[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
POST TRAUMATIC STRESS DISORDER AND
PERSONALITY DISORDERS: CHALLENGES FOR
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
JULY 25, 2007
__________
Serial No. 110-37
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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further refined.
C O N T E N T S
__________
July 25, 2007
Page
Post Traumatic Stress Disorder and Personality Disorders:
Challenges for the U.S. Department of Veterans Affairs......... 1
OPENING STATEMENTS
Chairman Bob Filner.............................................. 1
Prepared statement of Chairman Filner........................ 74
Hon. Steve Buyer, Ranking Republican Member...................... 2
Hon. Ciro D. Rodriguez........................................... 3
Hon. Phil Hare................................................... 4
Hon. Corrine Brown, prepared statement of........................ 74
Hon. Stephanie Herseth Sandlin, prepared statement of............ 75
Hon. Cliff Stearns, prepared statement of........................ 75
Hon. Ginny Brown-Waite, prepared statement of.................... 76
Hon. Harry E. Mitchell, prepared statement of.................... 76
WITNESSES
U.S. Department of Veterans Affairs, Ira R. Katz, M.D., Ph.D.,
Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Health Administration................................. 54
Prepared statement of Dr. Katz............................... 95
U.S. Department of Defense, Department of the Army, Colonel Bruce
Crow, Chief, Department of Behavioral Medicine, Brooke Army
Medical Center, Fort Sam Houston, TX, and Clinical Psychology
Consultant to the Army Surgeon General......................... 57
Prepared statement of Colonel Crow........................... 96
______
Committee on Veterans' Compensation for Post Traumatic Stress
Disorder, Institute of Medicine and National Research Council,
The National Academies, Dean G. Kilpatrick, Ph.D., Member, and
Distinguished University Professor, Director, National Crime
Victims Research and Treatment Center, Medical University of
South Carolina................................................. 44
Prepared statement of Dr. Kilpatrick......................... 89
Kors, Joshua, New York, NY, Reporter, The Nation, and
Contributor, ABC News.......................................... 9
Prepared statement of Mr. Kors............................... 80
Satel, Sally, M.D., Resident Scholar, American Enterprise
Institute...................................................... 46
Prepared statement of Dr. Satel.............................. 91
Shea, Tracie, Ph.D., Psychologist, Post Traumatic Stress Disorder
Clinic, Veterans Affairs Medical Center Providence, RI,
Veterans Health Administration, U.S. Department of Veterans
Affairs (on behalf of herself)................................. 42
Prepared statement of Dr. Shea............................... 87
Town, Jonathan, Findlay, OH...................................... 6
Prepared statement of Mr. Town............................... 78
Veterans for America, Jason W. Forrester, Director of Policy..... 5
Prepared statement of Mr. Forrester.......................... 77
Veterans for Common Sense, Paul Sullivan, Executive Director..... 11
Prepared statement of Mr. Sullivan........................... 83
SUBMISSION FOR THE RECORD
Miller, Hon. Jeff, a Representative in Congress from the State of
Florida, statement............................................. 98
POST TRAUMATIC STRESS DISORDER AND
PERSONALITY DISORDERS: CHALLENGES FOR
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
----------
WEDNESDAY, JULY 25, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner, Brown of Florida, Michaud,
Herseth Sandlin, Mitchell, Hall, Hare, Berkley, Salazar,
Rodriguez, Donnelly, McNerney, Walz, Buyer, Stearns, Moran,
Baker, Brown of South Carolina, Brown-Waite, Turner, and
Lamborn.
Also Present: Representative Kennedy.
OPENING STATEMENT OF CHAIRMAN FILNER
The Chairman. This hearing of the House Committee on
Veterans' Affairs is called to order. Today, we will be
focusing on the relationship between treatment for post
traumatic stress disorder (PTSD) for our returning veterans
from Iraq and Afghanistan and the diagnosis of personality
disorder and how that affects later support for our veterans.
Once again it seems that America has to be educated by the
media. Just as we found out about Walter Reed from good
reporting in the Washington Post we have had incredibly
persuasive documentation on this issue from members of the
press, especially one of our panelist here today, Mr. Kors,
working for both The Nation and ABC News. And we thank you for
educating America and we will hear more from you.
What the press has learned is that thousands of cases, over
20,000 of the cases in recent years, of soldiers who were
claiming PTSD or other mental issues with regard to their
service and their claim for disability were in fact diagnosed
with a personality disorder. Then the military says that this
was a pre-existing condition, which begs the question, of why
these young men and women were taken into the Armed Services to
begin with and what our obligation is after that occurs, but
allows discharge with a very difficult time to get later care
from the U.S. Department of Veterans Affairs (VA).
If the facts that we have read in the press are true or if
the statements that we read in the press are true, this is
doing an incredible disservice to our young men and women who
are serving this Nation. We have heard that they are not
getting the full story of what the implications are for that
PTSD discharge. We have representatives of servicemembers and
servicemembers who have talked to the press that we will hear
today that they were not given the full truth in their
evaluations. They were lied to in terms of the implications of
this diagnosis.
In addition, there is some indication that higher policy is
leading to this or--policy made at higher levels. I have
personally talked to a doctor psychiatrist who told me that his
commander told him to make the diagnosis of personality
disorder rather than PTSD which would lead to further cost and
obligations by this Nation to our veterans.
So we have a real problem here. Not only are soldiers being
denied treatment for a very real problem, but they are put in
the position where it is very, very difficult to get that
treatment even later on. So once the servicemember is diagnosed
with personality disorder we want to know what happens at the
VA and how to deal with--how the VA deals with those veterans.
Is the burden on the veteran to prove that he or she doesn't
have a personality disorder? Will that diagnosis prevent the
veteran from receiving healthcare once the initial period for
coverage ends? What barriers does the veteran face?
So we want to look at this, at first from the soldier's
perspective and that is what our first panel is about, to let
them tell the story of what happens with this diagnosis, how
that affects their lives and the lives of their comrades..
So we thank you all for being here. It takes a lot of
courage for you to testify and talk about your own lives. And I
know that is hard. And we will hear from Mr. Kors who talked to
many, many of these veterans. We will have a panel that deals
with the response from the VA and, in this case, the Army
Surgeon General. We want to know if this is being taken
seriously; what is being done if these statements are true;
what is being done to rectify it.
There is legislation that has been introduced. I believe in
the Senate that makes personality disorder on the diagnosis not
a valid one. That would get rid of that as a potential
diagnosis in dealing with, or at least in terms of the
obligations that we have for treatment, and we may have to do
that on the House side also.
So we have, I think, a very important issue to look into
today. We thank both the soldiers who are here, their
representatives and the reporter who first brought this to
America's attention.
I would yield to the Ranking Member of this Committee, Mr.
Buyer.
[The prepared statement of Chairman Filner appears on p.
74.]
OPENING STATEMENT OF HON. STEVE BUYER
Mr. Buyer. What was originally focused and appropriate for
this review was a Subcommittee hearing on post traumatic stress
disorder compensation and veterans claims at the Department of
Veterans Affairs. That is how this began. We have now morphed
it out of the Subcommittee to the Full Committee. And the focus
is now on lanes outside the jurisdiction of this Committee. If
the Chairman wanted to explore these matters, what would have
been substantive and helpful to all of us is for this to have
been a joint hearing with the House Armed Services Committee.
While we can have witnesses before us, we can take no
substantive action. There are many times when we are the
receiver of individuals based on policies and actions from the
U.S. Department of Defense (DoD).
So a lot of this is important, but we should be working in
concert with the House Armed Services Committee. The
legislation I think that the Chairman was referring to, was
legislation introduced by Senator Obama, and Senator Obama's
legislation would stay the discharges for a personality
disorder. I think that is a bad idea. We have individuals who
are taken into the military. We do the best we can as a nation
to screen individuals. At some point through the military
matriculation process, individuals begin to exhibit certain
types of actions that would not be appropriate. When you put a
weapon into someone's hands and you ask them to work in concert
and as a team with other individuals, it requires mental
steadfastness. And it requires a lot of other institutional
values and virtues in order for that team to work with great
cohesion and for them to be the very best.
And we have no idea as a country when an individual is
going to break down. And in fact, if there are personality
disorders, we have no idea when they are going to exhibit
themselves. And to disarm the military from this ability to
essentially discharge this individual so there is no harm not
only to the individual, but also to the team, is extremely
important.
So while what perhaps well intentioned, I think Senator
Obama's legislation would be very harmful to the military and
thereby the national security of the country. It is also
equally important for us not to confuse PTSD and personality
disorder. These are clinical diagnoses. For individuals to be
discharged from the military for personality disorders, you
just can't have a company commander or a first sergeant or a
master chief come forward and say, ``Well, I think this person
has got a personality disorder. I want to get rid of them.'' I
mean these are clinical judgments made by psychiatrists and
doctorate level psychologists through a peer review process.
And this allegation that they can just be thrown out is false.
So while much of the testimony we are going to hear today
is interesting and might be helpful, much of this is outside
the jurisdiction of this Committee. I also do recognize that
when we take an issue to the Full Committee, generally the
Veterans' Affairs Committee seeks the counsel and input from
many of the chartered veterans service organizations (VSOs),
and they are absent here today. And I find that to be a curious
matter.
I yield back.
The Chairman. Thank you, Mr. Buyer. I guess once again we
understand only for the last 4 years, these issues were not
taken up and not explored. This is a scandal. And I don't care
who's jurisdiction it is, although we have tremendous
jurisdiction in this. It is up to this Congress to deal with
it.
Are there any other opening statements by my colleagues?
Mr. Rodriguez.
OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. I just would make a comment that eventually
it will become our problem, because when someone is diagnosed
incorrectly, eventually that individual is going to come to the
VA and that diagnosis remains with that individual. So it will
become our problem as dealing with veterans.
The other reality is this: I worked over 8 years in the
area of mental health and I understood very quickly when I was
told that in order for us to provide any service to any
individuals, they have to receive a specific type of diagnosis
otherwise we couldn't deal with them. And so that also drove
unfortunately a lot of times what we could do or not do based
on the specific diagnosis that they were given.
So I am, and it is an area that we ought to be, concerned
about and I know personally this, in terms with when you are
diagnosed in that area, presupposes that the individual came in
with those problems prior to. And so, that is important for us
to come to grips with that as quickly as possible and making
sure that that is not occurring and is not happening. And if
anyone is going to get diagnosed, that we do everything we can
to diagnose them appropriately as much as we can. And in some
cases, if that is the case then we got to go back and reassess
in terms of what has been happening and what is occurring with
those soldiers that are out there.
And so with that, I will stop and look forward to the
testimony.
The Chairman. Thank you, Mr. Rodriguez. Mr. Hare.
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. Mr. Chairman, I would respectfully disagree with
the Ranking Member. I think this is well within this
Committee's jurisdiction. I cannot, for the life of me, believe
that we would see 22,000 plus of our best and our brightest
treated like this. I think it is grossly unfair. I think it is
beneath what they certainly have deserved. There is substantive
action that I would suggest to my friends on the other side
that we can take and that would be including perhaps sponsoring
my bill H.R. 3167, the ``Fair Mental Health Evaluation for
Returning Veterans Act.''
I would again disagree with the Ranking Member. I don't
think Senator Obama idea is a bad idea at all. I think from my
perspective, when we see something wrong I don't think we need
to wait around for another Committee to tell us what is wrong.
I think we need to, as a Committee, get together and to try to
help our servicemen and women. So from my perspective, I think
this is well within the purview of this Committee. I commend
the Chair for holding this. I have said many times at this
Committee, if not us, who? And if not now, when?
And I want to thank you, Mr. Chairman, for doing this and
to the witnesses I look forward to hearing this. But we cannot
take the treatment of people in our military like this anymore.
And I am not here to worry about whether or not the Armed
Services is here. I am here. We are here. And I want to hear
from these witnesses. And I want to see this problem solved.
So I thank you, Mr. Chairman, for giving us the opportunity
to listen today. Thank you.
The Chairman. Thank you, Mr. Hare. We will hear from the
first panel. If you have a written statement, that will be made
a part of the record.
Jason Forrester is a representative from Veterans for
America (VFA). We thank you for what your group is doing and we
thank you for being here today.
STATEMENTS OF JASON W. FORRESTER, DIRECTOR OF POLICY, VETERANS
FOR AMERICA; JONATHAN TOWN, FINDLAY, OH (VETERAN); JOSHUA KORS,
NEW YORK, NY, REPORTER, THE NATION, AND CONTRIBUTOR, ABC NEWS;
AND PAUL SULLIVAN, EXECUTIVE DIRECTOR, VETERANS FOR COMMON
SENSE
STATEMENT OF JASON W. FORRESTER
Mr. Forrester. Thank you, Mr. Chairman. Chairman Filner,
Ranking Member Buyer, Members of the Committee, Veterans for
American works closely with Congress, DoD, the media, active-
duty troops and veterans to identify the unique challenges
facing today's military. Much of our work is investigative.
Specifically, our work at Ft. Carson, Colorado, where we first
met Specialist Town, and our current work at Camp Pendleton,
California, has prompted considerable media attention and
Congressional action and has helped identify where our country
is failing our servicemembers.
Given the distressing disconnect between VA and the DoD,
the greatest service that VFA can provide today is to highlight
the trends we have identified and are working to correct within
DoD and to offer some ideas regarding how the VA can help
ensure that those who have served in Iraq and Afghanistan get
the assistance they deserve.
It is important for VA to understand that the experiences
of nearly one million servicemembers from Iraq and Afghanistan
who are still on active duty and who will eventually enter the
VA system. The DoD's Mental Health Task Force found that 49
percent of Guard members, 38 percent of soldiers, and 31
percent of Marines are experiencing some mental health issues
after serving in Iraq and or Afghanistan. DoD characterized
post traumatic stress disorder as a signature wound of today's
wars. At Ft. Carson, we found soldiers who had been diagnosed
with chronic PTSD who are only receiving 1 hour of individual
therapy per month. Often, these soldiers saw a new therapist
each visit.
At Ft. Carson, we worked with soldiers who were not
receiving the treatment they needed even though they clearly
indicated on their post-deployment health reassessment that
they were having difficulty readjusting to post-deployment
life.
In some cases, these soldiers had been re-deployed only to
have their wounds compounded by further exposure to combat. In
other cases, undiagnosed and untreated PTSD led soldiers to
turn to drugs and alcohol. The civilian medical community has
long recognized that substance abuse is a symptom of PTSD.
Unfortunately, it is DoD policy not to treat soldiers for PTSD
until their substance abuse problems are addressed. There are
no DoD dual track PTSD and substance abuse programs. We have
worked with several soldiers who have suffered greatly from
this deficiency and in a few cases, have gotten them into VA
facilities that offered dual track care.
Since PTSD is so prevalent, VA must increase the number of
dual track programs that treat substance abuse and PTSD. VA can
help greatly reduce anti-mental healthcare stigma by increasing
its outreach to servicemembers and their families on bases and
within military medical facilities. Today's servicemembers need
to know that PTSD is an injury and that they deserve every
opportunity to recover. PTSD is not a sign of weakness. It is a
proven medical reality of sustained exposure to combat.
Finally, another distressing trend that we identified at
Ft. Carson was the prevalence of pre-existing personality
disorder discharges for soldiers with clear service-connected
mental health problems. The consequences of such a dismissal
are severe, including denial of VA benefits due to the disorder
being, ``pre-existing.'' At Ft. Carson we met numerous soldiers
who had been diagnosed with a pre-existing personality disorder
regardless of the fact that they were deemed fit when they
entered the service and regardless of the fact that they have
been diagnosed with PTSD post-deployment to Iraq and
Afghanistan.
Pre-existing personality disorder discharges remove the
government's burden to help the servicemember deal with their
service connected injuries. It is unacceptable to ask an
American to sacrifice for this country and not to treat the
consequences of their service.
In May of this year, as a result of our work at Ft. Carson,
a congressional staff delegation returned there where they met
with the soldiers and family members who we had been helping.
This visit prompted a U.S. Government Accountability Office
(GAO) investigation into mental health treatment in the
military and it led to a bipartisan group of 31 Senators
sending a letter to Secretary Gates calling for a moratorium on
pre-existing personality disorder discharges. This problem
provides a great opportunity for VA leadership.
While VA has no obligation to treat a veteran with a pre-
existing personality disorder discharge, these men and women
need help. To address this problem, VA should create a
streamlined process for face to face medical evaluations for
such discharges. We owe these veterans a second chance to get
much needed help for their service connected injuries.
This concludes my statement. Thank you.
[The prepared statement of Mr. Forrester appears on p. 77.]
The Chairman. Thank you very much.
Jonathan Town is an Army veteran who was diagnosed with a
personality disorder. And I understand after all the publicity
about your case, the VA, or you can tell us, the VA has decided
they we owe you treatment. We thank you for your courage in
coming forward. Many soldiers who are in the same position as
you are do not feel comfortable about testifying, and we thank
you for speaking on behalf of thousands of soldiers.
STATEMENT OF JONATHAN TOWN
Mr. Town. Thank you for the opportunity. Mr. Chairman,
distinguished Members of the Committee, ladies and gentleman,
thank you for inviting me to address the Committee to tell my
story.
On January 20, 1961----
The Chairman. Mr. Town. Could you just--get the microphone
right up to you and make sure it is turned on. It is hard
sometimes to hear, if not.
Mr. Town. On January 20, 1961, a United States military
veteran and Purple Heart awardee who was being sworn in as
President at that time said during his inaugural speech, ``Ask
not what you can do for your country, ask what--ask not what
your country can do for you, ask what you can do for your
country.''
Since January 2000, countless citizens have answered this
call to duty and served in the United States Armed Forces.
Thousands, in fact, 22,500 of these servicemembers who served
honorably have been discharged from the military with a Chapter
5-13, Personality Disorder Discharge. The result of which they
have all been denied medical care and disability benefits by
our government.
There has now arisen a debate about whether these
discharges were done to save the government money or to help
with the military wartime and deployment strength. Regardless
of the reason, it is an outrage that these servicemembers and
their families have been put through this.
Now I would like to tell you my story. I served 4\1/2\
years honorable years at Fort Knox, Kentucky, as an
administrative specialist. I was then given orders to permanent
change of station (PCS) to Korea. After arriving in Korea, I
was told that the unit I was assigned to had just received it's
deployment orders to Iraq. In August 2004, the STEEL battalion
which I was now a part of, deployed to Ramadi, Iraq. On October
19, 2004, I was running mail for our battalion and incoming
rounds started exploding across the street from where my
vehicle was parked. While running for shelter in my S-1 shop's
office, a 107 millimeter rocket exploded three feet above my
head, leaving me unconscious on the ground with a severe
concussion, shrapnel in my neck and blood pouring from my ears.
I was taken to the battalions aid station where I was
treated for these various wounds. I was given quarters for the
rest of the day and went back to work the next day. Two months
later, I was awarded a Purple Heart for my injuries I suffered
on that traumatic day in October. This is when everything
started to go downhill health-wise for me. Throughout the next
9 months while continuing to serve my country, I battled severe
and non-stop headaches, bleeding from my ears, and insomnia.
We finally got the word that we were headed home and then I
would finally be able to get some assistance for the medical
issues I was going through. After a few days back in the United
States, I realized a new battle was taking place. My ability to
adjust to loud noises, large groups of people and forgetting
what happened to my unit and myself while we were in Iraq was
going to be another battle.
About 45 days after coming back stateside to Ft. Carson,
Colorado, I was finally able to see a psychiatrist. The first
few meetings with the doctor were good and it seemed like he
actually cared about helping me get through my issues, if it
were possible. Then word came down that our unit was going to
be re-deployed. The next time I went to see the doctor, he
informed me that he was going to push a Personality Disorder
Chapter and explained why.
The doctor said, ``You have the medical issues that call
for a medical board, but the reason I am going to push this
Chapter is because it will take care of both the needs of the
Army and the needs of you. You will be able to receive all the
benefits you would if you were going to go through a medical
board, get out of the military, and focus on your treatment to
get better. For the military, they can get a deploy-able body
to fill your spot.''
I told him that this is--if this is what the thought was
best for the military and my family that he could do what he
needed to do. I never realized that everything that was said to
me during that day was all lies. I went through the final out
process to leave the military. The day I was signing out, I was
told by the final out personnel that I would not receive any
severance pay or benefits and I actually owed the military
$3,000.
I do not know everyone in this room, but I think that if
you were to work hard for a company or an agency, only to be
told that you owe them money, that you owed them money when you
went to leave, you would obviously be--you would obviously
think something is wrong. If it weren't for my family taking us
in and supporting us both financially and emotionally and new
friends helping us, I don't know where my family and I would be
right now.
The last 9 months have been spent trying to get assistance
both medically and financially through the Veterans Department,
getting the word out to the public about what is happening to
my fellow servicemen and myself, and trying to get my family
and myself back on our feet.
Eight months after being denied medical benefits as a
Chapter 5-13 discharge, the Veterans Administration awarded me
the disability status that my Purple Heart and wounds I
suffered entitled me to. I am fortunate because my story
received national exposure, unfortunately there are many, many
injured military personnel Purple Heart winners also who have
never received their benefits that they are entitled to.
In the absence of a concerted effort by the Committee to
right this horrible wrong, I am afraid that the other 22,499
veterans will not be as lucky as me.
I think the government should fix the personality disorder
issue in the time it takes a servicemember to receive the start
of their disability from the time they leave the Armed Forces.
The Chapter 5-13 personality disorder should be completely
taken out of the DoD regulation, or if the military really
wants a way to get servicemembers out of the service that do
not have over 6 months of active service or have not been
deployed overseas, then it needs to be written that way in the
regulations.
It is 100 percent wrong to be able to use this discharge
for any servicemember that has been on active service for a
substantial amount of time or who has fought in a war for their
country. Some have suggested a way to reduce the amount of time
a servicemember has to wait till they finally start receiving
disability after leaving the Armed Forces. The servicemember
starts his or her disability paperwork and process at the
station where he or she is currently stationed 2 months prior
to getting out of the service. The servicemember should not be
able to final out from their branch of military until he or she
is either guaranteed or denied their disability claim. By going
through this route it will allow the servicemember to receive
their first disability check immediately after their last
paycheck from the Armed Services and they will be able to
receive medical assistance as soon as they leave the service.
Such a system would also facilitate the electronic transfer
of the servicemembers medical records from the service branch
of the veteran--to the Veterans Administration, thus allowing
the Department of Defense to better work hand in hand with the
Veterans Administration to assist these soldiers in need.
In closing, I want to state that I did not have a
personality disorder before I went into the Army, as they have
stated in my paperwork. I did not suffer severe non-stop
headaches. I did not have memory loss. I did not have endless,
sleepless nights. I have post traumatic stress disorder and
traumatic brain injury (TBI) now due to injuries I received in
the war for which I received a Purple Heart. I shouldn't be
labeled for the rest of my life with a personality disorder and
neither should my fellow soldiers who also incorrectly received
this stigma. I would like to ask the Committee and panel
members to thoroughly think about the ideas I have mentioned to
fix some of the issues we as veterans are facing. Please help
those who have helped their country and remember that every
time the military discharges a servicemember out of the Armed
Service the way I was discharged, not only do you destroy hope
for healing, but they destroy the soldier's families hope for
healing as well.
[Applause.]
[The prepared statement of Mr. Town appears on p. 78.]
The Chairman. Thank you, Mr. Town, you did not sign up to
have to do this, but you are helping a lot of people and we
thank you for----
Mr. Town. It is an honor.
The Chairman [continuing]. Your courage.
Joshua Kors is a journalist. He has written on this topic
extensively and has been the source of much of the facts and
stories around us, both for The Nation and for ABC News. So we
thank you, Mr. Kors, for what you have done and we look forward
to your testimony.
STATEMENT OF JOSHUA KORS
Mr. Kors. Good morning. I have been reporting on the
personality disorder discharge for the last 10 months.
The Chairman. Please speak close to the microphone so we
can hear.
Mr. Kors. I have been reporting on the personality disorder
discharge for the last 10 months and I am here today to talk
about the 22,500 soldiers discharged in the last 6 years with
that condition.
A personality disorder discharge is a contradiction in
terms. Recruits who have a severe pre-existing condition like a
personality disorder do not pass the rigorous screening process
and are not accepted into the Army. The soldiers I interviewed
this past year passed that first screening and were accepted
into the Army. They were deemed physically and psychologically
fit in a second screening as well before being deployed to Iraq
and served honorably there in combat. In each case, it was only
when they came back physically and psychologically wounded and
sought benefits that this pre-existing personality disorder
discharge was discovered.
Discharging soldiers with a personality disorder prevents
them from being evaluated by a medical board and getting
immediate medical care. This can be life threatening for our
soldiers. A good example is Chris Mosier who served honorably
in Iraq where he watched several of his friends burn to death
in front of him. After that, he developed schizophrenic-like
delusions. He was treated at Ft. Carson for a few days then
discharged with a pre-existing personality disorder. He
returned home to Des Moines, where he left a note for his
family saying that Iraqis were after him, they are in Iowa,
then shot himself.
