those who wanted to improve themselves put in a lot of work.

“You do so much work in the morning group that I would leave out of that group sometimes extremely emotional, really, really torn up,” he stated. “And just like we’re all taught from day one, you pick your brother up. And here’d be the guys and we’d go downstairs and take a break and smoke a cigarette and we wouldn’t talk about drugs or anything. You’re opening up about your life to these guys and things that really matter to you and they’re not disrespecting that. They’re honoring that.”

He said he had doubts about the VA system before he was admitted, but discovered quickly that his impression was wrong.

“From the moment I walked in the door, the nurses and staff were welcoming, they show a genuine concern for the veterans, they actually care.

It was harder on the last day than it was on the first day because I honestly wasn’t ready to leave.

Mikel Brooks can attest to the power of the program in 3H. “I know it works because it saved me,” he said.

Brooks is also an Iraq War veteran. He now runs We Are the 22, a volunteer organization that intervenes when veterans attempt suicide. He remarked that telling them about the dual diagnosis program often convinces them to keep living.

“I believe it’s one of the best in the country,” he said. “I haven’t been on the opiates since I went to the program. And, I know that a lot of the guys that we respond to, obviously, are dealing with PTSD, TBI, and drug addiction. And we recommend this program to them almost every time.”

Dr. Tina McClain, Chief of Staff at CAVHS, said the dual diagnosis program has existed in its current form for more than two decades. It is about to be redesigned, in a move that has been planned for three or four years. “We intend to improve on that program and grow that program, and to continue to offer those services going forward,” she said, “but in a different treatment setting.”

Instead of being an inpatient ward that is exclusively for patients in the dual diagnosis program, it will be converted into a more open domiciliary, or residential unit.

“The residential model is actually more flexible with regard to the breadth of conditions that we will be able to accept into the residential program,” McClain stated, “as well as providing more autonomy for our patients.”

The remodel will allow the ward to expand from 20 beds to as many as 28, which means more veterans can receive care, whatever their needs. One benefit of that expansion is that the total numbers of residential beds on the campus will pass 150, which allows CAVHS to hire more staff.

“We’re going to be able to add two clinical social workers and two clinical psychologists to the treatment team, which will really bolster our ability to provide evidence-based treatments,” said Michael Ballard, Acting Associate Chief of Staff for Mental Health Service.

McClain said switching from an inpatient setting to a domiciliary setting has been a trend at VA facilities around the country for several years.

It is a national directive, but it also is being done because that’s where the evidence tells us we can get the best treatment outcomes.

“It will be more flexible,” she explained. “Whereas our inpatient program had fairly-prescribed tracks, if you will, on our inpatient program, that last X number of weeks, our residential setting will allow us a little more flexibility. So, if a veteran needs three weeks, four weeks, that’s fine. But if they need a longer period of time, we can better accommodate that, as well.”

Ballard said the change will also limit the sense of isolation that can exist in 3H.

“Some of the dually-diagnosed veterans find it difficult to interact with people that they’re not familiar with,” he stated. “So, I think there’s been a tendency for that program to work in relative isolation, and I think that has benefits and minuses, I think. So, as Dr. McClain said, our goal is to create a more community-like setting, so veterans have the opportunity to learn to interact with folks that they’re not as familiar with, because they’re going to need to do that in the community.”

Brooks agreed that community interaction is an important part of the program. He said that weekly outings are important social events.

“That’s pretty powerful for a lot of our guys who’ve begun to isolate because of their PTSD or their mental health issues, or because the drugs and alcohol, they’ve kind of withdrawn into themselves,” he said. “That really gets them out into the communities. They go to ball games, they go to movies, they go to AA classes out in the community, and it helps to reintegrate that veteran—while they’re in the therapy—into the community, and I think that’s a pretty powerful thing to do.”

“And once you’ve really started to work and the group has started to work, you form that bond,” Crawford added. “And you go off campus and you’re running around with your guy, you’re having fun, you’re laughing, it’s a good time, you come back, you’re sober. It’s awesome.”

Crawford said his life has changed dramatically since he entered the program in 2016. “I’m not doing drugs,” he said with a laugh. “I have no desire to eat a bullet. I mean I can walk around, I’ve started counseling. I’m taking a proactive approach to life instead of just sitting around waiting, and I learned all of that in that program.”

He added that he is concerned that the changes will harm the program.

The [domiciliary] does not have the same structure that dual diagnosis does.

“It doesn’t have the same rule sets, doesn’t have the same accountability," he explained. "So, you bring people that aren’t committed to a specific recovery and you put them around people that are fighting for their lives. To me, that’s not smart.”

Crawford mentioned two other problems that could result from having patients in the dual diagnosis program share rooms with patients undergoing different kinds of treatment.

First, it removes the element of privacy that is so important to the dual diagnosis veterans. Crawford mentioned that patients are required to forfeit their cell phones at the start of the program. Because of the stigma connected to both addiction and mental illness, most patients do not want outsiders to know that they are in treatment. To further protect privacy, the ward is only accessible to staff and patients, via a keypad on the door. Changing to a domiciliary would make the ward public space, which might limit the patients’ privacy.

Crawford’s other concern is about having roommates in different treatment plans who need different medications. One veteran who went through the program and asked to remain anonymous said he recalled cohorts being kicked out because they succumbed to the temptation to take opioids while in the program. Patients are frequently tested for drugs and alcohol, and having a roommate on an opioids pain management plan could ruin the recovery of a dually-diagnosed addict.

“Now you bring the temptation in, and the program’s set up to alleviate and extinguish the temptation all around you,” Crawford explained. “Now you bring it in and put it right in somebody’s face. And you know, a guy’s having a hard time sitting there and opening up to somebody… cause that what he’s used to, and all it takes is that ‘Hey man- I’ve got- I got oxy in my room’, ‘I’ve got hydrocodones in my room,’ and then he’s lost again.”

Brooks said he supports the idea of renovating 3H to increase the number of beds available to veterans in need. He believes the number of veterans looking for health care services from the VA will increase in years to come.

“We’ve been in war almost 20 years now already,” he mentioned, “and it’s really not looking like we’re gonna come out of that any time soon. In fact, there’s always the chances of us hitting another conflict in the near future.”

Crawford understands the benefit of giving more care to more veterans, and likes that additional staff will be hired. He believes it should not come at the expense of the program that brought him back from the depth of suicide.

“Sometimes you have to rob Peter to pay Paul. But in this case, Peter saves lives,” he said. “It’s the best program they have on that campus. It’s the best program I’ve ever heard of, much less been through. It has no business being changed.

“That specific environment, and the way that it’s set up, and the veterans that are in there… if I hadn’t attended that program, I’d be dead today.”

McClain and Ballard both defended the quality of care that veterans with dual diagnoses will receive after the transition in 3H. “I just want to be crystal clear that there will continue to be dual-diagnosis beds,” McClain stated, “and that we will utilize those beds in order to provide that care.”

“Change can be scary to folks,” Ballard added, “and I think there has been a lot of anxiety about it. I’m really excited about the change. I think it’s—in the end—it’s gonna be a much better program for veterans and for staff. There will be a much greater engagement. I think the quality of care will improve, and outcomes will improve.”

Ballard said CAVHS recently submitted its designs for the remodel. Because of the layers of bureaucracy in the VA system and the time required for renovations to some of the spaces in the ward, the changes to the program will likely not take place the beginning of 2019.