To the leadership of VA mental health programs nationwide:
I am writing as a Special Operations combat veteran, a Medi-Cal Peer Support Specialist candidate, and an incoming Master of Social Work student. I am writing because the standard intake model for VA trauma care is losing veterans — and the losses begin before a clinician ever sees them.
The numbers describe a funnel
Door one is trust. RAND’s Invisible Wounds of War research estimated that only about half of service members with PTSD or major depression seek treatment at all. Before any assessment is conducted, the population has already been cut in half by veterans’ judgment, earned over decades, that the system is not built for them.
Door two is intake design. Of the veterans who do reach trauma-focused care, published research on VA populations documents dropout from the standard protocols at rates of roughly one in three — a finding that has held for a decade, with current research placing dropout in routine care settings at 38.5% to 51%. When a veteran walks out, his chart typically records noncompliance. The design of the pathway that lost him goes unexamined.
The two doors feed each other. Every veteran who drops out becomes a voice in the veteran community reporting that he tried and the program was not built for him — which widens the trust gap that shrinks the next cohort at door one. The one-in-three dropout rate is not merely a program statistic. It is the engine manufacturing the distrust.
And the stakes are not administrative. VA’s own annual suicide report counts more than seventeen veteran deaths by suicide every day, and the majority of veterans who die by suicide had no recent contact with VHA care. They are on the far side of door one. Every intake policy that pushes a veteran away moves him toward that side of the line.
Veterans built this science
Bessel van der Kolk’s The Body Keeps the Score begins at the VA. His first clinical post was at the Boston VA in 1978, treating Vietnam veterans, and his work with that population helped establish PTSD as a formal diagnosis in 1980. Trauma science was not delivered to veterans. It was built from them. The measure of any VA trauma program is whether it still practices what veterans taught it.
His central finding is that trauma is stored physiologically — in the nervous system and the body, not only in cognition and memory. Yet the standard front door for a veteran seeking trauma care remains a symptom checklist followed by a choice between two manualized protocols — one cognitive, one exposure-based. Those protocols help many veterans. But that intake was not designed for the veterans van der Kolk documented: those whose trauma presents in the body rather than in reportable symptoms, those carrying significant dissociation, and those whose nervous systems are not yet regulated enough to relive their worst day on a schedule. Those veterans do not fail treatment. Treatment was never built for them, and the dropout data says so.
The assessment is compromised at the source
A structured diagnostic interview is only as accurate as the veteran’s willingness to disclose — and disclosure of trauma is a function of trust and rapport, which the intake, by design, has not yet built. Veterans trained to contain, compartmentalize, and distrust institutions do not narrate their worst experiences to a stranger at first contact — least of all to an unknown civilian clinician with no shared frame of reference.
The predictable result is minimization: symptoms underreported, dissociation missed, severity scored low. The pathway is then set on degraded data, and the record treats that data as truth. The intake model demands the trust that belongs to the end of the therapeutic process as the price of admission to its beginning — and codes the veteran’s silence as his clinical picture.
For many veterans, rapport built veteran-to-veteran is not an amenity. It is the precondition for honest clinical engagement. That is why peer support belongs at the front of the process, not the end of it.
Trust cannot be conditioned on compliance
The problem compounds when declining carries consequences. When continued outreach is conditioned on accepting the referral or program offered — decline the option presented, and the calls stop — the intake is not requesting consent. It is applying leverage. Veterans are trained to recognize coercion, and they read it instantly. An institution in that posture is not in a position of trust; it is attempting to manufacture trust, and manufactured trust is precisely what veterans walk away from. Consider what that arrangement communicates to a person being asked, in the same conversation, to share the most intimate details of his life with a stranger: comply, or be cut off. Trust cannot be commanded and it cannot be conditioned. It has to be earned — and the earning has to come first.
The fix requires no new authority
Every tool needed already exists inside VA. EMDR is already a recommended trauma-focused psychotherapy under the VA/DoD Clinical Practice Guideline. Whole Health and complementary and integrative services — including the trauma-sensitive yoga van der Kolk’s team studied under NIH funding — are already authorized within VHA. Peer support specialists are already an established VA workforce.
What does not yet exist is an intake designed to use them. Five changes, built entirely from tools VA already owns:
- Assess somatic presentation and dissociation at intake, alongside the standard diagnostic interview, so treatment matching reflects how each veteran’s trauma actually presents.
- Present the full menu of guideline-recommended options at intake, including EMDR and adjunctive Whole Health services, so veterans make an informed choice rather than a binary one.
- Build a stabilization-and-readiness pathway for veterans not yet able to tolerate exposure-based work, so readiness becomes a treatment stage instead of an eligibility screen.
- Track completion and dropout by modality and review it with veteran feedback — and stop recording pathway-design failures as patient noncompliance.
- Integrate peer support at the intake itself — a warm handoff from a fellow veteran — because trust is the first door, and a fellow veteran is the credential that opens it.
The point is a VA that veterans walk toward
Much of what the system records as pathology is adaptation — survival responses that kept veterans alive, and that begin to resolve when safety and connection are restored. An intake that pathologizes those adaptations pushes veterans away. An intake that recognizes them, and earns trust before demanding disclosure, invites veterans in.
I write this to see the VA succeed, not to catalog its failures. Veterans built this science. We taught American medicine what PTSD is, and we are entitled to a system that practices what we taught it — a front door that earns trust rather than demanding it, so veterans walk toward the program instead of away from it.
The tools are on the shelf. Take them down.
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Ren Ross is the Founder & CEO of Invictus Veteran Solutions LLC, a Service-Disabled Veteran-Owned Small Business. He is a Special Operations combat veteran (19th Special Forces Group), the author of Heroes and Handcuffs: Police, PTSD, and De-escalation (2016), a Medi-Cal Peer Support Specialist candidate, and an incoming MSW student at the USC Suzanne Dworak-Peck School of Social Work.
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