Surgeon General Gale Pollock agreed to review a stack of
personality disorder cases. After 5 months, she produced a memo
saying her office had, ``thoughtfully and thoroughly'' reviewed
the cases, including Jon Town's, and determined all of them to
be properly diagnosed. With further reporting I discovered that
as part of that thoughtful and thorough 5-month review,
Pollock's office did not interview anybody, not even the
soldiers whose cases she was reviewing. Some of those soldiers
said they called the Surgeon General's office offering
information about their ailments. Their efforts were rebuffed.
The one thing the Surgeon General's office did do was
contact a doctor at Ft. Carson where many of the personality
diagnoses were made, and ask him whether his doctors got it
right the first time. The doctor said yes, his staff's original
diagnoses was correct and Pollock shut down the review at that
point.
The Surgeon General's office denied that for many months,
insisting that the review was conducted by a panel of health
experts who were not involved in the original diagnoses. This
wasn't a case of one many reviewing his own work, they said.
But eventually it did come out that the only reviewer was
Colonel Steven Knorr, who as Chief of Behavioral Health at Ft.
Carson, oversaw many of the personality disorder diagnoses and
in his capacity as a psychiatrist was reportedly involved in
creating many of them as well.
When the problems with Walter Reed became public, the
Pentagon took two actions: It accepted the resignation of
Surgeon General Kevin Kiley and it hired the public relations
firm LMW Strategies with a $100,000 no-bid contract to put a
positive spin on those events. This past week as these
personality disorder discharges became public, VA Secretary
Nicholson stepped down. And today, Surgeon General Pollock is
not here to discuss the issue.
As a journalist it is not my role to make any
recommendations, but I do want to share with you the hopes of
the wounded veterans I spoke to this year, which is a hope that
someone be held responsible and that officials go back through
the 22,500 cases and seek out the thousands of Jon Towns who
are waiting there, struggling right now without benefits or the
media spotlight.
[The prepared statement of Mr. Kors appears on p. 80.]
The Chairman. Thank you, Mr. Kors.
And concluding this panel will be Paul Sullivan
representing Veterans for Common Sense. And we thank you again
for your efforts at making these kinds of situations public for
the American people to understand.
STATEMENT OF PAUL SULLIVAN
Mr. Sullivan. Thank you, Mr. Chairman. Chairman Filner and
Members of the Committee, thank you very much for inviting
Veterans for Common Sense to testify about post traumatic
stress disorder and about personality disorder discharges among
our Iraq and Afghanistan war veterans. My oral testimony
focuses on offering solutions so our veterans receive prompt
medical care and prompt disability benefits for PTSD.
So far, the Department of Defense has discharged more than
22,000 veterans in the past 5 years with a personality disorder
or PD. The current DoD system assumes soldiers are malingering.
And the current VA system is designed to fight fraudulent
claims. These DoD and VA barriers to prevent abuse of the
system are blocking too many deserving veterans from getting
the high quality medical care from VA, and the prompt
disability benefit payments from VA that they need and they
earned.
When the military uses PD to discharge a veteran who fought
honorably, then the military is breaking it's own rules.
Chapter 5-13 states that if a veteran was in combat then the
military is generally prohibited from using PD. VA's recent
review of PTSD claims found no evidence of fraud. A veteran
discharged with PD is usually denied VA healthcare and benefits
based on VA rules prohibiting services for a pre-existing
condition.
Here are VA's latest statistics on post traumatic stress
disorder. As of March 31, VA diagnosed 52,000 Iraq and
Afghanistan war veterans with PTSD. However, VA approved only
19,000 PTSD claims. This disparity should be investigated.
Veterans for Common Sense urges Congress to adopt a robust
package of policies listed in our written statement so Iraq and
Afghanistan veterans with PTSD receive prompt medical care and
benefits. Here are our top three proposals.
First, Congress should legislate a presumption of service
connection for veterans diagnosed with PTSD who deployed to a
war zone after 9/11. A presumption makes it easier for our
dedicated and hard working VA employees to process the veterans
claims. This results in faster medical treatment and faster
benefits for our veterans.
Second, the military should stop discharging Iraq and
Afghanistan war veterans uses PD. The military should review
all personality disorder discharges for veterans deployed since
9/11. Congress should order VA to review applications for
healthcare and benefits where PD was an issue at VA.
Third, DoD and VA should establish a policy to reduce the
stigma against people with mental health conditions that
military studies confirm hinders many of our war veterans from
seeking care. The scope of PTSD in the long term is enormous
and it must be taken seriously. PTSD is real. When all of our
1.6 million servicemembers eventually return home form the wars
in Iraq and Afghanistan, based on the current rate of 20
percent, then VA may face up to 320,000 total new veterans
diagnosed with PTSD.
In conclusion, Mr. Chairman, if America fails now to act
and overhaul the broken DoD and VA disability systems, there
may be a social catastrophe among many of our returning Iraq
and Afghanistan war veterans. That is why Veterans for Common
Sense reluctantly filed suit against VA in Federal Court this
week. Time is running out. The consequences of failure among
our veterans are severe, including broken families, lost jobs,
stigma, drug abuse, alcoholism, crime, homelessness, and
suicide. The disastrous consequences are preventable, yet our
window of opportunity to prevent these problems from happening
is closing.
Thank you, Mr. Chairman. I would be more than happy to
answer any of your questions.
[The prepared statement of Mr. Sullivan appears on p. 83.]
The Chairman. Thank you all very much. You have made some
very powerful statements. I am going to call on Members of our
panel in the order in which they got here. The Chairman of our
Health Subcommittee is Mr. Michaud and the floor is yours for 5
minutes.
Mr. Michaud. Thank you very much, Mr. Chairman. I want to
thank the panel for the enlightening testimony. And I have a
few questions. First of all, for Mr. Town. You had mentioned in
your testimony that when you went through the final out process
to leave the military, when you signed out that they said that
you actually owed them money. What was the reasoning they gave
why you owed them $3,000? Was it for medical bills or?
Mr. Town. While I was in Iraq I re-enlisted for 6 years and
a $15,000 tax-free bonus while in Iraq. And when I came back
stateside, or when I was being chaptered out, they said I had--
I had served 1 year of that 6 years. So I stilled owed $12,000
roughly. And there was, I had leave that I was selling back to
Defense Finance and Accounting Service, and I sold my leave
back. And how it came out is, I still owed $3,000 of that
$12,000. And that is how that debt was made.
Mr. Michaud. Okay. Thank you. For Mr. Sullivan, you had
mentioned the lawsuit and being a former VA employee we have
been dealing with a lot issues dealing with traumatic brain
injury, and PTSD. If the lawsuit is successful and VA has to
respond, the lawsuit might also say in order to respond to the
huge influx of men and women from this conflict and previous
conflicts, Vietnam era conflict, what are your thoughts about
the VA not utilizing to the degree that they probably should be
to take care of the influx as far as contracting out services,
particularly in rural areas for mental health services? Would
you comment on that? Do you think that that is what they should
do in the short term to help with the influx is to fee for
services?
Mr. Sullivan. Thank you for your question, Congressman. I
am not an expert on rural care for veterans, but there are two
pretty simple standards that VA should be held to. The first
standard is when a veteran comes home from war and he needs an
appointment for a mental health condition. It shouldn't matter
if he lives in Nome, Alaska, or New York City. The
servicemember turn veteran should be able to see a mental
healthcare provider as soon as possible so the condition
doesn't worsen.
It is better for the veteran to get treatment sooner, it is
also cheaper for the taxpayer so that you don't have more
complicated problems later on. So it would be a very good idea
for VA to make sure, especially for Guard and Reserve units,
that they beef up their rural programs.
One note related to that. I mentioned that there are fewer
claims for PTSD that are approved then there are veterans who
are diagnosed. One related concern is this: National Guard and
Reserve, mainly from rural areas, are about half as likely to
file a claim. However, Congressman, they are about twice as
likely to have their claim denied. So not only do they need
access to healthcare, they also need access to a good
representation to assist them with their claim.
Mr. Michaud. Well why is it that they are half as likely to
file, because they don't know about the services or they just
afraid of the stigma that is attached to it?
Mr. Sullivan. I don't know the answer to that, Congressman.
However, I did raise it while I worked at VA and it was in some
of the briefing materials that I provided to VA executives.
However, I am not aware that they took any action. You may want
to ask them if they have investigated the discrepancy and if
they have any answers.
Mr. Michaud. Okay. Thank you. And my last question to Mr.
Kors is being a journalist you definitely have the power to
inform the public of what is going on. Have you ever been
persuaded by one side or another to be more aggressive or less
aggressive as you move forward in dealing with this issue of
claims?
Mr. Kors. Sure. Well any journalist works hard to keep
their neutrality, but certain issues seem logical when looking
at them. For example, in Jon Town's case, they gave him a
Purple Heart for his wounds of war, but yet Surgeon General
Pollock says he was not wounded in war. Contradictions like
that call out the strangeness, the sense of absurdity here. And
I think actually that question deserves a little more detail.
Following the review that said that Jon's case and the
stack of others was properly diagnosed, the Pentagon released a
second statement that went a lot farther. A statement by
Lieutenant Colonel Bob Tallman, what has become known to the
reporters reporting on this issue as the Tallman memo. In the
Tallman memo, they said not only did they review the stack of
cases presented to them, but they went back and reviewed all
the cases from the last 4 years at Ft. Carson where Specialist
Town was based. After it was revealed that--after it was
revealed that there were no interviews in this 5-month
thoughtful and thorough review, I later discovered that the 4-
year review was simply invented.
I called Lieutenant Colonel Tallman to ask him about this.
How they could call this a thoughtful and thorough review when
not a single soldier was interviewed. And he said to me, well
he really didn't think that they could. And he said, ``Joshua,
let me be clear with you. I didn't write this memo and I have
no knowledge of it's contents.'' He told me that the memo was
ghost written by Surgeon General Gale Pollock's office.
Something that Pollock's office readily admitted. And after it
was revealed that the review was simply invented, the 4-year
review referred to here, they really said that was all the
information they could provide.
Mr. Michaud. Thank very much. That is very enlightening.
Thank you very much for all of the work that you all are doing,
I really appreciate it.
The Chairman. Thank you. Mr. Moran?
Mr. Moran. Mr. Chairman, thank you very much. I appreciate
the opportunity to learn about this circumstance that our
servicemen and ultimately veterans are facing.
Mr. Kors, apparently--if I understand the situation,
apparently pre-existing, that word is very significant. And I
guess my initial question is, are there findings with our
servicemen and women, that they have a personality disorder as
a result of actions or activities that occur in war that result
in the designation of a personality disorder for which the
there is no pre-existing--let me ask this question. I am not
very clear, but I want to make sure do we have a non pre-
existing condition? And in that case, is there a different
result? Or is everything found in these circumstances to be
pre-existing and, therefore, the consequences are bad in each
and every case? What makes Mr. Town's situation different? Are
other servicemen and women found to have a personality disorder
but not a pre-existing one?
Mr. Kors. Well that is exactly the point, Congressman. And
that is why it is such an important VA issue. The VA is not
required to treat pre-existing conditions. They are required to
treat wounds of combat. And why is Town's case unique? It is
not and that is precisely the point.
I looked at cases of one soldier for example who suffered a
bilateral hernia in Iraq. His condition was decided as the
result of pre-existing personality disorder. Another case, for
example, the soldier who damaged the lens of eyeball in Iraq.
That ocular damage was seen as the result of a pre-existing
personality disorder.
Mr. Moran. Are there cases in which there is no finding of
a pre-existing condition? And those soldiers are treated
differently than Mr. Town?
Mr. Kors. Well in Town's case, as in all the others, there
is no previous history. And in fact, it goes further to the way
that the Army looks at how one does--how do they discover that
a person had a condition that was pre-existing? Standard Army
policy is to interview no one. In fact, I got a call recently
from a psychiatrist at a major east coast Army facility who
said that he is the only person in the in his Fort Hospital who
does interview families. You know, for Town's case for example,
you know, perhaps his family would of noticed if he had severe
hearing loss before joining the Army.
This doctor was the one and only who did seek out families
to interview to see whether it was pre-existing. He said he was
ceaselessly mocked by both the Chief of Behavior Health at his
Fort's hospital, and others, as being completely out of step
with the Army and VA ways.
Mr. Moran. So the finding of the condition to be pre-
existing is nearly automatic in each and every case?
Mr. Kors. It is simply asserted without proof. I think that
is the best--I mean you know at that point we really have to
look at why this is happening. And that was a considerable part
of my 10-month investigation.
Jon Town and the others here have talked about the
financial components. By preventing these wounded veterans from
receiving their benefits, the military is saving $12.5 billion
in disability and medical care. With that financial pressure
comes political pressure. I spoke to multiple trial defense
services lawyers who said the commanders at their base were
pressuring doctors to falsely diagnose. What one told me he
knew this was happening because the commander had come to him
and confessed to doing it.
On a basic level, on simply a practical level, the
hospitals there are overrun, both at the Army and the VA. And
you have situations where they need to get someone out of their
hair fast to free that space up for the four or five soldiers
who are waiting to take it. As Frank Ochberg, the doctor who
codified post traumatic stress disorder for the government
said, there's a further public relations issue that even goes
deeper than simply getting soldiers out of their hair. And that
is making soldiers like Jon Town invisible. If Town comes back
with a Purple Heart and severe problems with memory, with
sleep, with headaches, we can delete him from the cost of the
war if we simply say it was a pre-existing condition unrelated
to his military service.
Mr. Moran. Mr. Town, thank you very much for your service
to our country. You indicate now that the VA is providing
benefits to you? Is that true?
Mr. Town. Yes, sir.
Mr. Moran. But are those benefits unrelated to a
personality disorder?
Mr. Town. Correct. They actually diagnosed me with post
traumatic stress disorder. The VA has.
Mr. Moran. And are you being treated by the VA for those
for that condition?
Mr. Town. Yes, sir.
Mr. Moran. And the reason that you were successful or your
case is no longer considered ineligible for benefits because it
was pre-existing is what? Why the change? Is there some
medical----
Mr. Town. Well----
Mr. Moran [continuing]. Finding that allowed the VA to
reach a different conclusion or----
Mr. Town. No.
Mr. Moran [continuing]. They just reached a different
conclusion?
Mr. Town. No. They just--I saw this psychiatrist for about
25 minutes when I got to the Dayton VA. And she was pretty much
in tears after I had talked to her for about 25 minutes. And
that was all she needed for her evaluation of what I had been
going through for the last 2 years.
Mr. Moran. Thank you very much, Mr. Chairman.
The Chairman. Mr. Moran, just as I understand it,
personality disorder is by definition pre-existing. If the
other possibility is PTSD which means we gave it to you, which
means you are eligible.
Mr. Sullivan. That is correct.
The Chairman. And, you know, Mr. Town was called, I think
from a very pretty high level of in the VA, after all the
publicity came out about it. He----
Mr. Moran. The--excuse me, Mr. Chairman. But the
distinction is that the VA still has not--they will still
consider Mr. Town, at least initially, of having a pre-existing
personality disorder. Now they have reached the conclusion he
has post traumatic stress syndrome, which then qualifies him
for assistance from the VA.
Mr. Kors. Congressman? That is another key issue here. The
VA flatly rejected the Army's diagnosis. In cases where a
soldier gets a tremendous amount of press, this often happens.
He was decided after the Army decided he wasn't disabled at all
the VA decided he was 100 percent disabled. And top officials
at the VA explained to me why this is such a severe problem for
the VA. False diagnoses of personality disorder short flagged--
short circuited the VA's red flag system. That is internal VA
speak for the way in which the VA keeps it's eye out for those
who are severely wounded to get them immediate medical and
disability benefits.
They keep their eye out by looking at the Army's medical
board and who comes out of the medical board with a very high
disability rating. Soldiers like Jon who got a pre-existing
personality disorder are denied the opportunity to see a
medical board, thus they don't get a disability rating at all,
thus they fly under the VA's radar and in Jon's case, didn't
receive a single doctor's visit for 8 months.
Mr. Moran. So, Mr. Chairman, we have one diagnoses by the
military and one diagnosis by the VA resulting in a different
outcome?
Mr. Kors. That is right.
Mr. Moran. Thank you.
The Chairman. Right. But that person has to come to the VA,
there has to be an aggressive effort. And in conditions which
make them very vulnerable and they have to fight for that new
diagnosis. So fighting the bureaucracy when you are suffering
from these kinds of things is not the easiest thing to do.
Mr. Kors. In Jon's case he submitted his paperwork five
times before the VA decided to take up his case and look at his
medical condition.
The Chairman. Thank you. Mr. Hare, you have the floor.
Mr. Hare. Thank you, Mr. Chairman. I have to tell you I am
beyond even angry. I don't even know what word I can use.
Let me--I want to see if I can sum up this because this is
almost surreal. As I understand it, we have over 22,000 people
who have who got in the military, somehow slipped under the
radar screen. Now they are being diagnosed incorrectly. Mr.
Town, I am amazed that not only did they, since you obviously
weren't wounded according to them, that not only they asked for
$3,000 I am surprised they didn't ask for your Purple Heart
back.
I think this is amazing. And so if I get this straight
then, nobody has reviewed any of these cases for any of these
people at all, but they made up the fact that they did. They,
someone in the military or some has said, that they interviewed
these people. Nobody, not one person has been talked to about
this. And their lives and their families and everybody is
affected. And not one person. So I guess what I would like to
understand is, and maybe somebody on the panel could help me
out here, in your opinion, did this really say to treat people
like Mr. Town and thousands of other people to save $12.5
billion in savings that they don't have to pay out? And then
you had to try to get this five times on your own? And what
about the people that give up or they feel frustrated that some
how--and now we are suing the veterans once again, have to go
back and sue people because of the way they are being treated.
Unbelievable.
And I want to commend you, Mr. Kors, for your reporting on
this issue. I know this is just maybe an opinion I would like
to get from you. Are you after doing this investigation
convinced that the reason that these people that this happened
to them was they were just trying to get out of saving $12.5
billion?
Mr. Kors. I think there are a multitude of reasons. And,
you know, it goes from the ground level to the top level. I
think where the pressure on the commanders to pressure the
doctors to purposely misdiagnose comes from. That is something
that, you know, perhaps we are here today to look at.
You are absolutely right that the 22,500 soldiers in the
last 6 years, none of them had been looked at. Not the 5,600
from the Army itself, or the of the stack of cases directly
presented to the Surgeon General. I think another key feature
we need to look at when we are figuring out how this happened
is to talk at a ground level how this goes from doctor to
soldier. As Specialist Town said, he like every soldier I
looked at was directly lied to by their military doctor. The
doctor would say, ``If you accept the personality disorder
discharge you will get disability pay, you will get VA medical
care, you will get to keep your signing bonus for the years
that you are too wounded to serve.'' Their final day as they
are walking out the door, their last day in uniform, they find
out none of those promises are true.
For the soldiers that further resist, those block of
soldiers all told me of an arm twisting tactic that the doctors
would use. They would say, ``Look, you know you don't have a
personality disorder, we know you don't have a personality
disorder. But if you accept this discharge we can get you out
in a few days whereas if go for medical board, it will take
about 6 months. Your unit is redeploying to Iraq and you are
wounded. Your job in Iraq is going to be to cover your friends
back. Do you really want your friends to die because you fought
for further benefits? Wouldn't it be better to forget about the
benefits and let your friends live.''
And at that point a lot of these guys say, ``Well you know,
I know I don't have a personality disorder, certainly wasn't
pre-existing as is mandated by the personality disorder
discharge. But, you know, I care about my fellow unit members.
I want them to live. Sure, I'll take it.''
Mr. Hare. I will tell you this, someone mentioned that
somebody needs to be held responsible for this. And whoever
that somebody or someone are, I hope this Committee will
thoroughly hold those people responsible. In my opinion, they
have no business, absolutely no business dealing with any of
these men and women in the military. I think this is shameful.
Absolutely shameful. And to have to sue, you know, and thank
goodness that you are doing that.
And I guess one last question, Mr. Town, and I thank you
for your service and for your bravery and for your
steadfastness. What do you think from your perspective, you
sir, what do you think this says to the people who are
currently serving? Not just to those 22,000, who is next? I
mean and to the people who are going to enlist that if
something happens they are going to try to duck it by
mislabeling you and putting the blame on you. What do you think
it says?
Mr. Town. Hopefully right now it says a lot and the
situation gets fixed. And they take it out of the regulation.
They fix the way that the veterans are receiving their
disability when they get out of service and how long it takes.
And people see then that the VA, the DoD, the government does
care about their soldiers. And I hope there is citizens out
there that are thinking about serving don't veer away from the
Army. Army was, I mean you know, I would have done 40 years in
the Army if I could. I loved it. Loved it to death. And
hopefully that doesn't discourage anybody from joining the
military or the people that are in the military right now. And
the situation can get fixed in the near future so they are
taken care of. Yes, sir?
Mr. Hare. Thank you.
Mr. Forrester. If I may, Congressman, just quickly
regarding what is at the root of the problem and so to the
question of who is to blame. I would like to take a step back
and say that I think that this is an issue that crosses
partisan lines. There is no partisan divide on this issue.
Fortunately, the DoD Mental Health Task Force which reported
out about a month ago has done a great service for this
country. And I would, I am sure that many of you have read it,
but for those who haven't I would recommend that you read it,
because in this official document of the DoD Mental Health Task
Force, they talk about the great magnitude of the mental health
problems coming out of the war. They talk about the inadequate
resources that have been devoted to treating mental health
problems within the military, the poor training that exists in
some cases. And then the pervasive stigma against treatment.
As people within the military mental health community will
tell you, the military, as we know, is part of society. And so
these are in some ways societal problems where people haven't
been well educated on the mental health needs and mental
health, proper mental health treatment as for instance, your
bill works to address some of these issues. Once again, I am
heartened by the fact that in the Senate--while Senator Obama
was quite prominent in the proposing of this amendment to have
a moratorium on PD dismissals--as we know, the letter calling
for this was signed by 31 Senators. This is a bipartisan group.
Fortunately the four offices that lead on this issue in the
Senate are Senator Christopher Bond from Missouri, Senator Joe
Lieberman from Connecticut, Senator Barbara Boxer from
California, and then Senator Obama among others. So just to
tell you, those four offices, putting those four offices
together shows that this is not a partisan issue, this is an
issue that we as a country are beginning to recognize the
magnitude and as I said, fortunately, documents such as the DoD
Mental Health Task Force, we will just call it an achievable
vision have helped to lay out the path forward.
Mr. Hare. Thank you, Mr. Chairman.
The Chairman. Thank you. Mr. Lamborn?
Mr. Lamborn. Thank you, Mr. Chairman. Mr. Kors, this is a
very important issue and I want to look at the numbers that you
are using to make sure that we are using the best numbers
possible.
You talk about 22,500 soldiers. Now I see that from your
table on page three that you are including in that number of
Army, Air Force, Navy, and Marines.
Mr. Kors. That is right. The 22,500 from the last 6 years
that spans the entire Armed Forces. You can see how this is a
problem that is crossed services lines. In the last 6 years in
just the Army, it is 5,631.
Mr. Lamborn. Okay. Now out of that those troops, how many
of them that were discharged under the Chapter for personality
disorder do you believe had PTSD?
Mr. Kors. We don't know. We don't know. Having reported on
this issue and looking at dozens of cases, all of the soldiers
either had PTSD or like in Jon's case, traumatic brain injury.
But who exactly these people are I think is precisely why we
are here today.
Mr. Lamborn. Okay. I have only got 5 minutes so I will have
to interrupt here. Now of that 22,500 I noticed that 8,000 are
Army and Marines. And 14,000 are Air Force and Navy. Now I
think you would agree with me that the brunt of the ground
combat has been the Army and Marines. Our Air Force and Navy
have done really wonderful on other things, but the brunt of
the ground combat are of those two branches of the services.
And of those 8,000, how many of them do you think had PTSD
versus pre-existing personality disorder?
Mr. Kors. I just don't know. Those figures simply don't
exist yet because no one is looking.
Mr. Lamborn. Now the 14,000 who were Air Force and Navy, do
you think that they had post traumatic stress disorder?
Mr. Kors. You know, part of the difficulty of finding out
the answers to those questions is that getting access to the
medical records for those soldiers has been locked off to the
media. It has only been soldiers like Jon Town who have bravely
stepped forward or internal people like Jeff Peskoff who
processed these personality cases----
Mr. Lamborn. Okay. Thanks.
Mr. Kors [continuing]. Come forward----
Mr. Lamborn. Okay. Thank you.
Mr. Kors [continuing]. That shares these numbers.
Mr. Lamborn. Now without seeing all of these individually,
I don't know the answer either, but is it more likely that PTSD
is associated with ground combat, even though it can probably
come from a lot of different other reasons, but is it a safe
assumption that it is more associated with ground combat and
the experiences, the traumatic experiences, suffered in ground
combat as opposed to some of the other military service
experiences?
Mr. Kors. I think that is a safe assumption. The soldiers I
looked at all had served in Iraq came back changed by that
experience.
