Psychotherapeutic issues in a Veterans Administration outpatient clinic

Psychotherapeutic issues encountered by beginning therapists in a Veterans Administration outpatient clinic are described. Emphasis is placed on the differences between the VA outpatient setting and the traditional dyadic, fee-for-service model of psychotherapy. In particular, issues of institutional transference, third-party presence, and disability compensation are discussed as possible obstacles to psychotherapy. Illustrative case vignettes are provided. The need for the beginning therapist to recognize these issues is stressed, in order to overcome potential therapeutic pessimism and improve treatment.