Mr. Lamborn. And you used the years 2001 and 2002 in this
same table, but the current conflict in Iraq started in 2003.
So wouldn't it be more accurate to start it from 2003 forward?
And if you did that you would have 5,500 instead of 8,000. I
mean would that be a fair gloss to put on this number?
Mr. Kors. If you wanted to look at that segment, I mean,
that would certainly be, you know, a good approach as well.
Mr. Lamborn. Okay. Well anyway I just wanted to ask those
questions, Mr. Kors, because 22,500 tells me something
different than, you know, 5,500.
Mr. Kors. Uh huh.
Mr. Lamborn. Either way, this is a vital thing and I do
wish we were working with the Armed Services Committee on this
as well, but we are not, so we will do what we can. But thank
you all for being here today.
Mr. Kors. Thank you.
Mr. Forrester. May I quickly add, Mr. Chairman? The GAO--
there is--I am sorry Congressman Lamborn. But there is a GAO
investigation afoot that is asking the kind of questions that
you are asking right now. And we have and among others we have
been in touch with them and they have asked for input. So we
are hopeful that within the next few months they will release
their report and that they will be able to provide a lot more
information on this.
I know that one of the criteria that they are looking at is
have the regulations been followed when PD discharges have been
affected. And so once we start to get that sort of level of
detail, I am hopeful that we will have a much better
understanding of the numbers.
Mr. Lamborn. Okay. Thank you all for being here today.
Mr. Town. Thank you.
Mr. Lamborn. I yield back, Mr. Chairman.
The Chairman. Thank you, Mr. Lamborn. Let me make clear, by
the way, that we are working with the Armed Services Committee.
They just could not schedule either a Subcommittee and our Full
Committee before the August recess, and I thought it was
important for us to hear about this problem. So we are working
with them and we will continue to do that.
Mr. McNerney is next, please.
Mr. McNerney. Thank you, Mr. Chairman. First of all, I want
to thank Mr. Town and all the active duty members in the
audience and all the veterans in the audience for their
service. It is difficult to listen to what we have heard today
without feeling something is amiss here. And it is going to be
our duty to get to the bottom of that and to find out what the
proper course of treatment is.
There is something in particular that is bothering me a
little bit about the data that you have presented here Mr.
Kors, in your presentation. It looks to me like the rate of
examining or coming up with this discharge, this personality
disorder discharge, hasn't increased that much since the start
of the war.
Mr. Kors. Uh huh.
Mr. McNerney. Now that tells me that this problem or this
treatment of servicemembers has been going on for a long time
before the war started. Could you address that please?
Mr. Kors. Absolutely. I spoke with a psychiatrist who had
been looking at this personality disorder issue, you know, back
as far as the Vietnam era and said this has been a common
thing. We see this outside the military as well with insurance
problems people discovering pre-existing conditions as a way of
not paying. It is a longstanding problem.
Mr. McNerney. So the war itself hasn't been something that
has caused a large increase in this sort of treatment, is that
true?
Mr. Kors. Well, the numbers on a broad scale would say not.
I think at individual installations it is, it has. We look at
Ft. Carson where Jon Town is from. Jeff Peskoff who stepped
forward for our Night Line broadcast and talked about the
discharges there. He said that it started off normal and then
at one point he was getting two or three personality discharges
a day. Then he say the numbers sharply rise in recent years.
So how that averages out over, you know, Ft. Campbell, Ft.
Polk, all the other installations, we just don't know at this
point.
Mr. McNerney. Well it is certainly incumbent upon us to
make sure that no servicemembers are treated in an
inappropriate way. I am just trying to understand if we look at
the numbers for the Air Force, they are higher before the war
and the Navy, then they decrease, whereas, the Army--excuse
me--seems to increase. So we, as a Committee, need to look at
this pattern. If it has been continuing on since the Vietnam
war, how many of people have been mistreated like this? And if
not, what is the appropriate way to describe the situation?
Mr. Kors. Frank Ofberg, the doctor I referred to earlier
who codified post traumatic stress disorder, he said in the
olden days it was actually much worse when there was no such
thing as post traumatic stress disorder. He said at that point
you either got a false personality disorder diagnosis or
nothing. There was no alternative. At least now, some lucky few
who fight aggressively are able to reach a medical board and
get disability pay.
Mr. McNerney. Thank you, Mr. Kors.
The Chairman. Thank you, Mr. McNerney. Mr. Brown?
Mr. Brown of South Carolina. Thank you, Mr. Chairman.
Thanks for holding this hearing today. And it has just been
very informative for me and I know, and as personal note my
brother-in-law had PTSD and his last few years on Earth was not
very pleasant. And so, we understand the need for it and this
is something that we have been addressing for some time. Thank
you for coming and help sharing some of the information that
has, you know, surrounded that issue.
Mr. Sullivan, are you a veteran?
Mr. Sullivan. Yes. I am an Army veteran. I served in the
First Armor Division as a cavalry scout in the invasion of Iraq
in 1991.
Mr. Brown of South Carolina. Okay. My question is, and I
guess like Mr. McNerney, is looking at those numbers that, you
know, before the Iraqi conflict and after Iraqi conflict, is
there a good pre-screening for the enlistees that come into the
military to be sure there are no pre-existing conditions?
Mr. Sullivan. Is that addressed to me or to----
Mr. Brown of South Carolina. Yes. Yes. To you. Anybody who
wants to answer. I guess I am trying to get a handle of how the
numbers really hadn't changed very much on a yearly basis, but
before and after the conflict. And so, I am just trying to look
for some other reasoning in this questioning. So I am just
going to start with that. I have got some other follow ups on
that too.
Mr. Sullivan. Thank you, Congressman. What Veterans for
Common Sense is doing is asking for the investigation. We know
that there is a GAO investigation that started on this. Our
concern is this: Is deployment one of the factors in the
personality disorder diagnosis discharge? We are concerned that
it may be impacted at specific military installations like Ft.
Carson where it may be going up. And it may be masked by
decreases at other locations.
So, Congressman, we won't know until there has been a
thorough analysis. What that Joshua Kors has done is provide
the initial statistics to indicate that there is a problem.
What we need is some further analysis to make sure we get at
the why. And then as soon as we know that, then we can begin to
correct it.
That is why we also called for a moratorium on the
Personality disorder discharges until they can figure out what
is going on.
Mr. Brown of South Carolina. And I guess that is what
raised the question to me is that is there something in the
military lifestyle that maybe I know that the battle weariness
is certainly one of those components. But or is there something
that is in training or something that is involved in the
military that would, you know, would influence the PTSD? And I
guess that is since those numbers certainly don't seem to move
very much whether we are at war or not at war, there must be
some underlying other reasons that influence PTSD. I know you
know certainly with the Mr. Town, I can understand his. But
there are other events that must influence you know PTSD too.
And I guess that is a broader range and I don't whether Mr.
Kors whether he actually looked at that or not or whether he
was just focused, just on the those influenced by some level of
battle.
Mr. Kors. Pardon me. Whether I looked at what now?
Mr. Brown of South Carolina. The overall picture. You saw
those numbers, right? That they the numbers really have not
moved much prior to the conflict in Iraq and the years, the
last 3 years coming up to that. And I have, you know, so I
was--I am just kind of concerned that if there are some other
major issues out there in the military that would influence
causing PTSD other than just being a part of the battle
conflict.
Mr. Kors. I just can't say. And I should back up Paul's
comment by saying it is not just important to talk about the
why, but the who. Who are these, you know, 22,000 people? Who
are these 5,600 from the Army? I know the veterans groups like
Paul has expressed to me. There is a hope that not only will we
look to Obama's amendment to stop this from happening, but to
go back and look at the thousands of other Jon Towns who need
help right now.
Mr. Brown of South Carolina. And let me say, I am very
sympathetic for that. And I think we have got to address that.
But what I am more concerned with, not more concerned with, but
absolutely concerned with is, is there, if we can some how
eliminate the cause.
Mr. Forrester. Congressman, if I may? To this question of
what causes PTSD, the Mental Health Advisory Team, MHAT IV.
Well there have been four of them now. This is done by the Army
Surgeon General's office. They have done detailed studies on
what is happening in theater at present and how combat
experiences among other stresses, family stresses, combat, and
so forth, are affecting the mental health.
And this is once again a good resource that we have and
that I think will be fed into these GAO studies and others to
get a better idea of how this whole system fits together from
CONAS to theater and back. The DoD Mental Health Task Force,
when they talked about the resource problem, they talked about
a lot of the mental health resources having been surged into
the field as people would expect. So that has a left a
deficiency in the United States and a lot of the military
facilities.
And fortunately, and I know Ft. Carson has been raised a
number of times, but to take Ft. Carson, the leaders at Ft.
Carson are talking about increasing the number of mental health
providers. They know they have a mess on their hands----
Mr. Brown of South Carolina. Right.
Mr. Forrester [continuing]. And they are doing what they
can to address it. So as we all know it is a mini--a multi
faceted problem and so hopefully after more study we will have
a better idea of how it all fits together.
Mr. Brown of South Carolina. Well let me say, thank you
very much for coming and thank you Mr. Town for your
perseverance on this. And although I know that you are one of
22,000, at least you know you have been able to get your
message. And we certainly have a commitment to those other
22,000 to be sure their needs are being met too.
But I just wanted to put in there a caveat too that we
would like to be able to help solve the recurrent problem,
whatever it is in the military to be sure that those lifestyles
are being addressed that would help prevent more. I know you
had a particular incident that you can relate to, but maybe a
lot of others can't. But it is certainly a major concern. It
has been a major concern of mine since I have been on this
Committee for 7 years. And I appreciate you all's advocacy on
it.
And thank you all for being here. Thank you, Mr. Chairman.
Mr. Sullivan. Congressman Brown, if I could add one other
point. Not only is combat one of the important variables, we
also have an increase in sexual assault and rape both of women
and men, servicemen and women in theater. And that can also
play a role in the development of PTSD and someone who went to
a war zone. And sometimes someone who did go to a war zone.
Mr. Town. And, sir, I actually have a comment as well. As
far as the screening that you were asking about. I was screened
prior to coming into the military. I was screened prior to
PCSing to Korea. I was screened prior to deploying to Iraq. I
was screened when I came back from Iraq and that is when I was
diagnosed with a personality disorder.
Mr. Brown of South Carolina. So the other screening's
reflected no indication at all?
Mr. Town. Correct.
Mr. Brown of South Carolina. Okay. Thank you very much.
The Chairman. Thank you, Mr. Brown. Mr. Rodriguez?
Mr. Rodriguez. Thank you, Mr. Chairman. And first I want to
personally thank you for holding this hearing and I am glad you
didn't wait. And I am really concerned and I think that it
might even be worse because if someone is diagnosing and is
doing it for the purpose and knows full well that the purposes
are to try to just come up with then there is no doubt that
they could be doing that on other diagnoses. I know that if my
son or daughter were diagnosed in this way that I would quickly
ask for a second opinion if not a third. I am interested in the
recommendations that you have, Mr. Sullivan, and I know the
Chairman has already touched upon them, about trying to come up
with a way for our soldieries who fall under a war zone to
automatically have to go through some process of assessment so
that they won't be a--there won't be a stigma to that. And just
make it a mandatory kind of approach that that would be doing.
Does your lawsuit include the Department of Defense and the
VA or is it just the VA?
Mr. Sullivan. At this time the lawsuit, I have a copy of it
with me if you want to see it, is against the Department of
Veterans Affairs, but it also includes the Department of
Justice and some of their responsibilities.
Mr. Rodriguez. The DoD. Now you also asked, you know, and I
agree that we need to go back and reassess, not just those 22
because once again if there is a psychiatrist there that has
diagnosed them wrong, whatever other diagnosis ought to be in
question. You know and so I think that we have a more serious
situation.
I had done some studies when I taught 11 years at the
School of Social Work, and I knew that there were some
disparities and discriminatory practices as it dealt with
certain diagnosis when it came to women or African Americans
and those kind--have you picked up on any types of disparities
besides you know individuals and PTSD?
Mr. Kors. On racial or gender lines I haven't. But you make
a very strong point about the doctors themselves. I am so glad
you asked that.
As I mentioned before, Surgeon General Gale Pollock tapped
Colonel Steven Knorr, the Chief of Behavior Health at Ft.
Carson, as the one and only reviewer. And when we look at who
he is, I think that is critical. National Public Radio's Daniel
Zwerdling, an award winning reporter, wrote a fantastic recent
piece about Knorr as this key figure in this national review.
And I just want to read a small snippet of that.
``Knorr has written a memo warning commanders that trying
to save every soldier is 'A mistake.' We can't fix every
soldier, Knorr's memo states, we have to hold soldiers
accountable for their behavior. Everyone in life besides
babies, the insane, the demented and the mentally retarded has
to be held accountable for what they do in life.''
Knorr's memo, which he posted on his office's bulletin
board, also warns commanders not to make another mistake.
``Procrastination on discipline and separation, translation,
officers should get rid of troubled soldiers quickly.''
He seems a strange choice to be the one and only person to
look at these issues.
Mr. Rodriguez. And it is unfortunate. I want to personally
thank you, Mr. Town, for being here with us. I want to
personally thank you for your service to our country and for
what you are doing now, and because I know that it will have an
impact in terms of what are we going to be doing to making sure
that we do the right thing and start in that direction.
And so--yes, sir?
Mr. Forrester. If I may, very quickly add, Congressman
regarding your question about the racial and or sexual issues
within the military. At present the Wounded Warrior Bill in the
Senate has a provision calling for a comprehensive study of the
readjustment needs of this generation of servicemembers and
veterans. This amendment was unanimously approved by the Senate
Armed Services Committee about a month ago. And was also later
approved on the Floor and we are hopeful that it will make its
way to Conference eventually.
This study would get at the kind of questions that you are
asking. Let us look at our military from top to bottom. Those
people who are coming out of these wars, as we know each war
creates a unique set of needs. And so our argument is that we
should not wait a decade as we did after the Vietnam war to do
a national study of the readjustment needs of this generation
and all--and there are many diverse parts as we know.
And so I would also urge Members of this Committee to
consider this provision which there may be a House version
introduced soon as well.
Mr. Rodriguez. And I agree. And that there is also a large
number of individuals afterward that have committed suicide.
And that is something that we all need to look at. I know I
heard a personal story about a soldier that supposedly
committed suicide in Iraq, and was treated very differently
from the other soldiers that have lost their lives. And of
course the family is devastated.
And so I am still trying to get a personal assessment of
that since the parents had a discussion with the soldier the
day before, and all indications were that things were okay. So
once again, let me thank the entire panel for what you are
doing here and hopefully we will get to the bottom of it. Thank
you.
The Chairman. Thank you. Mr. Stearns. Okay. I have the list
if you want to change, that's fine. Ms. Brown-Waite?
Ms. Brown-Waite. Thank you, Mr. Chairman. There certainly,
when reading through the testimony, I didn't, Mr. Kors I have
to say I did not see the television show. But reading through
the testimony, certainly I am glad that the Chairman said that
he is working with the Armed Services Committee, because this
clearly is a Department of Defense situation.
The Chairman. Ms. Brown-Waite, if you could use the
microphone. Thank you.
Ms. Brown-Waite. Certainly. It is a Department of Defense
situation where they made that decision. But, Mr. Kors, I want
to ask you a question. I am completely diametrically opposite
to this. I had a constituent who had been diagnosed with
personality disorder. Turned 18. Went to the local recruiter
and the local recruiter said stop taking your medicine, do not
tell anyone. This very impressionable 18 year old got into the
military. Had a nervous break down. Parents and grandparents
both contacted me.
Had you the opportunity to look into this at all about
recruiters misleading those people before they join, as an
incitement to join getting them to not take their medication
because some of the recruiters are desperate. If you could
answer that.
Mr. Kors. Congresswoman, I am glad you mentioned that. Just
recently my conversation with that psychiatrist from the
prominent east coast Army facility, he talked about that
approach to recruiting soldiers, warm bodies as they call it
with the recruiting shortage that we are facing now because of
the Iraq war. He quoted his Chief of Behavior Health at the
Hospital as phrasing it this way: Regardless of what their
problems are, if they are not homicidal or suicidal, let's get
them to Iraq. If they can't function anymore, as was the case
with Jon's memory loss, let's find a way to slip them out the
side door with a pre-existing condition.
Ms. Brown-Waite. You know it is very interesting because
specifically what happened was this young man only spent out of
2\1/2\ months, he only spent 2 weeks in boot camp. The rest of
the time they were paying for him to be in a private facility.
I was talking with the brass and saying to them, I can get you
his previous mental health records. This recruiter, by the way
who only got a slap on the wrist, who really encouraged him
first of all to stop taking his medication and to virtually lie
to get into the military. I can't help but believe that this
doesn't happen more often.
And then, when he was in, it was a ``he is here and we are
going to make a man out of him. You are not getting him out.''
Well the parents went and contacted the Army. My office
contacted the Army. I spoke to his commanding officer who
basically said ``he is here, he is ours, you are not getting
him back. If he lied, he committed fraud. We will bring him up
on charges, but we are not letting him go.''
It was last summer I spent a great deal of my summer
fighting for this young man who never ever should of been
enlisted in the military. And when, you know, when this issue
goes before the Armed Services Committee, Mr. Chairman, I hope
that you will also make sure that that issue is brought up.
That is a serious problem. The one thing that I said was, ``So
you are willing to spend almost $1,000 a day to keep this young
man in a private facility, when you would not want him next to
you on the battlefield,'' because certainly the multiple mental
health issues that he had do not make him any where near fit
for the military, let alone to go into a war zone.
It was it really was--he at that point was a captured
prisoner by the U.S. Army. So I do hope that we will also look
into that situation where truly he had a personality disorder.
They had him and they were not going to let him go. So it is
180 degrees from the situation with Mr. Town.
But let me ask one other question.
Mr. Kors. Congresswoman? I just----
Ms. Brown-Waite. Yes.
Mr. Kors [continuing]. Can I address that issue? The
accusation you highlighted that the soldiers lied during their
incoming screening is, has really been, the salt in the wounds
for these disabled soldiers.
Ms. Brown-Waite. I didn't say that.
Mr. Kors. No, no. No. This is what the----
Ms. Brown-Waite. Right.
Mr. Kors. No, no, no. You meant you quoted----
Ms. Brown-Waite. Right.
Mr. Kors [continuing]. The Army officer as saying that. And
that has been a common refrain from the upper brass of the
military in ourNightline piece. Surgeon General Gal Pollock's
top psychiatric official Ellsbeth Richey quoted that accusation
as really the only understanding of how these soldiers with the
severe psychological pre-condition could get into the military,
they simply didn't cough up the information during their
initial screening.
Ms. Brown-Waite. One other question, Mr. Chairman, if you
will indulge me. I also have heard from some in the mental
health community who are treating veterans with PTSD who are
telling me that in an effort to save some money, that the VA
has gone to a 13-session PTSD module. And it really is a module
of treatment that is meant for a sexual abuse or a rape victim.
Have you at all, anybody on the panel, also been aware of that
phenomena?
Mr. Kors. No.
Ms. Brown-Waite. Okay.
Mr. Forrester. No, ma'am.
Ms. Brown-Waite. Mr. Chairman, I yield back the balance of
my time.
The Chairman. Thank you. Ms. Herseth Sandlin?
Ms. Herseth Sandlin. Thank you, Mr. Chairman. And I too
want to thank you for this very important hearing and thank
each of our witnesses today for their very unique and important
roles in bringing attention to this very serious matter. And I
have a few statements that I think are necessary for the record
before posing some questions based on the discussion that has
already taken place. And I look forward to the further analysis
that will be provided so that we can better identify how we
target our manner of addressing this problem. I, for one, don't
need any further evidence or analysis that this a problem. And
if we want to focus on the numbers that is fine, but the fact
that we have one individual and Mr. Town who was treated this
way, whether it is 22,000 or 5,500; whether it is just from the
Army and Marines or the Air Force and the Navy, which we should
all acknowledge the Air Force and the Navy have contributed a
number of servicemembers who have been in ground combat. So
making these distinctions among the branches, making
distinctions about what years we are talking about, whether we
start with 2001 or 2003, I don't need any further evidence. And
part of it is because we have to take this issue in the broader
context of what we have been dealing with in the last few years
that this is additional evidence that we were not prepared to
take care of another new generation of veterans.
So we can talk about making distinctions about years and
about numbers and about branches, but I think we have enough
evidence already to say that this is a problem. And the further
analysis will shed light on how we best address effectively
solving the problem. I also think that there has been important
testimony here today about the broader context of society at
large and hopefully we will make some important progress there
by passing Congressman Patrick Kennedy's bill on mental health
parity so that this problem can be addressed, not just in the
military, not just in DoD installations and the VA facilities,
but in the private insurance industry, in our public health
programs, and the values issue of how we take care of one
another.
I think it speaks volumes that the Surgeon General isn't
here today despite the invitation to join us. Mr. Town, I can
understand why the psychiatrist that you met with at the VA was
in tears after about 25 minutes. When you re-enlisted in Iraq,
was that after the explosion in October of 2004?
Mr. Town. It was before the explosion.
Ms. Herseth Sandlin. And all of the prior screenings that
you described, was there any screening once you were in Iraq,
either prior to re-enlistment or after re-enlistment?
Mr. Town. They had a screening 2 months after we got to
Iraq. I can't be--I can't remember what it was about, but they
had a screening for medical issues at that time.
Ms. Herseth Sandlin. Okay. And I think that either you
testified or Mr. Kors you did, in addition to being diagnosed
with PTSD, Mr. Town, have you also been diagnosed with
traumatic brain injury?
Mr. Town. Yes, ma'am.
Ms. Herseth Sandlin. When you met with the doctor at Ft.
Carson, and either you can answer this or others on the panel,
if there were concerns that the doctor, the psychiatrist, at
Ft. Carson had about the symptoms that you were exhibiting even
though there was no diagnosis there of PTSD, but there was
clearly a concern on his part about redeploying you. Were there
any other options other than the personality disorder to
prevent Mr. Town's redeployment?
Mr. Town. Soldiers can go through a medical board. And it
is a little lengthy process, but you go in front of a board of
medical doctors and they listen to your case. And they make a
decision if you are not fit for duty or fit for duty at that
time.
Ms. Herseth Sandlin. And thank you for explaining that and
I know that is a lengthier process, but there is no other
option for a treating psychiatrist other than the personality
disorder or the medical board process to prevent a redeployment
in the--in the case of a servicemember who is clearly suffering
from the affects of prior ground combat for PTSD? Is there any
other----
Mr. Sullivan. Well what I hear you asking for,
Congresswoman, is there a second opinion? And the answer is I
am not aware that there is. And one of the biggest problems
facing soldiers unlike Specialist Town is that they have no
advocate. It is a denial of their civil rights. It is a denial
of their dignity as a human being, and an American soldier that
they be provided with some assistance before being discharged
for a medical reason, especially if it involves a brain injury
that is clearly documented or a mental health condition.
Denying the soldier basic due process is unconscionable
after they have been wounded. And if I may give this analogy:
How many people here would agree that if I was in a car wreck,
that the attorney of the person who ran into me, and it was
their fault of course, was at my bedside in the hospital asking
me to sign paperwork on a settlement. We know that that is
absolutely unethical. And what is happening in these situations
because the soldiers don't have advocates, they are losing out
on the due process. That needs to be fixed. Not only for the
service, but also at VA.
Ms. Herseth Sandlin. Thank you, Mr. Sullivan. Mr. Chairman,
if I might ask one quick follow up question?
The Chairman. Please.
Ms. Herseth Sandlin. Mr. Town, or Mr. Kors I know you are
very familiar with Mr. Town's case. Did you--you said that you
filed five different times with the VA before they would
actually review your case?
Mr. Town. Yes, ma'am. I filed one a month prior to me
getting out of service. One 2 months after and a month in
between the next three. And the last one I filed was a month
prior to the article being written in The Nation by Joshua. And
that is when I got the call from VA that said, ``Hey, we have
caught wind of--we want you to come down to Dayton as soon as
possible.''
Ms. Herseth Sandlin. Thank you all. Thank you, Mr.
Chairman.
Mr. Kors. I followed up with the VA on exactly how that
happened. Their--the VA's explanation was pretty simple. They
said, ``We lost it.'' We lost each of those five submissions.
The Chairman. Thank you Ms. Herseth Sandlin. I ask
unanimous consent to allow our colleague Congressman Patrick
Kennedy to sit with us. He has been a leader on issues of
mental health. Thank you for joining us. Hearing no objection.
Ms. Brown, if you have one question before you have to go?
Ms. Brown of Florida. Yes. Thank you. Thank you, Mr.
Chairman for holding this hearing. And first of all let me
thank Mr. Town for your service. Thank you very much. And I do
have a question for you, but let me just say to Mr. Kors, it is
important to see the media at the forefront of government. And
when they don't do their job, this is the result, we have a
failure in the system.
I always know it is more than one side, but we have to get
it out there. And all of us know the amount of casework for
veterans we do in our offices, when the system is giving them
the run around. And we, you know the Members of Congress, we
stop it for individual veterans, but the system needs to be
fixed.
Let me say, Mr. Town, I have a question for you. Later we
are going to hear from Colonel Crow and in his testimony he
states that, ``Before separation soldiers have the opportunity
to consult with an attorney.'' And they are told about their
abilities to petition the Army Discharge Review Board or the
Army Board of Correction or Military Records for Administrative
Review of their cases. Did this happen with you, sir?
Mr. Town. I did go see the Judge Advocate General (JAG).
The process is as you go see JAG with your non-commissioned
officer (NCO) or the person in command of you. You go over
there, they say that you need to sign this paper, this paper,
this paper and they give you a paper. I actually do not have
that with me, but I will have to get that document. And it said
what I was suppose to get when I left the Army with this
personality disorder discharge. And it had, you know, the
severance pay, benefits, and free, you know, the free burial. A
whole of list, a whole page and a half of stuff. And of course
that was all lies and that was given to me by JAG there at Ft.
Carson.
Ms. Brown of Florida. Okay.
Mr. Kors. Congresswoman? The----
Ms. Brown of Florida. Yes?
Mr. Kors [continuing]. Army Board of Military Correction of
Records is an interesting organization I looked into. And in
the past year, all the cases that I reviewed, only one was
overturned in through that Board. That was the case of William
Woldridge who began suffering schizophrenic delusions after he
accidentally ran over a young Iraqi girl who was pushed into
the road. He was hauling a supply truck and she was killed. She
was about the age of his young daughter. And later in his
apartment in Arkansas, he was haunted by the mangled ghost of
that girl.
That condition was seen as the result of a pre-existing
personality disorder and he fought it through the Army Board of
Correction of Records. That case was pretty clear, not just
because of the facts of the case, but also because the only
reason it was overturned was because he had a top connection in
Washington who worked behind the scenes at the Board to create
that overturn.
Ms. Brown of Florida. Thank you. And thank you, Mr.
Chairman.
The Chairman. Mr. Stearns?
Mr. Stearns. Yeah. Thank you, Mr. Chairman and I thank you
for holding this hearing. I am a little more optimistic than
the gentle lady from South Dakota when she said the VA is not
prepared to take care of another generation of veterans. I
think with the money and resources that we have provided them,
I think they are working admirably to do that. There is going
to be cases like this and this is reprehensible what happened
to Mr. Town. But I think when that the VA is working diligently
and I think this case is an example where there needs to be
improvement. Obviously, this Committee doesn't have the full
jurisdiction. The jurisdiction is in the Department of Defense
and that is where the hearing should be. But we welcome the
opportunity to talk about this.
Mr. Kors, you keep mentioning the 22,000 and Mr. Lamborn
brought out that the 22,000 is included in that number is not
even when the Iraq war had started in 2003. And he pointed out
that roughly only 5,500 were actually Army/Marine combat
veterans. Of the 22,000, do you know how many were combat
veterans who actually served in combat?
Mr. Kors. No. And that is another key point as well.
Mr. Stearns. Right.
Mr. Kors. Bob Woodruff and I asked that question to Colonel
Ellsbeth Richey in our Nightline report and she didn't know
either.
Mr. Stearns. Do you think that is a relevant point?
Mr. Kors. I think it is. And I think a full review that
hopefully could come from a hearing like this----
Mr. Stearns. Yeah.
Mr. Kors [continuing]. Will determine just how many of
those thousands of soldiers served in Iraq.
Mr. Stearns. Colonel Bruce Crow who is coming later in this
panel, has talked a little bit about statistics and he gave,
for example, about 70,000 soldiers were discharged from the
active Army, just the Army, in 2006. Of those discharged
roughly 1,100 were separated for personality disorder of which
roughly 300 of those individuals had served in a theater of
combat. To the uniform civilian and contract healthcare
professionals that care for soldiers, the thought of even one
soldier being inappropriately discharged for personality
disorder is disturbing.
So I mean, that really explains how the Veterans
Administration feels too. With that in mind, in fact, the
acting Surgeon General, Major General Gale Pollock, has
directed each and every one of these 300 records be reviewed by
behavior health professionals to verify that appropriate
actions were taken and that all health concerns were considered
in the discharge.
So I think the VA is well aware of this problem, and is
trying to make efforts. Mr. Kors, I think in your statement,
your opening statement, you indicated that perhaps the
Secretary of Veterans Affairs had to step down and you linked
it with Walter Reed--when you mentioned that in your previous
sentence--and the Surgeon General Kiley resigning also. I don't
think it is fair to say that Senator Nicholson stepped down
because of the personality disorder discharges.
Mr. Kors. No. No. I certainly didn't mean it----
Mr. Stearns. But your statement here implies it and I think
you are inappropriate to indicate that in the same sentence
when you talk about these other people resigning.
The Chairman. Did you say Senator Nicholson?
Mr. Stearns. Secretary Nicholson.
The Chairman. Thank you.
Mr. Stearns. Thank you for the correction. Yeah.
The Chairman. We were wondering why----
Mr. Stearns. Right. Right. No. So I just if you would like
in open testimony to say that is not what you implied, that
would be appreciated.
Mr. Kors. I don't think that the fallout from the publicity
on this issue was certainly helpful to him, but I did not mean
to make a one-to-one correlation.
Mr. Stearns. Right. And I didn't think you did, so I wanted
to make sure that you had that opportunity to disclaim that.
Mr. Sullivan, when you made your suit, did you contact any
VSOs to say here's the evidence, the American Legion, or any of
the VSOs to say, what do you think? Just yes or no.
Mr. Sullivan. I would direct that question to the attorney
handling the suit, Gorden Erspamer at Morrison and Foerster in
San Francisco.
Mr. Stearns. Well aren't you the one that--you are the
executive director of the Veterans for Common Sense. You are
making the suit, is that correct?
Mr. Sullivan. Yes. That is--I am not making it on my own
behalf, the organization is.
Mr. Stearns. Yeah, the organization. And you are the
executive director, so you are what we call the talking head
for the group. And with that in mind, did you ever call any
VSO? Did you ever contact the American Legion about this suit
or the Veterans of Foreign Wars or anybody?
Mr. Sullivan. Again, Congressman----
Mr. Stearns. If not, I am curious----
Mr. Sullivan [continuing]. I already answered the question.
If you want to ask that, you can ask the lead attorney on the
case. Thank you.
Mr. Stearns. Well I think the lead attorney would be a good
one to contact, but he takes his directions, I think, from the
organization that is making the suit, which is the Veterans for
Common Sense. So I just think that for the suit to have to be
extremely valid, should also encompass some of these VSOs and
their opinions, I would say.
Let me ask the last question. In reading the lawsuit you
filed in Federal Court, Mr. Sullivan, it is unclear to me what
you expected the court to do. Were you looking for an
injunction of some kind or something else? What do you--what
does your organization ultimately expect to happen?
Mr. Sullivan. Thank you for asking the salient question,
Congressman. The bottom line goal of the suit as described in
it is very simple. If a servicemember goes to war and they come
back wounded, injured, ill, and they need medical care, the
country has an obligation, social contract, to provide that
care. They don't, the veteran should not have to file 23-page
claim form. The veteran should not have to wait endlessly for
Health Maintenance Organization (HMO) like decisions. The
veteran should be able to see the doctor right away. We are
very familiar with the case of the veteran Jonathon Shulzy in
Minnesota who tried to go VA multiple times and was turned
away. A very disturbing case. That shouldn't happen.
In a similar manner, the suit is looking to fix this other
question. If a veteran is disabled and has difficulty working
or having problems with the quality of their life and they need
disability benefits, again the veteran shouldn't have to wade
through endless paperwork by themselves to try to get a
reasonable disability check so that they can put food on the
table for their family, pay their rent, and make sure they
don't go bankrupt or get foreclosed. It is a very solemn
obligation our country has with that veteran. And we want to
make sure that the veterans have their civil rights protected
as individuals, that they get the due process that they earned.
For example, having an attorney when they initially file a
claim so that when they want to be able to get the healthcare
and benefits they earned, they don't have to wait.
These are basic, common sense, human dignity issues. And we
can talk about numbers, Congressmen, or who is on the suit or
who is not. The court issue right now that the backlog of
claims is soaring. It is taking longer for veterans to get
their disability checks. Veterans are being turned away because
some VA facilities don't have mental healthcare. And that is
according to VA's own top officials.
Those two things need to be fixed, Congressman. We went
through some of this with the gulf war where veterans were
coming back and if we had problems trying to get care. And I
remember working at VA and when I saw the numbers coming in on
mental healthcare and some other disabilities, I used facts and
numbers and what I thought was very thorough analysis to send
up a red warning flag that the crisis had hit VA. And
unfortunately VA did not ramp up in 2004, in 2005. And we are
suffering the consequences now for the failure to act earlier.
The suit will have the purpose of not allowing addressing
this issue in court, which every American has the right to do,
but the suit will also raise the issue in the court of public
opinion, because at the end of the day, the people run the
country. And if they start call their Congressmen and their
Senators and saying, ``Lets make sure that veteran gets his
healthcare. Lets make sure that veteran gets his disability
benefit.'' Then we also served another purpose. And that is
what I hope we can do what we can do with the suit.
Mr. Stearns. Thank you, Mr. Chairman.
Mr. Kennedy. If I could speak out of order. I believe this
lawsuit is a catalyst to get the VA to work with community
mental health providers to get the necessary mental health to
our veterans yesterday and today that they can't postpone any
longer. The VA is not at capacity right now. As you know, this
Congress appropriated $500 million in last year's supplemental
for mental health that the VA was not able to expend because it
didn't have the mental health professionals to hire.
The reason they couldn't hire them is that they weren't out
there. They shouldn't be hiring them, they should be
contracting out with existing mental health providers already
in the community. But guess what? The VA doesn't want to
contract out because the VA wants to keep everything in-house
because they are so insular. Because no one wants to share
their turf. And who is suffering because of this turf battle
but the veterans. And I hope as a member of the Milcon VA
Appropriations Subcommittee, that in the conference, that we
get to put this Committee's authorizing language allowing for
the VA to share resources with outside mental health providers
into the Milcon VA Appropriations Conference Committee Report
so that we can force the VA to contract with outside mental
health providers, in this Conference Committee Report that will
be coming up.
And I thank you, Mr. Sullivan, for instigating this
lawsuit.
Mr. Buyer. Will the gentleman yield?
Mr. Kennedy. Yes. Be happy to yield.
Mr. Buyer. Mr. Kennedy, I will work with you and I work
with Mr. Michaud. Before you came in, that was Mr. Michaud's
point in particular to try to be persuasive to the VA to do
more contracting of care. It shouldn't just for mental health,
but for many other types of rehabilitative----
Mr. Kennedy. Absolutely.
Mr. Buyer [continuing]. Services and I will work with the
gentleman.
Mr. Kennedy. Absolutely. Thank you.
The Chairman. Thank you, Mr. Kennedy and thank you for your
leadership on this.
Mr. Baker.
Mr. Baker. Thank you, Mr. Chairman.
The Chairman. We just had--Mr. Donnelly is next. And then
you.
Mr. Donnelly. Thank you, Mr. Chairman. And thank you Mr.
Town for your service and to all the veterans here.
I wanted to ask you, Mr. Town, you were diagnosed with
traumatic brain injury, is that correct?
Mr. Town. Correct.
Mr. Donnelly. When you were leaving the service, what
options did they tell you you had in regards to treatment for
your traumatic brain injury?
Mr. Town. Dr. Wexler, the psychiatrist that I was going to,
he stated that when I got out the VA would take care of me.
Mr. Donnelly. Did he tell you that there were specific VA
centers that specialized in traumatic brain injury?
Mr. Town. No.
Mr. Donnelly. Okay. Did they ever indicate to you while you
were still on active duty that you had an option to go to
places like the Chicago Rehabilitation Institute?
Mr. Town. No.
Mr. Donnelly. It was pretty much just said the VA can work
with you and good luck?
Mr. Town. Pretty much. Yes, sir.
Mr. Donnelly. Secondly, when did you first see the terms of
your termination? You indicated that you worked with JAG. When
did they first start to tell you, ``Here are the terms that you
will go out under.''
Mr. Town. When I saw JAG they showed me the terms of the
benefits that I was going to receive when I left the service,
but the day I actually left the service is when I found out
what the real benefits were and that it was a pre-existing
condition. That was the first time I ever found out that is was
a pre-existing condition to me being in the military, thus
meaning it is not service connected.
Mr. Donnelly. Did you have a copy of what they had
previously promised you?
Mr. Town. Yes. I have a copy, not with me. I have to get
that out. I will get that.
Mr. Donnelly. And at the time you were leaving the service
did you say, ``Hey, listen, I have got a whole different plan
here that was promised to me.''
Mr. Town. Yes, sir.
Mr. Donnelly. And their response was?
Mr. Town. That they didn't have a responce. The gentleman
who does the final out has actually come forth and done
interviews now. And the day I was signing out he actually gave
me IAVA's card and said that they had been doing this injustice
by what they were doing to the veterans that are getting out of
the service. And suggested that I call IAVA and talk to them
and see what I could do about this situation.
Mr. Donnelly. So the gentleman signing you out at the time
he was signing you out basically told you that you were getting
a raw deal?
Mr. Town. Yes, sir.
Mr. Donnelly. Okay. And you showed him and you said,
``Listen, I have been promised other terms.'' He said those
terms are no longer applicable?
Mr. Town. Correct. And then he showed me the paperwork that
said I had a re-enlistment bonus that I needed to pay back.
They were going to only let me sell back 30 days of my leave
and all that was going to go to my debt. And then I still owed
$3,000 to the military.
Mr. Donnelly. And when you were first told about the terms
that were so different from the final terms, did they give you
any documents to sign off at, at that time, or how long before
your final departure did you finally get the documents that
said, ``These are the final terms. Sign here.''
Mr. Town. That day.
Mr. Donnelly. No 24-hour buyer's remorse?
Mr. Town. No. It was that day.
Mr. Donnelly. Okay. Again, thank you very much for your
service and to all of you for being here today.
Mr. Town. Thank you, sir.
The Chairman. Thank you, Mr. Donnelly. Mr. Baker?
Mr. Baker. Thank you, Mr. Chairman. First, just a brief
report to the Ranking Member and Chairman and we still don't
have a decision on the VA hospital replacement in New Orleans
between the State and the VA. Just want to keep the Chairman's
attention on that matter.
Having said that, let me express deep concern for the
reports of the mistreatment and negligent behavior that appears
to have occurred on significant number of occasions. I do not
believe one case is an acceptable outcome that results in
someone's claims not being adequately met. But I do think it
important to balance the hearing record to some extent in
recognizing at least for the VA, the Committee has
responsibility for that enterprise only in this matter. That it
is an entity made up of significantly higher number of veterans
being employed, almost 33 percent. There is about 220,000
employees. That means within the walls of that agency
describing it nationally, there are in excess of 72,000
veterans. I cannot imagine anyone who is more dedicated to the
adequate and fair treatment of veterans than veterans.
Of the residual number of employees, many an excessive
number, are lifetime people committed to serving the military
veterans of this Nation. I would not want us to leave the
hearing today and have the words in part of the written
testimony the unconscionable, outrageous, intentional actions
taken by the Department of Veterans Affairs to prevent Iraq and
Afghanistan war veterans from receiving prompt care and
disability compensation to be the only statement with regard to
the performance of this agency.
Reading from one of the witnesses own comments citing as of
June 2007, 202,000 Iraq and Afghan war veterans have made
disability claims. As of June 2007, 157,00 had been satisfied.
That is a 77-percent rate of those who have applied, have
gotten some resolution. So I say on behalf of the decent people
trying to do the right thing with perhaps limited resources,
yeah, we don't get it right all the time, but I am not willing
to throw them all out on the street and say they are all a
bunch of thugs trying to beat people out of their just due.
I am here simply to say lets move in a measured pace; lets
find out those who have acted in an unprofessional and
irresponsible manner; lets provide the consequences for that
conduct, but not at the same time disregard the service of
those who have put their own life on the line and who are now
serving within the agency at a number in excess of 72,000
people.
I yield back.
The Chairman. Thank you, Mr. Baker. Mr. Hall?
Mr. Hall. Thank you, Mr. Chairman. And thank you, Mr. Town
and the rest of our panel for your presence and your testimony
and your service.
I would point out to my colleague, Mr. Baker, at 77 percent
a rate of applicants who are satisfied with the result is good,
but not necessarily in most schools considered excellent. And I
would hope that when it comes time this September for bonuses
to be given to those in the top brass of the VA, that they will
be given for excellent performance, not just merely for passing
performance.
I have a couple of stories to relate for my district. Last
night, there was a hearing of the CARES (Capital Asset
Realignment for Enhanced Services) Commission at the Montrose
New York VA Center. And I just asked my district director, has
sent me a report, because I of course couldn't be there. And
she said there was a lot of anger from vets as to how they are
being treated by the VA and the process. They feel a decision
has already been made to move service and sell off the land
despite all their testimony and opposition. This is a facility
in Westchester County, the most affluent county in New York;
the most affluent county in my district; one of I think five of
the most affluent counties in the country where there is a
homeless population made up about 23 percent of veterans on the
street.
And the facilities that they are planning to close and
possibly we understand sell off to private, you know, condos or
townhomes along the Hudson River. It is beautiful. You can see
why a developer would want to acquire this property. It is
currently treating psychiatric cases and PTSD and my belief and
that of the veterans in my district is that the taxpayer of
this country paid for these facilities to take care of veterans
that we are just beginning now to understand the gravity and
the size of the problem that we are going to be dealing with
returning veterans from the Iraq and Afghanistan wars.
We are hearing stories of diplomats having PTSD. Of truck
drivers for contractors having PTSD. Of families and children
having PTSD because of the repeated stress, the repeated
deployments and seeing on the news explosions and burning and
bodies and not knowing if it is their daddy. When you are a
child, it is much easier to be affected severely by these
things than when you are a supposedly rational adult.
I also wanted to mention the case, one of many like all of
us who we deal with veterans cases in our districts, and we
recently had a soldier who had just left the service and become
a VA client, Alex Lazos who was being kept in a VA hospital for
extended time for treatment and was about to be released. He
had witnessed the death of an Iraqi girl in the cross fire,
held her while she died. And then came back here and was having
nightmares and was being told that he was okay. And that he was
not eligible for classification. And he was given a zero
rating. And called our office. He shouldn't have to call his
Congressman, but he did and I am glad that the people in my
office were capable and got him a 100 percent rating. And he is
now getting the treatment that he needs and the medical and
psychiatric treatment and also the disability compensation that
he needs while he puts his life back together.
And, you know, we are talking about people, we are talking
about the on-going impact and expense of a war which was a war
of choice. And the longer we stay in this war the more
expensive it is going to be in both human and financial terms.
I am curious to get to questions about, and maybe Mr.
Sullivan you might know this or other panel members, how many
of the soldiers are released so far and since 2001 or 2003,
whatever the average is, with other than honorable discharges?
Mr. Sullivan. Congressman, we have requested that
information under the Freedom of Information Act. However, we
have not received a full response. I do believe there is
pending legislation, H.R. 1354 in the House, and in the Senate
it is S. 117. It recognizes and honors the former Ranking
Member of the Committee, Congressman Lane Evans. And it calls
for a thorough set of data to be gathered by VA military. And
it calls for extensive reports on the financial and human cost
of the war. And of the things----
Mr. Hall. Okay. And I----
Mr. Sullivan [continuing]. That that bill calls for is
information on the types of discharges.
Mr. Hall. Thank you. My time is running out so I just
wanted to, I am sorry to interrupt you, but noting that I
believe it is Mr. Forrester's testimony said that 49 percent of
Guard members, 38 percent of soldiers, and 31 percent of
Marines are experiencing some mental health issues after
serving in OIF/OEF. After the Vietnam War, it turned out to be
in some cases years, decades even, before soldiers came forward
and were diagnosed with PTSD.
So I would guess that those numbers are going to go up. And
I, too, would associate myself with the comments of the Ranking
Member and Mr. Kennedy and Mr. Michaud and I believe the
Chairman and others who will hope to use private resources that
are available and that are coming forward and offering to help
so that we can make sure that our veterans get help in the
timely fashion that they deserve.
I yield back, Mr. Chairman. Thank you.
Mr. Kors. Congressman? If I could address the story you
told about your constituent, it was very sad about the soldier
who was denied, as you were remarking, after watching that
child die. It was stories like that, that we came across in our
year of reporting that was a tip off to myself and to the Army
Times and to other journalist who have looked into this
personality disorder issue. That there were questions of
leadership here. Not just with Surgeon General Pollock, but
down the line. I think about the review of personality disorder
cases at Ft. Carson. When this story broke they went back, they
said, and did a review of 56 more personality disorder cases at
Ft. Carson. Again, in which nobody, not even the soldiers
themselves were interviewed. They determined all of those cases
to be properly diagnosed, but they noted to me that they could
only find 52 of the cases. I asked the leaders at Ft. Carson
how they knew the other four were properly diagnosed when they
had lost or misplaced them. And they said they couldn't answer
that question.
The Chairman. Thank you, Mr. Hall. Mr. Buyer?
Mr. Buyer. I am neither a doctor of psychology nor of a
psychiatrist and I look forward to the testimony of Dr.
Kilpatrick and Dr. Satel.
Let me ask this question: To our reporter, I found this
very interesting, but I just can't ever remember a reporter
testifying before Congress and sitting on a first panel. Very
peculiar. Is personality disorder a recognized clinical
diagnosis?
Mr. Kors. Yes, Congressman, it is.
Mr. Buyer. Yeah. In your statement you said recruits who
had a severe pre-existing condition, like a personality
disorder, do not pass the rigorous screening process. What is
that? What is a rigorous screening process?
Mr. Kors. Well, I think Mr. Sullivan----
Mr. Buyer. No, I am asking you. What is you said that
recruits----
Mr. Kors. Uh huh.
Mr. Buyer [continuing]. Who have a pre-existing condition
like a personality disorder do not pass the rigorous screening
process.
Mr. Kors. Uh huh.
Mr. Buyer. What is the rigorous screening process?
Mr. Kors. Soldiers coming into the Army undergo a rigorous
physical and psychological screening process. Precisely what
tests are done in that screening, I think that is something
that others in the panel could better answer.
Mr. Buyer. Did you, have you served in the military?
Mr. Kors. No, sir.
Mr. Buyer. Do you know what you are talking about when you
say a rigorous screening process? What are you talking about?
Mr. Kors. Well the doctors I spoke to and the soldiers and
the veterans leaders all describe that initial screening as
rigorous. And went over precisely how they were screened.
Mr. Buyer. You give an emphatic conclusory statement.
``Recruits who have a severe pre-existing condition like
personality disorder do not pass the rigorous screening process
and are not accepted into the Army.'' That is a black and white
conclusive statement. Yet, you have no personal experience nor
you can give this Committee testimony about what a rigorous
screening process is.
Mr. Kors. Congressman----
Mr. Buyer. I--no.
Mr. Kors [continuing]. I don't think there is anybody in
this room----
Mr. Buyer. I am going to----
Mr. Kors [continuing]. Who would argue with the fact that
the Army's screening process is rigorous.
Mr. Buyer. Basic training is a matriculation process of
militarization. Is that what you are referring to as a rigorous
screening process? I don't know what you are referring to.
Mr. Kors. The process you underwent----
Mr. Buyer. No, no. I am asking the reporter. You can't
reach for a life-line. You give an emphatic statement to this
Committee. I just want to know what you are relying on. So you
are not relying upon any personal experience, nor can you
explain to this Committee what a rigorous screening process is.
I will just go to the next question. Let me go to, you give
this statement, ``Commanders pressuring doctors for
diagnosis.'' Who? What and where? What commander pressured
doctors for diagnoses? What commander pressured a doctor? Where
did that occur? When did it occur? Who is the commander and
what was the doctors name?
Mr. Kors. Congressman, I am not at liberty to reveal their
name. A lot of these people who came forward were extremely
scared that their careers were at stake. I have been asked in
most cases to keep them in the background.
Mr. Buyer. So you make an allegation to this Committee
about commanders pressuring doctors for diagnoses, but you will
not give the name of a commander; you will not give the name of
a doctor and you have no factual basis then to submit to the
Committee?
Mr. Kors. I----
Mr. Buyer. I will ask the next one.
Mr. Kors. I don't think----
Mr. Buyer. ``Every person who lied about the personality
disorders discharge. Every person has lied about the
personality disorder discharge benefits.'' That is your quote.
Who? Who lied? What person lied to an individual? Tell me the
person's name, when and where did it occur? Help this
Committee.
Mr. Kors. You are talking about the doctors.
Mr. Buyer. You are saying every person lied about
personality disorder discharge benefits. What doctor did that?
Give me a name.
Mr. Kors. I will, but first let me just go back and----
Mr. Buyer. No. Give me a name with regard to this question.
What doctor lied about this?
Mr. Kors. Congressman, I would like to answer your
questions.
Mr. Buyer. Please----
Mr. Kors. I would like to answer your question.
Mr. Buyer. All right.
Mr. Kors. I think every journalist relies on those who
speak off the record. I don't think I could do a story like----
Mr. Buyer. All right. So I am not going to get an answer
from you then.
Mr. Kors. I don't think we could do a story--no, I will.
Mr. Buyer. Let me ask this one:
Mr. Kors. Doctor Mark----
Mr. Buyer. An example of a doctor presenting--yes, you also
said you gave examples of doctors presenting persuasive
scenarios to why a soldier should accept a personality
discharge. You are not going to give that doctor's name either
I suppose?
Mr. Kors. I certainly will.
Mr. Buyer. So you answered a northeast fort clinical----
The Chairman. Mr. Buyer, he said he would answer the
question. So give him a chance to answer the question.
Mr. Kors. I will give the doctor----
Mr. Buyer. Hold on just a second. Hold on. Let me get in
the last one and then you can go.
Mr. Kors. All right.
Mr. Buyer. You also mentioned a northeast fort clinical
chief, ``. . . get them to Iraq or find a pre-existing
condition.'' So also tell me what is the name of that Fort and
who is the clinical chief?
Mr. Kors. Again, I am not going to volunteer his name or
his location. But you asked about----
Mr. Buyer. Well then let me just say this, Mr. Chairman,
what is really challenging when we have a reporter testify
before a Committee is that the reporter then gets to speak, use
this type of syllogism to a Committee. They get to speak in
generalities as the major premise and we don't know with regard
to the credibility or embellishments. As a minor premise they
get to use innuendo and the results then at times can be
reckless indictments.
The Chairman. It sounds very much like a Congressman I know
too.
Mr. Buyer. That is very challenging. Well the mirror looks
pretty good.
[Applause.]
Mr. Buyer. Well, Mr. Chairman, then the mirror looked
pretty good this morning to you.
Let me just say this: I am just saying I have a challenge
here because we have a reality. The reality is what disturbs me
the most is not the fact that there are individuals who may be
diagnosed with a pre-existing condition. What bothers me is
that, if the individual wasn't discovered somewhere along the
process when they go to war, then they come back with problems,
and with the next panel we will be able to get with the actual
doctors, that is what is most important here. These doctors,
because what is bothersome to me as a soldier is, once that
person goes to a war zone and they come back, we shouldn't be
saying that this was a pre-existing condition.
But I am not a doctor. But I am just saying that bothers me
immensely.
The Chairman. Thank you.
Mr. Buyer. With that I yield back.
Mr. Kors. Mr. Chairman? If you give me 30 seconds to answer
his question----
The Chairman. Please.
Mr. Kors [continuing]. I would be happy to do that.
Let's divide this into two sections. No amount of pressure
you put on me will move me to reveal my off-the-record
anonymous sources. That is not going to happen.
Second, you asked for a name of a doctor. I would be happy
to volunteer one that came up repeatedly in my reporting. Dr.
Mark Wexler at Fort Carson, he was Specialist Town's doctor and
several others. And I know the group, Veterans of America,
represented here also encountered many cases with him also
encountered many cases with him. If you are really interested
in specific cases with Dr. Mark Wexler named here in this
Committee, I am sure Jon will be happy to tell you precisely
how that one specific doctor behaved.
The Chairman. Thank you. We are going to have to recess in
a few minutes for votes. I was going to again thank the panel
and say how chilling your testimony was, how compelling.
Specialist Town, your description of having to sell back leave
to make up for your bill is just absolutely disgraceful, just
disgraceful. We have put you in a war where you were brain
injured. We tried to diagnose you to avoid any later cost for
benefits and for treatment and then we give you a bill for the
privilege of all of that. That was very chilling.
What is even more chilling is the questioning by the
Ranking Member. We have a problem here. Everybody, almost
everybody said whatever the numbers are, whatever--we have a
problem here. Nobody was questioning, I would say to Mr. Baker,
nobody was questioning the commitment of people either in the
VA or the military. But the system is leading to this
situation. The system is leading to this. No matter how good
the individuals are, how committed--I have been told by a
doctor, Mr. Buyer, and I am not going to reveal his name here
because he thought he would be fired, that he was told by his
commanders to diagnose people with PTSD and get them out. I
asked him to testify. He was fearful of that.
So we don't have to go beyond what we have here, as Ms.
Herseth Sandlin said. We have the evidence right here. It is
incumbent upon us to act and to act very quickly and that is
why I called this hearing even though we have joint
responsibility here. We have people like Specialist Town who
are suffering because they served their Nation. That should not
be, that should not be an option for this Nation.
And we thank you for being here. You are going to help us
correct this. We are going to work on this system and we are
going to make sure that those who serve, that we have repaid
them with the care and the honor and the dignity that they
deserve.
We will recess. I will--this panel can be dismissed. We
will go into panel two when we return from the votes.
[Recess.]
The Chairman. I apologize for the intermission. We just
can't avoid it.
Panel two, you have also had the advantage of listening of
panel one, so I hope that you can take that testimony into
account in your oral testimony. Your written statement will be
made a part of the record.
Professor Shea is an expert, I am told, in distinguishing
between personality disorder and PTSD. And I hope we can hear
from you, Dr. Shea.
Dr. Shea. Thank you, Mr. Chairman. I am honored at the
opportunity to----
The Chairman. Is your microphone turned on? Make sure the
microphone is right in front of you.
STATEMENTS OF TRACIE SHEA, PH.D., PSYCHOLOGIST, POST TRAUMATIC
STRESS DISORDER CLINIC, VETERANS AFFAIRS MEDICAL CENTER
PROVIDENCE, RI, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS (ON BEHALF OF HERSELF); DEAN G. KILPATRICK,
PH.D., DISTINGUISHED UNIVERSITY PROFESSOR, DIRECTOR, NATIONAL
CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY
OF SOUTH CAROLINA, AND MEMBER, COMMITTEE ON VETERANS'
COMPENSATION FOR POST TRAUMATIC STRESS DISORDER, INSTITUTE OF
MEDICINE AND NATIONAL RESEARCH COUNCIL, THE NATIONAL ACADEMIES;
AND SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE
INSTITUTE
STATEMENT OF TRACIE SHEA, PH.D.
Dr. Shea. Thank you. Mr. Chairman, I am honored at the
opportunity to provide testimony to the Committee on issues
related to post traumatic stress disorder and personality
disorders.
I come before this Committee not as a representative or
spokesperson for the Department of Veteran Affairs, but as a
mental health researcher who has conducted research on
personality disorders. My thoughts and opinions which I will
share with you today are my own and should not be taken as VA
views or policy.
The Committee has requested my testimony regarding PTSD and
personality disorders in context of servicemembers and
veterans. I am just going to start to quickly review what the
definition of a personality disorder is, according to our
official diagnostic manual. Personality disorder is defined as
an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual's
culture. It is manifested in cognition--that means ways of
thinking and perceiving--interpersonal functioning, meaning
relationships, impulse control and affect, in other words, the
range of the emotions and the expressions of feelings.
Now, what is important here is that for a diagnosis to be
made, there are several requirements that need to be met. First
of all, you need to see persistence of the behavioral pattern
over time and it also needs to be present in multiple
situations, not circumscribed situations. Second, its onset
should have begun--its onset needs to have started by late--at
least by adolescence or early adulthood. So this is not
something as we understand personality disorders officially in
our diagnostic system that would show up in later adulthood.
Third, there needs to be evidence of significant distress
or impairment in functioning associated with this pattern of
behavior. Fourth, and this is also important to the current
topic, the pattern of behavior should not or cannot be better
accounted for as a manifestation or a consequence of another
mental disorders. And I will come back to that. Fifth, the
pattern is not due to the direction physiological effects of a
substance such as drug or alcohol or medication or a general
medical condition, and certainly, traumatic brain injury would
be an example of that.
Since the onset of personality disorders occurs by late
adolescence or early adulthood, there should be evidence of the
behavior pattern prior to adulthood. You would not expect a
history of very solid, good, psychosocial functioning prior to
adulthood in an individual with a personality disorder. You
would expect problems to have shown up.
It is really critical to rule out other mental disorders
that might be responsible for the kind of behaviors you may see
in making a clinical diagnosis of personality disorder.
Following traumatic experiences, persistent or repeated
traumatic stressors, it is particularly important to determine
if those behaviors may be due to PTSD. And this is a statement
that our diagnostic manual, the DSM-4 explicitly states, and I
quote, ``When personality changes emerge and persist after an
individual has been exposed to extreme stress, a diagnosis of
post traumatic stress disorder should be considered.'' So as a
clinician, you really need to note that and look for that.
Exposure to severe and prolonged trauma can result in
behaviors that look like personality disorders. There are
criteria such as outbursts of anger, irritability and anger,
feeling extremely detached and socially withdrawn, having a
very restricted range of affect or a very volatile affect.
These are all features that are associated with PTSD but look
like personality disorders.
There is even a diagnosis in the International
Classification of Diseases that is called ``enduring
personality change after catastrophic experience'' and this
diagnosis is used in cases of persistent change in personality
following extreme stress. Features of this International
Classification of Diseases diagnosis include, again, changes
after exposure to severe trauma, hostility, distressful
attitude toward the world, social withdrawal, constant feeling
of feeling empty or hopeless, persisting feeling of ``being on
edge'' or being threatened without any external cause, in other
words, showing up in increased vigilance and irritability, and
a permanent feeling of being changed or being different from
others.
Again, you see these features often, I have often in my
work with veterans, seen features like this that can be linked
back to the trauma. The critical distinction is, again, whether
they represent change in personality following exposure to
severe traumatic stress in terms of what diagnosis you would
give the individual.
I also want to say that despite the fact that I am focusing
here today on the distinction between personality disorders and
PTSD, they are not mutually exclusive. They can co-exist. An
individual with a personality disorder can develop PTSD and
that happens. So it is not an either/or situation.
VA psychologists, which I am also, in addition to my
academic work, conduct assessments for service-connected
disability applications. These, what are referred to what they
call compensation and pension exams, follow established
guidelines and cover psychosocial functioning and symptoms of
mental disorder that are present prior to, during and following
military service. Military experience, including exposure to
traumatic events, is assessed, and the timing of the onset of
symptoms in relation to military service is determined in these
exams.
Most of the exams that I personally have conducted have
been to establish service connection for PTSD. And essentially
they require a detailed questioning of symptoms of PTSD as well
as other mental disorders, and again, with a focus on the
timing of the onset of the problems. If there is a pattern of
maladaptive behavior existing prior to military service, it is
again important to determine whether there has been a change in
connection with military service. Diagnoses reflect--diagnoses
will reflect a personality disorder if present, but in my
personal experience, this has been rare.
I thank you for this opportunity to testify and I will be
pleased to answer any questions you may have. Thank you.
[The prepared statement of Dr. Shea appears on p. 87.]
The Chairman. Thank you, Dr. Shea.
Dr. Dean Kilpatrick is Distinguished University Professor
at the Medical University of South Carolina and Director of the
National Crime Victims Research and Treatment Center and also a
member of the Committee on Veterans' Compensation for PTSD of
the Institute of Medicine and National Research Council for The
National Academies.
Thank you for joining us.
STATEMENT OF DEAN G. KILPATRICK, PH.D.
Dr. Kilpatrick. Good afternoon, Mr. Chairman, Mr. Ranking
Member and other Committee Members. Thank you for the
opportunity to testify on behalf of the Committee on Veterans'
Compensation for post traumatic stress disorder. As was just
mentioned, this Committee was convened by the National Research
Council and the Institute of Medicine. Its work was requested
by the Veterans Administration which provided funding for this
study.
Our Committee recently completed a report entitled, ``PTSD
Compensation and Military Service,'' that addresses some of the
topics under discussion today. I am pleased to share with you
the content of that report, the knowledge I have gained as a
clinical psychologist and researcher on traumatic stress, and
my experience as someone who previously served as a clinician
at the VA for approximately 10 years.
I will begin with some background information about post
traumatic stress disorder, although from hearing the testimony
and the questions today, I think the Committee understands post
traumatic stress disorder pretty well. So I think I will just
summarize that it is a disorder that, while it first was
identified in 1980 in the DSM-III, the symptoms that have been
described after people experience traumatic events including
war have really been around for centuries. And so, even though
the diagnosis is new, the pattern of behavior that people
experience is not new.
Our Committee's review of the scientific literature and the
VA's current compensation practices identified several areas
where changes might result in more consistent and accurate
ratings for disability associated with post traumatic stress
disorder. Excuse me.
There are two primary steps in the disability compensation
process. The first is a compensation and pension, or C&P, exam.
Testimony that our Committee heard indicated that clinicians
often feel pressured to severely constrain the time they devote
to conducting a PTSD C&P exam. In fact, one clinician mentioned
that it was not uncommon to take as little as 20 minutes to do
such an examination. The protocol, however, that has been
identified by a best practices manual developed by the National
Center for PTSD of the VA indicated that it really should take
maybe 3 hours or even more in complicated cases.
So our Committee believed that the key to a proper
administration of the VA's compensation and pension examination
program is a very thorough C&P examination conducted by an
experienced mental health professional. Most of the problems
and issues with the current process can be addressed by
providing the time and resources necessary for a thorough
examination. The Committee also recommended that a system-wide
training program be implemented for clinicians who conduct
these examinations in order to promote uniform and consistent
evaluations.
The second step in the compensation and pension process is
the rating of the level of disability associated with service-
connected disorders identified in the clinical examination. I
think the for the purpose of this hearing today, it is
important that it not only be something that occurred during
service, but if you had something preexisting that was
aggravated by something that happened in service, that that
also should be part of the evaluation.
The Committee found that the criteria used to evaluate the
level of disability resulting from service-connected PTSD were,
at best, crude and overly general. They were not specifically
designed to measure disability associated with PTSD. Our
Committee recommended that new criteria be developed and
applied that specifically address PTSD symptoms and that are
grounded firmly in the standards set out for mental health
professionals doing these evaluations.
As a part of this effort, the Committee suggested that the
VA take a broader and more comprehensive view of what
constitutes PTSD disability. In the current scheme,
occupational impairment, the ability to work, drives the
determination of the rating level. Under the Committee's
recommended framework, the psychosocial and occupational
aspects of functional impairment would be separately evaluated
and the claimant would be rated on the dimension upon which he
or she is most affected.
The Committee believes that special emphasis on
occupational impairment in the current criteria unduly
penalizes veterans who may be capable of working, but
significantly symptomatic or impaired in other dimensions. So,
for example, a veteran might be able to work pretty well by
overcoming the PTSD symptoms, but might have a lot of trouble
in his family life and relationships with other people. Thus,
if you just focus on occupational impairment, you may, in fact,
create a disincentive to work, which is a very important
element in recovery.
Determining ratings for mental disabilities for PTSD is
more difficult than for some other disorders because there is a
subjective component to it in that it is mostly a symptom-based
disorder. To provide, or to promote, rather, more accurate,
consistent and uniform PTSD disability ratings, the Committee
recommends that the VA establish a specific certification
program for raters who deal with PTSD claims and provide the
training to support that, and then also to recertify raters.
Rating certification should foster greater confidence in
ratings decisions and in the decisionmaking process.
To summarize, the Committee identified three major changes
that are needed to improve the compensation evaluation program
for veterans with PTSD. First, the C&P exam should be done by
mental health professionals who are adequately trained in PTSD
and who are allotted adequate time to conduct the exams.
Second, the current VA disability rating system should be
substantially changed to focus on a more comprehensive measure
of the degree of impairment, disability and clinically
significant distress caused by PTSD. Third, the VA should
establish a certification program for raters who deal with PTSD
claims.
Our Committee had numerous other recommendations, as you
can tell by the size of this report. I have just sort of hit
the high points here. And they are detailed in the body of the
report. I believe that the report has been distributed to the
Committee as a part of my testimony. And I would thank you very
much for your attention and would be happy to answer any
questions.
[The prepared statement of Dr. Kilpatrick appears on p.
89.]
The Chairman. Thank you so much.
Dr. Sally Satel is with the American Enterprise Institute
(AEI).
STATEMENT OF SALLY SATEL, M.D.
Dr. Satel. Thank you, Mr. Chairman and Congressman Buyer
and Committee Members. Thank you again for the invitation to be
here. I am a psychiatrist and I formerly worked with veterans
at the West Haven VA in Connecticut and currently I am at AEI.
Just one word about the Chapter 5-13 discharges that were
spoken about so much earlier. They raised two main questions.
The first, of course, has been exhaustively discussed and the
attention it is getting is very much deserved. It is the
question of whether military evaluators are erroneously
ascribing impairments caused by active duty to preexisting
personality disorder.
The second question is a mirror image of the first, that is
to say it involves situations in which personality disorder
discharge is indeed accurate. We don't know what the
distribution is between misapplications and accurate ones,
however. But clearly, some soldiers are going to fall into that
personality disorder category; there is a chance, though, that
he or she has gotten too far into his tour of duty by the time
that diagnosis is made.
So the question becomes whether the military's screening
procedures and ongoing evaluations are adequate to identify
these problem personnel, in a timely manner. And that issue may
sound like a military issue, but it has relevance for Veterans
Affairs as well. After all, it is those individuals, men and
women with pre-military evidence of severe misconduct or those
who have become disciplinary problems early in active duty are
particularly vulnerable to developing psychiatric impairment
under the strain of combat. And upon discharge, they may turn
to the VA mental health facilities for long-term care for
treatment--treatment of psychiatric conditions that might have
otherwise been prevented with proper screening.
Now, if and when they get to the VA, I really don't worry
so much that clinicians are going to misdiagnose PTSD as
personality disorders. And in fact, it seems to be the case
that Chapter 5-13 discharges often reflect an administrative
decision than a clinical confusion. But in any case, the core
symptoms of post traumatic stress disorder and neuropsychiatric
impairments like traumatic brain injury are distinguishable
from preexisting personality disorder. And I don't think there
is much debate about that at all.
Yet, even though they are distinguishable, as Dr. Shea
mentioned, there is no question that the two problems can occur
together in the same patient. In fact, one of the most striking
observations made by VA psychiatrists since the mid 1980's is
that the longer a patient suffers with PTSD, the more likely he
is to also have evidence of personality disturbance. And I use
the word personal disturbance and not personality disorder,
which as we know, is a preexisting, pre-military phenomenon,
because what looks like a personality disorder, may actually be
a character change induced by the experience living with
symptoms of PTSD for many years.
Now, remember, so much of this research has been done on
Vietnam veterans and so many of them--I don't have numbers, but
I would venture to say it is the vast majority--did not come
forward for help for at least 5 years after returning home, and
sometimes 10 and 15 years later. There was no outreach at the
time. PTSD wasn't even an official diagnosis recognized by the
American Psychiatric Association until 1980. And the National
Center for PTSD didn't exist until 1989.
So by the time those veterans, those Vietnam veterans, did
come to the attention of the VA, their conditions had often
festered and become quite complicated. And as I mentioned
before, living with pervasive anxiety, nightmares and other
sleep disturbances can lead to intense anger, chronic mistrust,
depression, substance abuse and social isolation, the kinds of
features that contribute significantly to disability, these are
also features that make it very hard to treat a patient who has
suffered them for 10 and 15 years and also to determine which
is the dominant disability, the symptoms of chronic PTSD or the
maladaptive behaviors, the personality disturbances, that it
induced.
So the vital lesson here is that new veterans, the young
men and women now returning from Iraq and Afghanistan, must get
treatment as early as possible. That is when combat induced
stress syndromes are going to be most responsive to care and
also when there are ripe opportunities to address the
considerable burdens of readjustment. Financial problems,
family and marital issues, occupational dislocation, these are
enormously important. They are not psychiatric conditions. They
are social problems. And they are burdens that can make a huge
difference in how well veterans cope and return to civilian
life and also the extent that they can cope with mental
distress. Distress, which I should emphasize, will most likely
resolve over time, and will respond well to the treatment if
care is provided early.
Certainly, some veterans will continue to suffer profoundly
even with treatment and won't be able to resume a productive
life. That is what compensation is for. I hope and predict they
will be a small minority. With early and competent treatment,
however, there is good reason to be optimistic that the vast
majority of veterans returning from Iraq and Afghanistan will
do well. They will be changed by the war. How could someone not
be? But most will not be permanently damaged.
Thank you very much.
[The prepared statement of Dr. Satel appears on p. 91.]
The Chairman. We thank all of you for helping us understand
this better. Mr. Michaud.
Mr. Michaud. Thank you, Mr. Chairman.
Just a couple of questions. You heard the testimony earlier
where it was Jon Town who said that he was screened before he--
when he went into the service, screened when he went to Korea,
screened when he went to Iraq. There was no indication that he
had a personality disorder, and actually, I think he was even
screened once he got into Iraq. Then when he came out, he had
personality disorder.
I would like to ask each of the three panelists, is it
possible that you can miss so many different types--so many
different screenings in that process? I guess I will start with
Dr. Satel.
Dr. Satel. Well, I would be very--I would be quite
skeptical that you could miss it at that many levels. At
enlistment, it is often hard to predict who will not succeed
and I know that screening has been a very confounding process
for the military family for years. Since World War II it has
been questionable. I understand, however, this is just from my
reading, not from my personal experience, that there are an
increased number of so-called moral waivers being given out and
these are for people who have known felonies. Multiple felonies
should certainly raise a red flag.
But, you know, those who have a personality disorder that
hasn't manifested in gross ways like for example, as an arrest
record, at enlistment, may well show maladaptive behavior as
they progress through active duty. Imagine a cardiac stress
test. Boot camp and early deployment are often the
psychological equivalent. And if you have a fragile
personality, a tendency toward maladaptive coping, it would be
very surprising to me if that didn't rise to the surface during
intense phases of duty.
I would predict that someone with a serious preexisting
problem in relating to others would not progress too far
through the system before coming to the attention of peers and
command. That is my opinion.
Mr. Michaud. Yes. Doctor.
Dr. Kilpatrick. Well, I would just add that in the case
where someone is, you know, injured in combat, that PTSD would
certainly come to mind a lot quicker than personality disorder
as the explanation for change in behavior.
Dr. Shea. I would just add that I think it is possible to
miss mild personality disorders, but I think it doesn't--that
is not so much the issue. I think the issue is, is there a
change? Is the behavior that is being used as a basis for the
diagnosis of personality disorder, does it represent a change
following the experience in military service? And if so, then
it is not preexisting in that sense. It could be exacerbated or
it could be new onset. Thank you.
Mr. Michaud. And my second question, I think Dr. Kilpatrick
brought it up, but for the other two--I haven't read the report
which I will definitely be reading. How long would it take if
someone is to evaluate someone either before they go into the
service or after they come out to adequately detect whether it
is a personality disorder or whether they have PTSD? And I
think it was Dr. Kilpatrick that said you can't do it in 20
minutes or something like that. What is the normal timeframe
for someone to go through that process?
Dr. Kilpatrick. Well, the VA deserves an enormous amount of
credit for their National Center for PTSD which developed a
model protocol that is not a one-size-fits-all, but gives some
basic parameters for doing these compensation and pension
examinations. It suggests the types of information that should
be gathered which includes information about pre-service
functioning and sources of social support, as well as
evaluating the level of combat and exposure to other war zone
stressors and to evaluate all of these things.
And I believe that they did not set an exact time limit,
but approximately 3 hours, but I mean basically the notion that
we are saying is, if you make a 20 minute examination, you are
more likely to miss something. If you do a more comprehensive
evaluation and basically get it right the first time, then
maybe veterans will have a better view of the fairness of that
evaluation because of its thoroughness.
And secondly, you are just more likely to get it right
which will maybe save money down the line because there are
appeals. And people who do not feel like they have had their
sort of ``day in court'' in terms of a fair evaluation and a
thorough evaluation may, in fact, later be more likely to
appeal these, which again, takes a lot of resources.
Mr. Michaud. Does Dr. Shea and Dr. Satel, do you agree with
what Dr. Kilpatrick just said?
Dr. Shea. I do. I just would like to add, I mean I have
done many, many of these exams in the VA in my role as a
clinical psychologist at the VA and I can say that you always
want more time because the issues can be complex. You don't
want to cut the veteran off. You want to hear the full story.
You want to get as much detail as you can.
You also are realistically working within time limits. I do
not think you can do this exam in 20 minutes. Personally, I try
my best to get them done, interview time an hour, the whole
process, including going over the chart, dictating a report, I
don't think I have ever done in under 2 hours. I have spent 3
to 4 hours on complicated cases. You just do that if you have
to.
The other point I would say is that individuals vary quite
a bit in terms of how difficult or easy they are to interview.
Some people are very good reporters and those interviews move
quite smoothly. They are able to articulate what their
experiences are in a way that makes it easy. Other people are
more difficult.
Dr. Satel. Just one quick point. One of the reasons it can
take 3 to 4 hours--20 minutes is so brief it is mind boggling--
is because, depending on the case, one has to spend a fair
amount of time interviewing spouses and collateral sources of
information, employers, and previous physicians, and so on.
The Chairman. Thank you.
Mr. Buyer.
Mr. Buyer. Thank you very much. I may have to step out
soon. We have a briefing from Secretary Shalala and former
Senator Dole on the Commission's findings. So I want to thank
you for your submitted testimony. I had a chance to read it. I
wish you had been the lead panel. You could have helped us
immensely. And I think what I take from this hearing is there
is a good reason why reporters don't testify.
We rely upon one's testimony to be factually based and
there was a lot of free wheeling going on. And so your
testimony is very important to us because we have to make
policy decisions based on what is happening out there. There is
this impression and the allegation that has been made, almost
an embellishment, that we have this large number, 22,000--one
of my colleagues even made the conclusion that I wrote down
that they are diagnosed incorrectly. That it is all made up.
And so a pretty strong impression is being placed out there and
that is why I had to ask the reporter is it, in fact, a
disorder? Is it a clinical diagnosis? I am glad he said yes.
The challenge for us is that we in the VA, we are the
receiver of whatever the DoD does. So I am curious about your
counsel to us, as we also oversee the armed services in our
other capacities as Members of Congress. Is it in the country's
best interest for us to say to DoD that you cannot discharge a
soldier because of a personality disorder? What is your opinion
with regard to that? Please, we will go right down the line.
Dr. Shea. I will say that that is a--I think that is a
quite difficult question personally for me to address, because
I think there are very complex issues involved in that that
have to do with military needs that I am not aware of. What I
would say is that I think it is critical that the evaluation
that is made be very comprehensive, second opinions be allowed,
that records from prior history be gathered, that every effort
is made to determine what the consequences of the service were
so that the person can receive adequate treatment and receive
adequate benefits to which they are entitled.
Mr. Buyer. Thank you. Dr. Kilpatrick.
Dr. Kilpatrick. Well, I would say--I would echo that and
agree with it and say that it is a difficult thing. But I think
we need to be very careful because when you say personality
disorder, that has a very pejorative term to it, I mean whether
in fact it is true or not. And so I guess in any case, what you
have done, the military has either accepted someone in who has
a preexisting personality disorder that was not captured, or
may have been, in fact, aggravated by, you know, something that
happened in service, may be misdiagnosed as a, you know,
personality disorder when it is a change in personality
functioning as a function of having PTSD or other war zone
related-problems.
So obviously there are some people who it takes a while to
get caught up to and particularly severe antisocial behavior
people who may not be fit for service. On the other hand, we
need to be, I think, very careful about describing people who
may not be fit for service right now, but who actually might be
fit for service if their PTSD was treated. And so, I mean, it
is a difficult situation, but summarily deciding if they are
not getting along well now, that must be that they have a
personality problem and therefore we are going to kick them out
of service which then has some implications for their VA
benefits later, including access to services, you know, can be
problematic.
Mr. Buyer. Well, that is problematic and also rather
callous if, in fact, that is why it is being done. I mean I do
recall even being a JAG on active duty with regard to--as a
lawyer for the hospital whereby the clinicians actually counsel
the commanders. You know, this allegation that the commanders
are putting pressure upon the docs, it is usually the docs
saying to the commanders ``do not put a weapon in this guy's
hand.'' Usually it is the counsel coming back to the commanders
and telling the commanders what to do, that is what my
experience has been.
Dr. Satel, do you have any opinion based off of the
testimony of the other two?
Dr. Satel. I certainly agree with what my colleagues have
said. I suppose when you hear the word ``personality
disorder,'' that should be a signal that a careful, what we
call differential diagnosis process, has to be instituted. And
if everything else is ruled out and you are left with someone
who is just unfit because they cannot adapt to the norms of the
military, you have to certainly act on that. You don't want
someone who is incapable of cooperating with others, of
following orders, disrupting group morale. Also, as I said,
such individuals are often at a higher risk for developing
combat stress syndromes.
But remember, if a soldier is behaving erratically,
impulsively, defiantly or bizarrely, the first thing is to make
sure we are not talking about traumatic stress injuries or
bipolar illness or early schizophrenia. New onset of
schizophrenia was one of the cases described earlier today. But
if not, and this is someone who is just not psychologically
equipped to conform to the rigors of the military, then that
needs to be dealt with. But most important is to rule out other
explanations for inappropriate actions on the part of the
individual.
Mr. Buyer. Doctors, I appreciate your testimony. I am just
a layperson and I look at my 27 years experience in the
military. I have recognized in that crucible of basic training
and AIT, that certain things can apply certain stressors,
whereby people--you will be able to recognize certain behaviors
or conduct. And then they get referred to the hospital for some
type of treatment or end up with diagnosis.
The concern I think that the Chairman has and myself and
other Members of the Committee is we would think that many of
these things could be identified early on, and that an
individual would actually go to war and that is when the so-
called a preexisting condition is then discovered, and they are
discharged after they come back home. Even as a layperson, as a
military guy, something doesn't fit here, doesn't seem right to
me.
And I read in your testimonies, both of you--all three of
you are--in agreement that you can have a preexisting disorder,
but you can also have PTSD; is that correct?
Dr. Kilpatrick. Yes.
Dr. Shea. Yes.
Mr. Buyer. Okay. So your testimony about careful analysis
is with regard to the DoD. When they make this discharge
determination, and when the VA receives it, the VA has to
examine this judgment with a rebuttal presumption, and be able
to come in and challenge what DoD has done. Would that--would
you agree with that? In other words, we shouldn't just accept--
--
Dr. Satel. Yes.
Mr. Buyer. We shouldn't accept that the VA should also have
the ability to have their own second opinion with regard to the
benefits, especially for these individuals that come back after
war. Would you all agree with that?
Dr. Satel. Yes, I would.
Dr. Shea. Yes.
Mr. Buyer. All right. Thank you very much.
Dr. Kilpatrick. And part of the problem is, is that people,
a lot of people with PTSD will develop alcohol problems. They
will have impulse control problems which may mimic some of the
personality problems that are disturbing to people. So that is
why the diagnosis is important, because something can be done
for the PTSD.
Mr. Buyer. Okay. Thank you very much.
The Chairman. We thank the panel. The panel was in total
agreement, while you were out of the room, Mr. Buyer, that they
were quite skeptical that personality disorder would not be
found out whether it is early screening or basic training or
beginnings of combat or whatever, that they would not find that
and have to do that post-deployment would be very unusual at
the very least.
Given that judgment of yours, I mean, Dr. Shea, were you
surprised at the testimony on the first panel which seemed to
indicate that many, many of these combat veterans were being
diagnosed with personality disorder? Did that surprise you at
all?
Dr. Shea. The particular cases that I heard and have read
about, yes, I am stunned by those particular cases, from what I
have read. They don't--it sounds like an inaccurate procedure.
I can say that. I mean I think it is hard to speak to the other
cases because we simply don't know the details.
The Chairman. Right. I understand. But I mean the numbers
in the testimony that we have had seems to say that. If a
veteran comes to you for a C&P examination, does the fact that
they have been diagnosed with personality disorder by the
military have any sway with you? Is it harder for them to even
get that far in the disability process and how would that
affect your evaluation?
Dr. Shea. Well, let me say for the first part, I would
defer that to Dr. Katz who is on the next panel because he is
much more familiar with the eligibility requirements and how
that process works than I am.
In terms of lending it to me, and if I see--I would look
very carefully at the medical records. I would look very
carefully at any documentation that was provided. I would look
at treatment records. I would probe for those--but most
importantly, what I would be doing is looking for symptoms of
post traumatic stress disorder if that was the basis of the
evaluation. I would have it in the back of my mind that this
person had been diagnosed with a personality disorder, but I
would be looking for, again, what specific behaviors and
symptoms have onset and what was the relationship to the
traumatic stressors. What kind of traumatic stressors did they
experience and what--can they link these symptoms of PTSD to
those? And that would be my concern. I would frankly be less
concerned about the personality disorder unless I thought that
I had to be careful not to make a mistake in diagnosing----
The Chairman. It was implied by their testimony that it is
hard even to get to that point. Again, you don't know about
that. You want me to ask Dr. Katz; is that what you are saying?
Dr. Shea. Yeah. I am not totally familiar with all of the
eligibility requirements for getting there. But I know we see
people who have prior diagnoses with personality disorder. So I
know that they can be seen by the VA, but I don't know of
anybody else.
The Chairman. And what--is there any generalization you can
make? In your evaluation, have you overturned all of those, or
some of them, or none of them? Was there a PTSD diagnosis from
you in contradiction to the personality disorder diagnosis?
Dr. Shea. Well, we are not typically asked to comment on
the previous diagnosis.
The Chairman. Right. But you give some sort of diagnosis.
Dr. Shea. Yes.
The Chairman. I was just wondering, were all of them given
PTSD diagnosis or none of them or half of them? I mean----
Dr. Shea. Oh, you mean--excuse me----
The Chairman. For those who had a personality disorder that
you can recall, a diagnosis from the military, how, in general,
do you diagnose them?
Dr. Shea. I have not had any compensation exams that have
come to me in recent times that have listed military diagnosis
separation due to personality disorder. So I just haven't had
that come up.
The Chairman. I thought you said that you have seen those,
so you know they can get in.
Dr. Shea. Well, I know through the years I have treated
many, many veterans, a lot of Vietnam veterans, as well as some
of the more recent Iraq veterans. And those veterans I may not
be doing comp and pen exams. I am just treating them. And I
know that they have a history in----
The Chairman. So you haven't given a C&P exam to anybody
who had a personality disorder? So for all you know, they may
have been screened out before you got there. I mean----
Dr. Shea. That is a possibility. Yeah.
The Chairman. Or just, you know, the luck of the draw that
you----
Dr. Shea. Yeah. I can't speak to that.
The Chairman. Okay.
Dr. Shea. That is right.
The Chairman. Well, we thank all of you for being here. We
thank you for helping us understand this better and we will ask
the third panel to come forward.
I have diagnosed a personality disorder on schizophrenia in
your changing of the nameplates. So you are trying to confuse
us also, right? You are not really Dr. Katz. Okay. I think we
should discharge you immediately from the VA.
Thank you for being here. Dr. Ira Katz is the Deputy Chief
for Patient Care Services for Mental Health in the Veterans
Health Administration, Department of Veterans Affairs,
accompanied by Ron Aument, Deputy Under Secretary for,
Benefits, Veterans Benefits Administration (VBA), and Paul
Hutter, Executive in Charge in the Office of General Counsel.
Dr. Katz, you have the floor.
STATEMENTS OF IRA R. KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT
CARE SERVICES FOR MENTAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY RONALD R. AUMENT, DEPUTY UNDER SECRETARY FOR
BENEFITS, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; PAUL J. HUTTER, EXECUTIVE IN CHARGE, OFFICE
OF GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
COLONEL BRUCE CROW, CHIEF, DEPARTMENT OF BEHAVIORAL MEDICINE,
BROOKE ARMY MEDICAL CENTER, FORT SAM HOUSTON, TX, AND CLINICAL
PSYCHOLOGY CONSULTANT TO THE ARMY SURGEON GENERAL, DEPARTMENT
OF THE ARMY, U.S. DEPARTMENT OF DEFENSE
STATEMENT OF IRA R. KATZ, M.D., PH.D.
Dr. Katz. Hello, Mr. Chairman and Members of the Committee.
I, too, was moved by what I heard from the first panel, as
everyone in the room must have been. I want to, before
beginning my prepared presentation, comment about the issues
that were raised in the last panel. The VA's evaluation,
whether it is an evaluation for purposes of treatment planning
or compensation and pension evaluation, is a de novo evaluation
that is independent and unbiased, evaluating the patient before
us and not bound or in any way determined by prior evaluations
in DoD. The VA evaluation is patient-centered----
The Chairman. But somebody has to come forward for that.
And if they were told, for example, by the Army that they
weren't eligible for the VA based on personality disorder, they
may never show up to you, right? You would give them a de novo
exam if they showed up. But if they don't show up, you
obviously can't do it?
Dr. Katz. Right. We work hard to promote access and to de-
stigmatize mental health to promote access.
I want to speak about the issue that was raised in the
previous panel about the fact that multiple diagnoses are the
rule and about how VA applies the principles that PTSD
frequently coexists with other mental health conditions. I
would like to request that my written testimony be submitted
for the record.
The Chairman. Certainly.
Dr. Katz. As of the end of the first half of 2007, almost
720,000 servicemen and women have separated from the Armed
Forces after service in Iraq or Afghanistan and over a quarter
million have sought care in VA. About 95,000 received at least
a preliminary mental health diagnosis and among these, PTSD was
experienced by about 45,000 or 48 percent of those with a
mental health condition. It is the most common of the mental
health conditions, but it is not the whole story, and
depression is a close second.
The average veteran with a mental health problem received
about 1.9 separate diagnoses. Multiple diagnoses, as was
suggested, is the rule, not the exception. There can be several
reasons for this. First, injuries of the mind, like injuries of
the body, can be nonselective, depending upon psychological,
physiological or genetic vulnerabilities. The same stress or
trauma could give rise to multiple conditions. It can produce,
for example, PTSD and depression or PTSD or a panic disorder.
Second, the disorders can occur sequentially. Some veterans
with PTSD may try to treat their own symptoms with alcohol and
wind up with a diagnosis related to problem drinking. Third,
some preexisting mental health conditions, like milder
personality disorders, could be quite compatible with
occupational functioning even in the military, but they may
increase a person's vulnerability to stress-related disorders
like PTSD.
VA has intensive programs to ensure that mental health
problems are recognized, diagnosed and treated. There is
outreach to bring veterans into our system and once they
arrive, there is extensive screening for mental health
conditions. Specifically, VA screens all new returning veterans
for PTSD, depression, traumatic brain injury and problem
drinking. The prompts for these screens are built into our
electronic medical records.
The Chairman. I am sorry. Dr. Katz, did you say--who does
the screening? Did you say--I didn't hear that sentence.
Dr. Katz. Usually it is the first provider that sees the
returning veteran----
The Chairman. No, is it the VA?
Dr. Katz [continuing]. Usually the primary care provider.
The Chairman. I am sorry. Was it the VA or the military did
you say?
Dr. Katz. VA definitely screens everyone who comes to us
for the----
The Chairman. Right. But you didn't say everyone who comes
to us in that sentence. You said every veteran is screened.
There is a crucial distinction between every veteran is
screened and every veteran who comes to us is screened.
Dr. Katz. I agree. We work hard----
The Chairman. I want to know what you said.
Dr. Katz. We work hard at outreach to get people to us----
The Chairman. I understand. But I bet you haven't gone to
those 22,500 and tried to get them in and see what is going on
with them.
Dr. Katz. We have gone to almost all of the post-deployment
health reassessment sessions to really work----
The Chairman. Did you call in the 22,500 people who have--
--
Dr. Katz. No, sir.
The Chairman. So that is what I would call outreach.
Dr. Katz. For those who screen positive for mental health
conditions, the next step is comprehensive diagnostic and
treatment planning evaluation. If someone screens positive for
symptoms of PTSD, we are, of course, interested in whether or
not they have PTSD. But we are also interested in whether or
not they have depression or panic disorder or problem drinking
or other problems. Regardless of the specific diagnosis, we
treat the person, not his or her label.
Clinical science regarding PTSD had advanced dramatically
since Vietnam. There is a firm evidence base for several
classes of treatment for PTSD, both medication based and talk-
therapy based. Specifically, several anti-depressants have been
found effective and safe for the treatment of PTSD and many
other medications are being studied.
Two specific forms of cognitive behavior therapy, prolonged
exposure therapy and cognitive processing therapy, appear to be
even more effective than medications and VA has currently
developed training programs to make these treatments more
available in all of our facilities.
In addition, there is increasing evidence for the
effectiveness of psychosocial rehabilitation treatments to help
veterans with residual symptoms function in their family,
community and on the job, even if they have symptoms left after
other treatments.
When patients have more than one condition, and most do,
clinicians must evaluate the severity of the conditions and the
patient's preferences. Plans must allow for combinations or
sequences of treatment as appropriate following clinical
practice guidelines.
VA also employs evidence-based strategies for beginning
PTSD and substance abuse treatment simultaneously when they
both occur. It may be difficult to diagnose personality
disorders in the face of PTSD or other mental health
conditions. For veterans with relevant symptoms, the clinical
approach in VA is to treat PTSD first. A subsequent step would
be to evaluate what symptoms or impairments remain and to plan
treatments accordingly.
In summary, treatment for PTSD and other mental health
conditions can work. For veterans with multiple conditions,
there must be a multi-stage process beginning with an evidence-
based intervention for the most severe of the patient's
conditions. Treatment begins with the most severe and continues
until the person recovers and beyond.
Thank you for this opportunity to testify. I and my
colleagues will be pleased to answer any questions you may
have.
[The prepared statement of Dr. Katz appears on p. 95.]
The Chairman. Thank you, Dr. Katz.
Colonel Bruce--is it Crow or Crou?
Colonel Crow. Crow.
The Chairman. Crow, is Chief of the Department of Behavior
Medicine at the Brooke Army Medical Center and is with us today
as the Clinical Psychology Consultant to the Army Surgeon
General.
We have your written statement, Colonel. If you can respond
to the first panel as opposed to going through what you guys
are doing. You know, all you guys are doing everything right.
As Dr. Katz said, he was affected by the first panel. I hope
you were. I would like you to respond to it in your statement.
If you think they are wrong, tell us. If you think they are
right, what are we going to do about it?
Colonel Crow. Well, Mr. Chairman, I actually have a oral
statement that is a little bit different, a little bit shorter
than my written testimony. I would like to read that, if I may.
Ms. Brown-Waite. Mr. Chairman, I want to make sure that his
written statement is going to be entered into the record.
The Chairman. All written statements will be made a part of
the record.
Ms. Brown-Waite. And he does have the opportunity----
The Chairman. He can do whatever he wants. I would ask him
to--we put the VA and the DoD as the last panel instead of the
first panel, as has been the practice here, because after the
first panel goes, they all walk out and they don't listen to
the citizens and the stakeholders. So now they have had a
chance--and I appreciate your sitting through that--to hear.
And it seems to me if I were in their position, I would say
well, they don't know what they are talking about, we do this,
or yes, they are right and here is what we are going to do to
fix it. They have this opportunity and if they choose to pass
it up, well, we will try to get to these matters in questions.
But I would say that that is not the most responsive way to be.
You have the floor, Colonel.
STATEMENT OF COLONEL BRUCE CROW
Colonel Crow. Mr. Chairman and Congressman Buyer who is not
here, thank you for the opportunity to address the
distinguished Members of this Committee. I am Colonel Bruce
Crow, the Clinical Psychology Consultant to The Army Surgeon
General and Chief of the Department of Behavioral Medicine at
Brooke Army Medical Center in San Antonio, Texas.
The soldiers of the U.S. Army deserve the very best mental
healthcare available. We know there is a stigma against seeking
mental health services in our society and in the military,
which is made worse if soldiers don't trust us as mental health
providers. The Army has highly qualified psychiatrist,
psychologists and social workers who are uniform or work as
civil service or contract employees. We are helping thousands
of soldiers and their family members every day deal with
problems of living. We are expected to do our job well and to
improve our system when we find problems.
Questions have been raised about whether Army psychiatrists
and psychologists have been negligent for misdiagnosing
soldiers with personality disorder instead of correctly
recognizing symptoms of PTSD or traumatic brain injury. This
would be wrong and should not happen. The ethics and standards
of our professions dictate that our patients receive accurate
diagnoses and appropriate treatment.
I strongly believe our providers have the best interests of
soldiers at heart. Our obligation is to our patients first and
above all else. We are committed to reviewing our clinical
procedures related to making a diagnosis of personality
disorder pursuant to administrative separation under Army
regulation. If there are problems with this process, they need
to be fixed.
The Acting Surgeon General of the Army, Major General
Pollack, has initiated a review of the administrative, medical
and mental health records for nearly 300 soldiers who served in
combat and were subsequently discharged for a personality
disorder. This initial review will include the 295 soldiers
separated from the Army in 2006 who had served in Iraq and
Afghanistan and had received a separation for personality
disorder. There were an additional 791 soldiers discharged for
personality disorder who had not served in combat, for a total
of 1,086 personality disorder separations in 2006.
For the period 2001-2006, the Army separated a total of
5,631 soldiers due to a personality disorder. A much smaller
portion of that number have served in combat. I may add, I
don't think the numbers would tell us whether or not we should
be concerned about a problem. One is too many and we should
look to see if there is a problem.
This review will be conduced by a team of senior mental
health providers looking at compliance with the procedures,
quality of clinical documentation and whether there are
indicators that these soldiers had conditions that should have
been referred for medical board evaluation. The results of this
review will help determine whether additional reviews should be
conducted. We expect to have results by early September with
release to the Senior Army and DoD leadership and then to
Congress.
The Army has designed an administrative separation process
that is intended to provide checks and balances so that
soldiers are treated fairly and correctly. It would be
absolutely unacceptable for our mental health providers to
participate in any way of a misuse of this process.
We have made many improvements to the Army mental health
system in the past few years and we believe we provide the
highest quality, most comprehensive, and most responsive mental
healthcare of any military in the world. We know there is more
work to do and more to learn about the psychological effects of
combat on our soldiers. Every soldier is important to us.
Especially important are those who need our help dealing with
traumatic stress or recovery from a brain injury.
We are dedicated to making our system better and we welcome
the opportunity to demonstrate our commitment to the highest
qualify of psychological care for our deserving warriors and
their families.
[The prepared statement of Colonel Crow appears on p. 96.]
The Chairman. Thank you, Colonel.
I will start the questioning with Mr. Michaud. But just
given some of the charges that we have heard and some of the
history, I would say that it is great that you are doing this
review now. It is a little late, but I am glad you are doing
it. I think it should be done by an outside panel, an
independent panel. I don't trust you to tell me what you all
did, because you are going to tell me it is right. We all know
that. So why bother?
Let's get an outside review. I am going to try to put that
into legislation because you should not be reviewing these kind
of charges that are based on--you are going to get the
information from the same people who are being charged with
negligence and you are going to ask them, well, was it right?
We know what these reviews are. You reviewed the first stack,
Surgeon General Pollack did, and every one was perfectly right.
They didn't ask a soldier. They didn't ask anybody else. They
just asked the doctor who gave the diagnosis so why should we
trust this review?
Mr. Michaud.
Mr. Michaud. Thank you, Mr. Chairman.
My first question is for Dr. Katz. If you were asked to
review someone who--a case that someone had a personality
disorder, to do a thorough and thoughtful review, what would
you do in that situation?
Dr. Katz. The first thing I would do is look for everything
else besides the personality disorder. We have effective and
safe evidence treatments for many psychiatric disorders. The
evidence and effectiveness for treatments of personality
disorders is lagging somewhat behind. So as a physician and
someone wishing to help, I would want to make sure that I have
looked for and excluded all other more treatable conditions
before making the diagnosis of a personality disorder.
Mr. Michaud. Would you also want to talk to the individual?
Dr. Katz. That goes without saying. I assumed you were
talking about an examination of the patient.
Mr. Michaud. Well, getting back to the question I brought
up earlier where Surgeon General Pollack was asked to do a
thorough and thoughtful--or do a review without--and she did. I
mean they did and they never talked to the individual. So that
is why I was kind of curious. If you are to do a thorough
review, what would the process be? And I agree with your
comments. If you were to do one, then it would seem to me you
would have to talk with the individual involved.
Colonel, the Chairman had mentioned about--and you
mentioned, you are doing a review of the process and the
Chairman had mentioned about having an independent review
process. In light of everything that is going on, particularly
with Walter Reed, and I have heard my constituents who said
that they were asked to be redeployed even though they had what
they thought were PTSD problems, but still they were told that
they had to go back over there. What is your thought about
having an independent review of this process? Would you object
to that?
Colonel Crow. No, sir, not in general. I mean if there are
questions about the quality of work done by us, and it is
more--there would be more confidence in a review by an external
group of experts, I don't think fundamentally there would be an
objection to that. I think when this idea was conceptualized by
our Surgeon General, the idea was this is something that we
could do, we can do immediately. We have access to the records.
But if the level of concern is such that you want to have a
high degree of confidence and not an appearance that it an in-
house and potential conflict of interest, I don't think there
would be an objection to that.
Mr. Michaud. Okay. When someone goes into the military, we
heard from the first panel that there is a rigorous process
that an individual has to go through. When you have active-duty
members, then you have the Guard and Reserves. What is
happening over in Iraq and Afghanistan, what process, or is
there a reevaluation for the Guard and Reserve members to go
through that rigorous process before they are asked to be
deployed over in Iraq?
Colonel Crow. Well, sir, the process was described as
rigorous. I would not describe it that way at all. In terms of
the initial processing into the military for medical
processing, it is basically a self-report questionnaire and the
psychiatric questions, they really have to do with is there a
history of certain kinds of serious psychiatric conditions,
depression, psychiatric hospitalization, suicidal behavior and
so forth. There is not direct----
The Chairman. Colonel, did you--excuse me for interrupting.
Did you just say the Army of the United States of America takes
troops into active duty without any rigorous medical
evaluation? Is that what you just said?
Colonel Crow. Sir, there is not rigorous psychological
evaluation. There is----
The Chairman. So you are saying a rigorous psychological
evaluation. Go on to one of the--in a combat situation which we
know is incredibly difficult and causing trauma and you can sit
there and say that the Army of the United States of America
does not have any rigorous psychological evaluation. That is
incredible. I just want to make sure I heard it right.
I am sorry, Mr. Michaud. You still have more time.
Mr. Michaud. Thank you.
I guess the distinction, what I would like to know,
Colonel, is where a big portion of the men and women who are
fighting over in Iraq and Afghanistan are from the Guard and
Reserves, and a lot of these folks haven't--are up there and
they really haven't had that ongoing military experience like
the active duty force. So I am just trying to figure out since
a good portion are over in Iraq, is there anything that the
Department of the Army is doing to make sure that before they
ship them to Iraq and Afghanistan that they are able to deal
with the issue. And actually, I heard from the earlier panel
that there is a rigorous process. So that is why I asked if
they had to go through that rigorous process to make sure that
they are able to do the job that they have to do.
Colonel Crow. Sir, I think the way that I would
conceptualize it is the presumption is that someone who has
enlisted in the Army is able to withstand the duty demands.
Once they have cleared the basic training, that they are able
to perform in their duty. And unless it is determined
otherwise, then the presumption would be that they are fit for
duty.
We do have two sets of screenings that are directly related
to deployment. At the point of redeployment, there is what is
called a post-deployment health assessment. So all soldiers who
have been to deployment and are returning are asked a series of
health questions that do include some questions about
psychological functioning. And 90 to 120 days following return
from deployment, there is an assessment called a post-
deployment health reassessments for all military, Guard,
Reserve, as well as active component, that asks about health
status, as well as more extended questions about psychological
functioning that are more sensitive to things like depression
and post traumatic stress.
The Chairman. Ms. Brown-Waite.
Ms. Brown-Waite. First of all, I want to thank you all for
being here today.
And Dr. Katz, if there are this 20 some thousand who had
been diagnosed and dismissed by the military with personality
disorders, do you know where they are so that they can be
helped? Is there any coordination going on now that we know
that there may be a problem in the system? Do you know where
these people are?
Dr. Katz. I do not. There is increasing communication and
list sharing to match people up. We are good at tracking those
who were discharged via a medical evaluation route, those with
polytrauma and other related severe injuries, visible or
invisible. But those who are discharged via more ambulatory
routes are followed primarily through the PDRHA and beginnings
of liaison with VA there and by community outreach and
education.
Ms. Brown-Waite. PDRHA, tell me what that is.
Dr. Katz. Post Deployment Health Reassessment that the
Colonel was speaking about. These are evaluations that are
conducted by DoD with co-participation from VA, primarily Vet
Center staff, usually peer outreach people to try to make
contact.
Ms. Brown-Waite. What about those that DoD has released
with a diagnosis of personality disorder? Is there any way that
you could reach them? Is there the sharing of the information?
In other words, Colonel Crow, if someone is released from DoD
with a personality disorder diagnosis, is that--do you ever do
followup?
Colonel Crow. No, ma'am. Followup of their living situation
or----
Ms. Brown-Waite. Followup of their mental health needs.
Colonel Crow. No, ma'am.
Ms. Brown-Waite. And obviously they are not eligible for
the VA because they have been discharged because of a diagnosis
of a prior condition.
Dr. Katz. No. That is really not the case.
Ms. Brown-Waite. Okay.
Dr. Katz. They are very much eligible for VA care and
benefits.
Mr. Aument, do you want to talk about the benefits side and
I will talk about care?
Mr. Aument. Certainly. In fact, I think it is worth
clarifying that, as long as there is an honorable discharge or
a general discharge, anything other than dishonorable
conditions, a diagnosis of personality disorder does in no way
disqualify a veteran from receiving disability compensation or
VA healthcare eligibility.
We would go through precisely the same evaluation process
if a veteran came to us seeking disability compensation for
PTSD. We would go through precisely the same process evaluating
that claim that we would for any other veteran who came to us
with that type of a claim.
The Chairman. Would you yield for 1 second?
Ms. Brown-Waite. As long as the panel isn't going to be
attacked, sir.
The Chairman. Okay. Would you--do you know how many people
who come to the VA with this personality disorder discharge
have come to the VA for help? Do you know?
Mr. Aument. No, I do not, Mr. Chairman.
The Chairman. Do we keep that information?
Mr. Aument. No, we would not, Mr. Chairman. In fact, that
information is not even reflected on their DD214. We would have
to go through and actively review their service medical records
and somehow capture that information for future use. And quite
frankly, if it is not relevant to a determination of PTSD, we
would have no reason to collect that information.
Ms. Brown-Waite. Let me ask another question reclaiming my
time. Would a Benefits Delivery at Discharge (BDD) physical
with VA and DoD practitioners evaluate a servicemember to
understand the history and possibly the exacerbation of mental
health conditions, new or old?
Mr. Aument. Do you want to take that, Doctor, or do you
want me to----
Dr. Katz. Any reliable and valid evaluation should include
those components.
Ms. Brown-Waite. But I think I am asking do they.
Mr. Aument. It depends upon what type of conditions have
been claimed. For benefits delivery at discharge, we conduct
the examinations that are relevant to the disabilities that are
being claimed as part of that process. For example, if there
has been no PTSD or other mental disorder disability that has
been claimed, it is unlikely that we would conduct any
extensive mental health examination.
Ms. Brown-Waite. I see that my time is up. Let me ask one
other question. Is part of the problem that the young man who
testified earlier, Jonathan Town, where he submitted the
information multiple times, is part of the problem that the
computer system has different programs to it? I know I
experienced this when trying to help a constituent and got a
very helpful person on the line from VA disability and he said
well, I knew the paperwork was there because the constituent
sent it in three times. I send it in once and he said let me go
to this program, let me go to this program, let me go to this
program. There were four different programs.
So perhaps that was part of the problem, because I know I
was being told that constituent's paperwork wasn't there when I
knew it was there. He had sent it in several times. My office
sent it in registered mail with return receipt. So we knew they
had it. Is that part of the problem?
Mr. Aument. I think in this case, Congresswoman, that is
probably the heart and soul of the problem. What you are
identifying here is a processing shortcoming on VBA's part in
this particular case, that we are certainly accountable for.
But I don't believe it was anything having to do with this
particular condition, just probably some sloppy service on our
part.
Ms. Brown-Waite. Well, this happened--this happened 3\1/2\
years ago. So I am asking you have you gotten--have you
improved the computer tracking system at all?
Mr. Aument. Yes.
Ms. Brown-Waite. Tell me how.
Mr. Aument. Part of the processing changes that have been
made has been to upgrade the claims processing system starting
from the very time that a claim is received, Congresswoman. We
have not completed that process. It is part of the replacement
of the compensation and pension payment and processing system.
It is the effort that is called Vetsnet, which, has a little
troubled history, but I believe we are on track now for
improving that and providing better service to veterans.
Ms. Brown-Waite. Let me ask you one other question. If
today an application is made for a disability, how many
different programs could that information be entered into? It
was 4, 3\1/2\ years ago. How many today?
Mr. Aument. I would say today, a receipt of a claim for
disability compensation would be entered in no more than two
systems, probably only one, but no more than two.
Ms. Brown-Waite. And that is system-wide?
Mr. Aument. That is correct.
Ms. Brown-Waite. Okay. All right. Thank you. I yield back.
The Chairman. But Specialist Town's applications were not
3\1/2\ years ago. They were far more recent and he said only on
the fifth one when he had a lot of publicity did he ever get
notice.
Let me ask a few questions and make a few observations. The
first panel shocked me. You guys shocked me even more.
Colonel, you came into my office yesterday to explain to me
this wonderful chain teaching approach of PTSD. And we are
going to educate the whole Army about this. And you said the
whole basis of this chain teaching is that support has to come
from the top so everybody knows it. And yet the implication of
what you said earlier was that to the Army, psychological stuff
is hardly very important. You said there is a high probability
they will adapt. We don't have to worry about it.
What kind of signal is that sending if the physical and the
mental--you have not parity whatsoever in your own mind. So how
can a soldier ever understand what PTSD is if at the very top
you are not understanding these issues?
Colonel Crow. Sir, I could comment about the chain
teaching. What we were wanting to describe is that we recognize
that stigma for seeking mental health services is a barrier to
care. We recognize----
The Chairman. And did you say anything today that would
remove that stigma? You said they will adapt. Real men adapt.
Real women adapt. Don't worry about this stuff with the
psychological thing. You went through basic training and you
are going to be a soldier. That is what you said today. So how
does that get rid of the stigma?
Colonel Crow. Sir, I didn't intend to give that
connotation.
The Chairman. The implication----
Colonel Crow. I think the question had to do is whether
there is rigorous----
The Chairman. Yes, and you dismissed it. You said we just
assumed that they are going to adapt to the conditions after
basic training. That is what you said. So clearly, it is not
important to you and that is what people get. And if they have
something, well, you better not admit it.
I have talked to soldiers and marines who filled out the
questionnaire about on entrance, on separation, that they are
supposed to self report about any medical conditions. They told
me when they submitted their questionnaire, their commander or
whatever said you have go redo this. You cannot admit any of
this psychological stuff. They will keep you here another 6
months. You want to go home. Change your questionnaire.
We have soldiers getting out of there that are slipping
through the cracks that have no evaluation for either brain
injury or for PTSD. You are sending back for second and third
deployments people who have brain injury and PTSD. If I was in
your position, Dr. Katz or Mr. Aument, and heard what I heard
at the beginning, I would have shocked this Committee and said,
you know, if there are 22,500 people that have been diagnosed,
maybe wrongly according to the testimony, with personality
disorder, let's go find them all, not just 10, not just 259.
Let's go after the 22,000.
The Army is a great record keeper, right? We could find
them. You say you have outreach. I don't know--I doubt if you
are going after--I would take a sample of these by the way and
we may have to do this in legislation, take a sample of the
22,000, maybe 1,000 and find out what is going on with them,
bring them to the VA. Don't just wait for them to come in.
We are responsible for them. We sent them into war. We sent
them into whatever we sent them to, whether they are in combat
or not. We have an obligation to them. And you all sit here and
say well, we have outreach and no, we don't know how many of
those personality disorders come in.
And Mr. Aument, you said everybody knows that they could
come in and we will do a de novo review. It doesn't have any--
none of what they had before affects us. But if you are a
soldier and you were told at age 20 that you are not eligible
for VA benefits, as these guys had papers that told them that,
and you cannot show up because you had a preexisting condition,
what are the odds that they are going to show up? I think
pretty small, although let's find out. Let's go after--let's
take 5 percent of that 20,000 and find out. Did all 1,000 come
in?
If you told me you went after 1,000 and they are all now
getting adequate treatment at the VA, I wouldn't be talking
like this. But I doubt that is the fact. But prove me wrong.
Anyway, given the fact that both the military and the VA
heard this testimony, which is very, very shocking, that there
is a systematic and a policy-driven misdiagnosis of PTSD as
personality disorder to get rid of the soldier early, to
prevent any expenditures in the future which are calculated in
the billions of dollars, I would take that pretty seriously if
I were you guys and say something about that. But, you said you
are affected, but nobody said well, let's go look at those
22,000. Maybe these guys are wrong. We are only basing it on a
few people.
Well, find out. I mean these are pretty serious, pretty
serious allegations. And if we had doctors' names and one was
listed and I have some that have told us that they were
misdiagnosing, it seems to me that you should go find that out,
Colonel Crow. You are just going to look at 300 records and
everything will be fine. Maybe there will be one or two.
There is something going on in your organization that is
wrong and it is hurting our young men and women. It has to hurt
your effectiveness as a fighting force. I mean for all I know,
we are doing so bad in Iraq because you are sending all these
brain injured kids back to the second deployment. I mean that
could account for how terrible the effort is we are doing.
But we have got a lot to do here. And if I heard one thing
from either organization, that you took it seriously and wanted
to do something about it and we are going to ask the Congress
to give us the money to go after these 20,000--why don't you
ever ask us that? I didn't hear anything like that.
Dr. Katz. Well, we are grateful for the money we have
received, including the supplemental funding and----
The Chairman. Yes, but nobody asked for that. We asked for
it.
Dr. Katz. And are using them to improve access, capacity
and quality to make VA mental health services----
The Chairman. Well, that is a generalization. I want to
know, I want you to tell me that we are going to look at 1,000
of these 20,000 PD diagnoses and figure out what happened to
them, working with the Army, get their names and addresses, go
after them. That would show me you cared about access.
All these generalizations don't tell me anything because I
have people coming into my office every day--and Ms. Brown-
Waite talks about specific soldiers coming in, who tell us they
can't get--they have called the VA. They think they have PTSD
and they have got to wait for three, four, or 5 weeks to call
back. Now, we know people have committed suicide in that
interval.
But everybody says we are outreaching. Soldiers come into
our office or call us. They cannot get the help they need. They
are dissuaded from coming in and, when they come in, there is a
limited number of sessions they can have and on and on. So
something is wrong.
Dr. Katz. We will take your suggestion for these specific
outreach and followup studies----
The Chairman. Thank you.
Dr. Katz [continuing]. And determine what can be done with
existing records
Ms. Brown-Waite. Mr. Chairman?
The Chairman. Yes, ma'am.
Ms. Brown-Waite. First of all, I have not told you people
came into my office on PTSD issues.
The Chairman. No. You talked about specific cases.
Ms. Brown-Waite. I have talked about specific cases, yes,
including one this morning. I just wanted the record to be made
clear. And I think that perhaps the record may not also be
clear about the conversation with Colonel Crow. That is not the
testimony that he gave here today. It may have been what he
said in your office. But your assessment of his saying oh, they
will be all right, that is not the testimony that he gave here
today.
The Chairman. If you read the transcript of his testimony,
he said, and we can take down his words and see it right now,
but we won't. He said, when asked about the rigorous
examination and I said you mean you don't have a rigorous
examination? He said, well, I was speaking mainly of the
psychological. And then in answer to a question from Mr.
Michaud, he said that--not exactly quoting, but something to
the effect that we assume that they will adjust after basic
training to the, to the war situation, right? I mean that is
what I heard. Is that what you heard or something like that?
Mr. Michaud. Yes. We would have to look at the record
because I couldn't hear.
The Chairman. And besides, if he said completely different
words and that is what this poor little Congressman heard, then
he is not communicating correctly and we gave him a chance to
change it. But he gave the impression, and I am sure it is in
the transcript, that the psychological evaluation was not as
rigorous and was not as important because a real soldier will
adjust.
And that is the whole problem we have.
Ms. Brown-Waite. I don't believe he said important.
The Chairman. That is why these people on panel one came to
us, because we don't have an understanding of these issues and
we don't have treatment of them and we have a systematic
effort, apparently, to try to get rid of them without having
more problems. They don't follow them. They took them into the
Army. It seems to me we have some obligation there. And we
don't follow them up or anything. They are back who knows
where.
So I hope that we can look at some of those personality
disorder evaluations. Thank you, Dr. Katz for saying that. And
we are going to either--the Surgeon General asked for an
independent evaluation or we will put it in legislation. But if
you think that we are going to believe an evaluation of 259
cases, whichever ones you happen to pick, I will tell you now I
am not going to believe it.
So why bother? Let's have an independent evaluation and we
will try to deal with it.
Mr. Michaud.
Mr. Michaud. Yeah, I just--I would have two quick
questions, but I don't know if Mr. Rodriguez had any questions.
But my two quick questions actually, one for Dr. Katz is, you
talked about taking care of our veterans. Quick question, what
do you do with someone who is a veteran who is employed by a
company like Blackwater who is currently over in Iraq and
Afghanistan but they might be a Priority 8 veteran but they
need help with traumatic brain injury or PTSD? Would you take
that individual into the VA system? And I don't need an answer
today if you can't----
The Chairman. What if they are not a veteran and they have
been injured in the war?
Mr. Michaud. So that would be my question for them. The
additional follow-up question to the Colonel would be, you had
mentioned earlier that every soldier is important to you. Some
of the concerns that I have heard from the men and women who
have been over in Iraq, who have come back from Iraq, when you
look at the ratings, if everyone is really important when you
look how you deal with the disability ratings, it is different
than the VA.
You look at the injury, as I understand it, whereas the VA
looks at an individual as a human being, as a whole person. And
that is why we are seeing a disparity in ratings. And when you
are reviewing this process, hopefully that you would look at
the soldier as an individual, and yes, they might have lost a
limb over in Iraq, but yes, they also might have caused other
problems such as PTSD or TBI. So hopefully that review process
will look at an individual as a whole person, similar to what
the VA does.
Dr. Katz. We will respond to the question about the
veteran/contractor for the record.
[The following was subsequently received:]
VA would provide care to a veteran who serves as a contractor
in either Iraq or Afghanistan, if the veteran is already
enrolled in the VA health care system. If the veteran is not
enrolled in the VA health care system, the veteran could apply
for enrollment, and VA would make an enrollment decision based
upon applicable eligibility factors.
If the veteran had no other qualifying eligibility factor
such as a service-connected disability, recipient of a Purple
Heart award and income under the applicable VA means test
threshold or determined to be catastrophically disabled, the
enrollment restriction for new priority 8 veterans would apply.
The Chairman. Mr. Rodriguez, do you have a concluding
comment or question?
Mr. Rodriguez. I haven't had a chance to----
The Chairman. Oh, I am sorry. I apologize for missing you.
I am sorry.
Mr. Rodriguez. And I apologize. I didn't get a chance to
listen to the panel either, to the whole panel. I know Dr. Katz
well, you know. So good seeing you again.
I don't know how many of you actually listened to the
initial testimony. As we look at the numbers of 22,000, I would
presume, and I want you just to comment on it, that that is
disproportional in terms of the diagnosis for that specific
diagnosis. Would that be accurate in saying that, that that is,
you know, if there are 22,000?
Dr. Katz. There have been 720,000 individuals discharged or
separated from the military after service in Iraq and
Afghanistan.
Mr. Rodriguez. Seven hundred and----
Dr. Katz. Twenty thousand.
Mr. Rodriguez. Okay.
Dr. Katz. Two-hundred fifty thousand have come to the VA
for care.
Mr. Rodriguez. So 22,000--usually there is a percentage out
there for, I guess, one-half percent or a percent of the
population falls into schizophrenia, what other percentages--so
is that something that is out of the, you know----
The Chairman. How many of those 250,000 were diagnosed by
the VA with personality disorder?
Dr. Katz. I could get back to you about that. That is not
one of the diagnoses we follow most closely.
[The following was subsequently received:]
From October 1, 2001 to March 31, 2007, 252,095 OEF/OIF
veterans were either evaluated or treated at VA medical
centers. Of that number, 2,316 OEF/OIF veterans were seen for
personality disorders (ICD-9 CM, 301).
It is important to note the ICD diagnoses used in this
analysis to obtain the number of OEF/OIF veterans seen for
personality disorders were obtained from computerized
administrative data. Although diagnoses are made by trained
healthcare providers, it may include provisional diagnoses
before confirmation by specialists, diagnostic tests, and a
followup evaluation.
Mr. Rodriguez. Yeah. I was just wondering----
The Chairman. Because you are not looking for it. You told
us you are looking for PTSD. They are looking for personality
disorder----
Mr. Rodriguez. Yeah, because I think--I just wonder where
there is a disproportional number in that population of that
specific diagnosis. That is the only reason I was asking.
Secondly, we know that--and it also brings some concerns.
And I know the Colonel and I am familiar with Brooke Army
Medical Center. They do great work there. Do we know in terms
of the data that we have now if there is a disproportional
number may be coming out of Fort Carson or other areas with
that diagnosis or do we know that for a fact, or we don't have
that information?
Colonel Crow. No, sir. You are raising some very good
questions in terms of prevalence rates of the diagnosis, let's
say, of personality disorders in general. How have they--
variance stayed constant over time, before war, after war,
given the different demographics of the soldiers that are
coming in. There would be a lot of questions, I think, that
could help answer whether or not there seems to be a variance
at this point in time with making that diagnosis.
Mr. Rodriguez. But see, there is a pattern that maybe from
some areas or some psychiatrist doing, going in that direction
versus others, in terms of their decisionmaking.
I would also be concerned--and you mentioned it also that
if there is one that we misdiagnosed that is one too many. And
so of the ones that we have dishonorably discharged, and I
don't know if we have those figures, if they were due to self-
medication, because I know that sometimes when they are ill,
there is a tendency to self-medicate and maybe get illegal
drugs. And I know that that is grounds for dishonorable
discharge.
And I am curious now whether there are some people under
that category that could have been ill and were not caught and
now find themselves dishonorably discharged as a result of
trying to self-medicate. Do we have any idea?
Colonel Crow. No, sir. I am now thinking of a way that we
would be able to answer that.
Mr. Rodriguez. We would have to go after the discharge--
they were dishonorably discharged, to get a grasp to see if
there is any, you know, because if we have made mistakes in
diagnosing, and I know full well that someone may be seriously
ill and we misdiagnosed, then we could have also, that person
could easily have gone to try to self-medicate in the process
of doing that and then find themselves, even though they might
have had a great record with the military, find themselves
dishonorably discharged as a result of that.
And so I would be concerned if there is just one who
deserves to have, not to have fallen into that category. I
wonder if you have any comments on that. Have we ever done any
assessments of that?
Dr. Katz. We have seen the press reports about that
happening and are very concerned about those tragedies. There
are processes in VA for appealing less than honorable
discharges to reclaim eligibility for benefits.
Mr. Rodriguez. The Chairman said, you know, we are in a
situation and we hear the report. I guess the frustration is if
we don't hear anything, we are not going to come up with a plan
as to what is best to get to it unless we hear that, and the
report tells us that no, everything was above board. But if
not, what would you recommend under those circumstances having
heard the allegations?
Colonel Crow. Well, sir, I think if the question is, is the
Army and perhaps the other military services doing an accurate
job of diagnosing personality disorders as they are
administratively separated, I think there would be some other
indicators that we could look at. One of the things that I had
mentioned in my oral statement was there is supposed to be
checks and balances in this process. And one of the balances,
if you will, is a review by a legal officer to make sure that
procedures were followed, that the soldier who is being
separated understands the nature of the separation, agrees with
it, understands their benefits.
That is not a medical procedure. I don't know if there are
suspicions or problems with that balance. Part of the problem
may be complaints by soldiers that this is not working well. I
really wouldn't know that. But I think that would be another
potential indicator.
Mr. Rodriguez. Yeah, because I know that that particular
diagnosis automatically disqualifies the personality disorder,
basically indicating that--now, the other diagnosis of
schizophrenia, we haven't heard anything on that. But that
onsets also early adult and it is under pressure that it
reveals itself. Do we have any data on those individuals?
Dr. Katz. Among those who have come to VA for clinical
care, among the 250,000, the number of those who have served in
OIF or OEF who have come back with a psychosis is really quite
small, under 2,000.
Mr. Rodriguez. Yeah. And in the regular population, that is
about 1 percent or less. So that seems--I don't know what the
numbers are. So is that about appropriate?
Dr. Katz. It is a percent or less that have a psychosis.
There are other psychoses besides schizophrenia, but one would
expect that the people with early onset, the most severe forms
of schizophrenia would not be in the military.
Mr. Rodriguez. Okay. Thank you very much.
The Chairman. Thank you. Do you have any final thoughts,
Ms. Brown-Waite?
Ms. Brown-Waite. Mr. Chairman, I would ask that the record
be reflected for the true statement that Colonel Crow made. I
just want to make sure that there is no misinformation out
there. I just think that that would be appropriate.
The Chairman. That is part of the--this is officially
transcribed. So all his words will be in the record, as will
mine.
Mr. Kennedy----
Ms. Brown-Waite. I just wish that there could be some way
that your words and your interpretation could be indicated
that--because I think that there was a very clever weaving of
what he said and how you interpreted it. And that concerns me.
The Chairman. Well, thank you for saying I am so clever.
But Mr. Kennedy, do you have any final thoughts?
Mr. Kennedy. Thank you. Yes, Mr. Chairman. I just wanted to
point out once again, as a Member of the Veterans'
Appropriations Subcommittee, that, you know, we are looking
forward to doing a Conference Committee and looking to address
the immediate--you know, we are talking all about these
problems, but we have got all these veterans out there
suffering right now. And we have got to get help to them right
away. There is a lot of talk going on, but we need action.
And we need to make sure that we get these services out to
them as soon as possible without delay and we need to do it
this year posthaste and I hope in this Conference Committee
that we can take this authorizing language that this Committee
has been working on on the contracting out and put--set aside
dollars for the Veterans Integrated Service Networks (VISNs) to
specifically use to contract out for mental health services and
other services with local community health providers to obtain
the services desperately needed by these veterans, that they
are not now currently getting and due to the fact that the need
is so great and the capacity is so limited within the VA.
And the intransigence it seems as though that there is,
within the VA, to want to share, you know, to go outside itself
to--and I know there is this insular attitude. I don't know if
any of you could talk to me about where that comes from. I know
it is kind of a sacred cow. I mean I am hearing it--I hear it
from my VSOs. They don't even want to hear me talk about any
contracting out of VA services because God forbid, you know,
anything but the VA provide services to veterans.
But I am telling you this. My veterans don't care where
they are getting their services now. That World War II
generation wanted to be with the World War II generation. Korea
wanted to be with the Korean generation. But after that, these
new veterans, they don't care where they get their care. They
want their care. Okay? And they don't care if they are with
their fellow veterans. They want to make sure they get their
care.
I just as soon we take a gold card and give it to every vet
that comes back and say you go out there and you get your care.
This notion that we are now trying to protect these sacred cows
so as to--and in the process letting our poor veterans go out
there and in the middle of all of this have to wait in line
and, you know, fight for what should truly already be theirs to
me is just something that is inexplicable.
But maybe you guys could shed some light on this issue to
me. You understand the issue, and I think we all do, that there
is a cohort of veterans from an earlier age that all love to be
together because of that sense of common experience, that there
is that bonding. They like to be together. But there is a new
generation of veteran that frankly wants to just get their
healthcare, get their benefits and get on with their lives,
that isn't as consumed with this notion of where they get it.
They just want to get their healthcare.
And maybe you can answer me why there is this sacred cow
and why we can't get these VISNs to give up their sacred
territory about contracting out with community mental health
providers, per se.
Dr. Katz. Mr. Kennedy, I would like to respond by saying I
have admired your advocacy, knowledge and passion for the
mental health issues for many, many years. All of us in the
mental health professions are very, very glad you are here.
I think that what we are protective and paternal about
isn't our turf, but the quality of care, as well as access to
care. And we would very much appreciate the chance for
technical discussion with you about how to optimize both access
and the quality of care.
Mr. Kennedy. Well, let's work on appropriate language. But
one thing I think that would be a conflict is if a local VISN
director has to make a choice of deciding where to put the
money and they are going to take that budget and that budget is
going to be chosen as to whether they are going to take their
money out of their hide and spend it on a community mental
health center or not, where are they going to spend it. They
are going to spend it within their own budget to make ends meet
as opposed to, you know, take a chance that looking at this
local community health center that does great work down the
way.
Now, that local community health center has certified
mental health professionals. Now, frankly, the experience of
these veterans run the gambit. Now, granted, you have the post
traumatic stress disorder and the VA has certain expertise. And
in fact, we are studying some of that in my district that is
some of the most cutting edge in the PTSD area. But there is a
great deal of work in substance abuse, in marital counseling,
in a whole host of areas that frankly, you know, there is
plenty of room where the VA doesn't need to be--where they can
be maximizing the use of these mental health professionals.
When you have got over 40 percent of the Guard and
Reservists right now suffering from PTSD, I would think that
you would err on the side of caution of getting them access to
some kind of mental health professional rather than saying hey,
we want the perfect to be the enemy of the good. I don't think
we want the perfect to be the enemy of the good, because
frankly, even if a mental health provider is not an expert in
PTSD, it doesn't mean that they don't have the kind of training
that they need to deal with trauma, because trauma itself is
not something that they aren't ill-equipped to deal with in
general.
So let's work together on this because with the magnitude
of this problem, we can't wait. We both agree that waiting is
not the answer. Failure, you know, is not a solution, as they
said in Apollo 13, because we know that delay here makes this
problem worse, not better. And I thank you for your work and
your concern about this.
And maybe I could ask, one of the problems I heard about at
my local VA hospital was that if not asked about whether an
Army, a Guard Reservist was being treated for PTSD, they would
be called back up. That was specific to my VA in Providence. My
PTSD supervising doctors told me that they were--saw some of
their patients being sent back to Iraq and as a matter of
policy, the Navy specifically prohibited, but the Army did not.
They said that the Army, if they did not specifically ask
whether they were treating someone for PTSD, that the VA did
not have to volunteer that information. Is that true?
Dr. Katz. VA's policy is to share information without
significant barriers for those with whom we share clinical
care. The redeployment decision is a command authority
administrative decision and VA's policy on sharing clinical
information for administrative command authority reasons is to
require that the veteran consent to VA sending the information
to DoD.
We are concerned that there may be cases for whom that
exposes veterans to risk, but we are concerned that without a
consent provision we may not be recognizing the rights of
people who may want a military career and respond to treatment
to continue their military careers. It is a tough tightrope in
balancing rights and responsibilities.
Mr. Kennedy. Well, what it seems to me is, they are
concerned that they can't say that I am getting treatment
because they know the military is going to say goodbye and
their military career is going to be over. Whereas, if they
said no, I am getting treatment, the military would say okay,
you can stay in the military, but here are some other options
for you in the military.
That is what I think is not--is the missing piece here.
Instead, what we have is, we have the military saying, you
know, don't ask, don't tell. And in the process, we may have
someone who comes back into the unit that may be a threat to
the unit if they are not properly treated, if they are not safe
to themselves and to the unit.
I mean you have basically said, if they are not--you are
balancing on the one hand the individual's needs with the
unit's needs, correct? So how do you do that?
Dr. Katz. VA's policy is to provide this information to DoD
with the veteran's consent. And our assumption is that the
Department of Defense examines people about to be redeployed
for mental health and other physical conditions that could
limit their effectiveness.
Mr. Kennedy. Right. Well, my--the thing is, my PTSD doctor
in Rhode Island said that they were--he was actively treating
PTSD Guard and Reservists who were on medical leave,
Reservists, okay, so that they were called up again and he
wasn't consulted as to whether they should be called back into
active service and so they went back to Iraq and presumably
they joined their unit and presumably they were fit to join
their unit and they weren't a threat to the security of the
unit or themselves.
But it is interesting that that is--that that fine point
has not been worked out. I believe in protecting the private
confidentiality of the soldier. But I also believe in the
safety of the unit and I don't think that in order to protect
the privacy of the soldier we need to sacrifice the safety of
the unit, and I don't believe that the soldier's future career
needs to be jeopardized.
I think that there ought to be other options for that
soldier to pursue. That is the big conundrum, that there is
this notion that if they reveal that somehow they have sought
treatment, that they somehow have no other--their options are
limited, absolutely limited from then on, which, of course, as
we know, is not true. So that I think is where the stigma comes
in.
Colonel Crow. I would like to make a comment. I am not sure
that it will really address what you are saying. But I think
the assumption has been made throughout the course of the day
that once diagnosed with post traumatic stress disorder it is
sort of a end of the line----
Mr. Kennedy. Right.
Colonel Crow [continuing]. Kind of connotation, and that is
not the case as we see it.
Mr. Kennedy. Right.
Colonel Crow. What we know is, we have soldiers who are
diagnosed with post traumatic stress disorder who continue to
do their job. They want to do their job. They want to stay on
active duty and perform. So there is not an automatic
disability associated with post traumatic stress disorder.
We also know that the models of treatment that have been
developed came from a different population at a time when we
didn't know very much about PTSD and we believe that it is
extremely important to rapidly develop, to the extent that we
can, models of treatment that allow us to provide interventions
close to the time that the traumatic event and the symptoms
appear. That is not a situation that we had in Vietnam. It is a
situation that we do have now as an opportunity. However, the
professions and the science had not matured to the point where
we have off-the-shelf capability to do that. That does need to
be developed.
We are extremely grateful that there has been a
considerable sum of money that will be provided to the
Department of Defense to help both with research, as well as
new clinical programs that I think will help quite a bit.
I also think it would be remiss to leave the impression
that the mental health providers in the Army or Department of
Defense don't know what they are doing. We have extremely well-
qualified and extremely well-trained individuals. If there are
problems with individuals who are outside the variance of
clinical practice, by all means, that needs to be correct. But
we have dedicated professionals. We have strong ethics within
the Army of taking care of soldiers and trying to do what is
right. And I think that needs to be recognized and not
overlooked.
The Chairman. Thank you. Thank you, Colonel Crow.
Mr. Kennedy. If I could, Mr. Chairman, we don't have enough
of them.
Colonel Crow. That is true.
Mr. Kennedy. We don't have enough of them and we also have
had an ethic of ``pull yourself up by your bootstraps,'' too
much of that ethic recently from the political establishment in
this town as of the last few years that, you know, believe in
God and country and you will make it through. And that, my
friends, has been what has been wrong with this. If you believe
in God and country, you will be all right. If you don't, that
is, you know, you have got some moral deficiency here.
That is what we have got to get over. This is a real
disease, a real effect of war and it is not some moral failing
of the person and not some character defect and unfortunately,
so much of the--there has been so many mixed messages coming
from political leadership at the VA and from the
Administration, whether it be other administration--Justice
Department, through the politicization of those other
departments, and so forth, that have sent these messages out
that I think has made it very difficult for people who have
been trying to seek care, to go out there and think that it is
all right for them to seek care.
Thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Kennedy. Thank you for your
leadership on this.
We thank the panel for being here and this meeting is
adjourned.
[Whereupon, at 3:06 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Bob Filner
Chairman, Full Committee on Veterans' Affairs
Thank you all for coming here today. The purpose of this hearing is
to examine: (1) how the VA addresses Personality Disorders; and (2) the
recent report by the Institute of Medicine on VA PTSD claims.
Let me start by saying that this is a real issue. Estimates are
that about one-third of Iraq and Afghanistan veterans may show signs of
PTSD. A national report last year said that the number of veterans
seeking help at VA walk-in Vet Centers for PTSD rose from 4,500 to over
9,000 between October 2005 and June 2006.
Mental health issues, however, are not confined to OIF/OEF
veterans. There are many older veterans who have yet to be properly
treated or diagnosed. Until recognized in the early eighties, PTSD was
considered a temporary ``war neurosis.'' For servicemembers who didn't
recover, the default diagnosis was to search for an underlying
Personality Disorder.
My concern is that this country is regressing and again ignoring
legitimate claims of PTSD in favor of the time and money saving
diagnosis of Personality Disorder. For instance, in the last 6 years,
the military has discharged over 22,500 servicemembers due to
Personality Disorders. Unfortunately, this Committee does not have
oversight responsibility for DoD; however, I have asked them to be
present today because they can provide insight on the initial mental
health treatment of our veterans.
Providing veterans with the correct medical diagnosis is key for a
variety of reasons ranging from receiving proper treatment to
eligibility for military and veterans benefits.
Once a servicemember is diagnosed with a Personality Disorder, he
or she has a much more difficult time receiving benefits and treatment
at the VA. I want to know how the VA deals with veterans who have been
labeled with a Personality Disorder.
Does the burden fall on the veteran to prove that he or she doesn't
have a Personality Disorder? Will such a diagnosis prevent the veteran
from receiving health care once initial VA coverage ends? What extra
barriers does this veteran face?
I am also very interested in learning more about the May 7th PTSD
Compensation and Military Service Report, which addressed the current
status of the VA's PTSD claims process. The Report was completed by a
Committee of preeminent professionals in the mental health field and
was paid for by the VA.
The Report offered numerous recommendations on how the VA could
improve its PTSD claims process. I want to hear the VA's opinion on
whether they can implement the many suggestions offered in the Report.
Or, is this Report going to wind up like so many others before it--on a
dusty shelf somewhere in the vast VA?
In closing, I want to say that our servicemembers who come back to
the states from serving in OIF/OEF should not be forced to fight a
second battle to receive a proper medical diagnosis and the benefits
and medical care they deserve. One battle in a lifetime is more than
enough.
Prepared Statement of Hon. Corrine Brown
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman for calling this hearing today to discuss
the relationship between PTSD and Personality Disorders and treatment
at the VA.
PTSD has been called many names through to many wars. From
``soldier's heart'' in the Civil War, to ``shell shock'' in World War I
and ``combat'' or ``battle fatigue'' in World War II.
Other terms used to describe military-related mood disturbances
include ``nostalgia,'' ``not yet diagnosed nervous,'' ``irritable
heart,'' ``effort syndrome,'' ``war neurosis,'' and ``operational
exhaustion.''
Yet the name is not important for the disease, but how those
affected are treated.
The men and women in our military are risking their lives to defend
the freedom of this country and for us to throw them away after their
operiational usefulness has ended is inhuman and un-American.
I am reminded of the words of the first President of the United
States, George Washington, whose words are worth repeating at this
time:
``The willingness with which our young people are likely to serve
in any war, no matter how justified, shall be directly proportional as
to how they perceive the veterans of earlier wars were treated and
appreciated by their country.''
I look forward to hearing the testimony of those panelists here
today and learn how to best help those who have bravely served our
Nation in war.
Prepared Statement of Hon. Stephanie Herseth Sandlin
a Representative in Congress from the State of South Dakota
Thank you, Chairman Filner for holding this hearing to review
assertions that Post Traumatic Stress Disorder claims are being
misclassified as pre-existing personality disorders and also to review
the May 7, 2007, report from the Institute of Medicine and National
Research Council on the Department of Veterans' Affairs PTSD disability
rating system.
I also would like to thank all of today's witnesses. I look forward
to hearing your testimony.
Like the rest of my colleagues on this Committee, lam committed to
the quality health care that our servicemembers and veterans deserve
and were promised, including honest and fair medical evaluation and
treatment.
Mr. Chairman, thank you again for holding this hearing. I look
forward to working with you to resolve these problems and other
problems associated with the Department of Veterans' Affairs and
Department of Defense's PTSD disability rating systems.
Prepared Statement of Hon. Cliff Stearns
a Representative in Congress from the State of Florida
Mr. Chairman,
Thank you for holding this important hearing on Post Traumatic
Stress Disorder (PTSD) and Personality Disorders among returning
servicemembers from areas of conflict. I am pleased we are holding this
hearing today, and look forward to participating in this discussion.
PTSD is the most prevalent mental disorder among returning
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
servicemembers. The hallmark characteristics of PTSD include
flashbacks, nightmares, intrusive recollections or re-experiencing of
the traumatic event, avoidance, and numbing. When such symptoms last
under a month, they are typically associated with acute stress
disorder, not PTSD. In order for a diagnosis of PTSD, symptoms have to
persist for at least a month and cause significant impairment in
important areas of daily life. However, some studies indicate that more
than 80% of people with PTSD also experience a major depressive or
other psychiatric disorder. Therein lies the difficulty in accurately
evaluating a patient has suffering from PTSD, or a Traumatic Brain
Injury (TBI) or as having a personality disorder. I am pleased that
beginning in 2005, the Veterans Health Administration created
``Returning Veterans Education and Clinical Teams'' in medical centers
to help, educate, evaluate, and treat returning veterans with mental
health and psychosocial issues. These programs collaborate with other
VA Medical Center PTSD, substance abuse and mental health programs, and
with polytrauma teams, TBI and primary care services, as well as with
Vet Centers in an attempt to provide comprehensive treatment. By the
end of this year, the VA anticipates that it will have 90 of these
programs operational throughout the country.
While the treatment for PTSD is improving in the VA system, we are
here today to ensure that all those who need such mental health
services are correctly identified, getting the appropriate treatment,
and able to receive the appropriate compensation for their disability.
A recent report from the Institute of Medicine regarding PTSD
compensation was very interesting and raised some good points. I was
interested by the Institute's finding that the VA's current approach
using the Global Assessment of Functioning (GAF) scale when evaluating
severity of PTSD for compensation and disability claims was inaccurate
and needed to be re-evaluated. In fact, the report states that the GAF
scale is, ``only marginally applicable to PTSD because of its emphasis
on the symptoms of mood disorder and schizophrenia and its limited
range of symptom content.'' In particular, the Institute advocates that
the system should look at the veterans' everyday life and social
interactions and not solely upon the impact upon the veterans'
employability.
Among some of the Institute's recommendations was the suggestion
the VA use only experienced mental health professionals to diagnose
patients claiming to suffer from the disorder, rather than standard
claims processors. The variation among evaluations spans sometimes from
a 20-minute conversation to the recommended full 3-hour evaluation.
Standardization among these evaluations is imperative to ensure
patients are diagnosed and treated correctly. To that end, VA leaders
should align their guidelines to those set by the American Psychiatric
Association, and implement certification procedures for workers dealing
with PTSD claims.
I feel it is important to note that the focus of this Committee
hearing should be on the VA claims process and criteria for PTSD
claims. While there have been publicized reports of problems with the
screening and discharge processes at the Department of Defense, the
jurisdiction and problem before this Committee is how the VA processes
and evaluates claims from veterans asserting PTSD for service-connected
disability status. It is a complex issue involving many psychiatric
components, and I look forward to our panels of witnesses shedding
light on the intricacies in these diagnoses for us today.
Thank you.
Prepared Statement of Hon. Ginny Brown-Waite
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman,
I appreciate all of the witnesses, and I especially would like to
thank all the healthcare professionals present here today. Your
involvement and expertise helps this Committee ensure we are meeting
the healthcare needs of the men and women that have so bravely served
their country in the Armed Forces.
The men and women of our military not only face grave physical
danger while on the battlefield but in some cases experience life
altering traumatic events that effect their ability to lead a normal
life when they come home. Today's hearing draws attention to a report
by the Institute of Medicine on how the VA handles claims of post
traumatic stress disorder. Post traumatic stress disorder is a serious
medical condition and our veterans should receive the care they need to
live a healthy and productive life.
Once again, I welcome you to the hearing and look forward to
hearing your thoughts on the issue before us today.
Prepared Statement of Hon. Harry E. Mitchell
a Representative in Congress from the State of Arizona
Thank you, Mr. Chairman. I am very pleased that this Committee is
addressing the issue of service-members who have been denied treatment
of their PTSD due to a determination of a preexisting personality
disorder. This topic is one which needs all the attention we can give
it. While I understand that this situation is happening in our Armed
Forces, I believe that Congress as a duty and responsibility to shed
light on this deplorable situation.
It has always amazed me that it is somehow acceptable to treat
people suffering from ``unseen'' mental injuries any differently than
if they had a visual wound or impairment.
I look forward to hearing from our panelists and to working with
this Committee to do everything in our power to make sure that this
practice stops.
Mr. Chairman, I ask that we continue to follow up with these
soldiers when they transition to our jurisdiction in the Veterans
Affairs system to make sure that they get the services they need while
this egregious policy is being rectified.
Prepared Statement of Jason W. Forrester
Director of Policy, Veterans for America
Chairman Filner, Ranking Member Buyer, Members of the Committee:
It is an honor to be here today.
Veterans for America--formerly the Vietnam Veterans of America
Foundation--focuses solely on meeting the needs of America's newest
generation of servicemembers, and veterans. We work very closely with
the Department of Defense, Members of Congress, the media, active-duty
troops and veterans to identify the unique challenges facing today's
military.
Much of our work is investigative. Members of VFA have visited
every major demobilization site in the United States and abroad.
Specifically, our work at Ft. Carson, Colorado--where we first met
Specialist Town--and our current work at Camp Pendleton, California,
has prompted considerable media attention and congressional action, and
has helped identify trends and areas where our country is failing our
servicemembers.
We also work closely with veterans trying to navigate the mammoth
VA bureaucracy. However, given the distressing disconnect between VA
and the DoD, the greatest service that VFA can provide here today is to
highlight the trends we have identified and are working to correct
within DoD and to offer some ideas regarding how the VA can help in the
process of ensuring that those who have served in Iraq and Afghanistan
get the assistance they deserve.
It is important for VA to understand the unique situations and
experiences of the nearly one million servicemembers from Iraq and
Afghanistan who are still on active duty--and who will be in the VA
system sooner or later.
It is our hope that once the VA has a greater understanding of the
specific needs of today's military and a greater understanding of the
deficiencies within DoD that the VA can help those who were failed
before they became veterans.
The DoD's Mental Health Task Force's report found that 49% of Guard
members, 38% of soldiers, and 31% of Marines are experiencing some
mental health issues after serving in Iraq and Afghanistan. The Task
Force recognized that programs within DoD did not adequately reflect
the increasing demand. These shortcomings are caused partly by a lack
of resources. In addition, stigma is a significant hurdle blocking
treatment. In the Task Force report, DoD characterized PTSD as a
``signature'' wound of wars in Iraq and Afghanistan.
Our investigative work supports these findings and demonstrates the
immense challenge of implementing solutions across the military.
At Ft. Carson, we found soldiers who had been diagnosed with
chronic PTSD who were only receiving 1 hour of individual therapy a
month. Often, these soldiers saw a new therapist each visit. In an
attempt to compensate for this deficiency, many soldiers were
prescribed medicines to help them deal with their PTSD. It was not
uncommon for us to meet soldiers on over 15-20 different medications at
once.
At Ft. Carson, we worked with soldiers who, having clearly
indicated on their Post-Deployment Health Reassessment (PDHRA) that
they were having difficulty readjusting to life post-deployment, were
not receiving the treatment they need. In some cases, these soldiers
have been redeployed only to have their wounds compounded by further
exposure to conflict. In other cases, undiagnosed and untreated PTSD
led soldiers to turn to drugs and alcohol.
The civilian medical community has long recognized that alcohol and
drug use is a symptom of PTSD, and, fortunately, many in the military
also recognize this. That said, this reality poses a significant
challenge for our military and has had unfortunate consequences for our
servicemembers. The maintenance of discipline is the top priority for
the military and the pressure to bring together units to be deployed is
immense. The combination of these two factors have inhibited adequate
treatment of the behavioral manifestations of PTSD.
At Ft. Carson, many soldiers addicted to alcohol and drugs have
been referred to the Army Substance Abuse Program (knows as ASAP), as
Army regulations dictate. While this program can be very beneficial to
soldiers who have only drug and/or alcohol addictions, it does not help
soldiers with service-connected PTSD. It is policy within DoD not to
treat soldiers with drug and/or alcohol addictions for their PTSD until
their addictions have been addressed. There are no dual-track PTSD and
substance abuse programs within the DoD. We have worked with several
soldiers who have suffered greatly from this deficiency and, in some
cases, we have managed to get them help within VA facilities that offer
dual-track care.
We also have seen many cases other where soldiers with PTSD have
been other-than-honorably discharged--losing any hope of treatment for
their service-connected injuries.
Many of the same issues are found at Camp Pendleton. The Marine
Corps still has not identified adequate approaches for dealing with
behavioral issues associated with mental health challenges. As a result
of our work, VFA believes that the stigma associated with mental health
is greater in the Marine Corps than in the Army. The Marine Corps often
confines Marines with behavioral issues to the brig. In the brig,
Marines are still given their medications, if they were lucky enough to
have received a diagnosis. However, they receive no therapy and are
left to deal with the consequences of their service-connected injuries
alone.
These problems within the DoD have created considerable challenges
for the VA. VA needs to recognize this challenge by creating new
programs designed for this generation of servicemembers. Since PTSD is
so prevalent--and dual-track treatment options within DoD for mental
health issues and substance abuse are absent--VA must increase the
number of dual-track alcohol/substance and PTSD programs. VA must also
create new programs for Iraq and Afghanistan veterans with unique
needs--such as women and Guard and Reserve members.
VA can help greatly with the issue of stigma by increasing its
outreach to servicemembers and their families on bases and within
military medical facilities. Today's servicemembers need to know that
PTSD is an injury and that they deserve every opportunity to recover.
PTSD is not a sign of weakness. It is a proven medical reality of
sustained exposure to combat.
Finally, another distressing trend that we identified at Ft. Carson
was the prevalence of pre-existing personality disorder discharges for
soldiers with service-connected mental health problems. From 2001-2006,
the Army discharged over 5,600 soldiers for pre-existing personality
disorders; over 22,500 have been discharged for this reason across all
the services. A personality disorder diagnosis often requires
servicemembers to repay their re-enlistment bonuses and denies them
their combat-related disability pay.
Some within the Army's personnel system have argued that
personality disorder discharges are an easy way out for the Army and,
unfortunately, for soldiers who are tired of reprimands and suffering.
That said, the consequences of such a dismissal are severe, including
denial of VA benefits due to the disorder's ``pre-existing'' nature.
At Ft. Carson, we met numerous soldiers who had been diagnosed with
a pre-existing personality disorder discharge--often in under an hour--
regardless of the fact that they were deemed fit when they entered the
service and regardless of the fact that they had been diagnosed with
PTSD post-deployment to Iraq and/or Afghanistan.
Pre-existing personality disorder discharges remove the burden from
our society to help the servicemember deal with their service-connected
injuries. It is unacceptable to ask an American to sacrifice for this
country and not treat and recognize the consequences of their service.
In May of this year, as a result of our work at Ft. Carson, a
congressional staff-delegation returned to Ft. Carson where they met
with the soldiers and family members who we have been helping. This
visit prompted a GAO investigation into mental health treatment in the
military, and it led to 31 senators sending a letter to Secretary Gates
calling for a moratorium on pre-existing personality disorder
discharges.
While we are hopeful that this moratorium will come into effect
immediately, it still would not address the problem of those who have
already been inappropriately discharged.
This problem presents a great opportunity for VA leadership.
The VA has no obligation to treat a veteran with a pre-existing
personality disorder discharge since the discharge implies that their
injuries are not service-connected. That said, these veterans can still
visit Vet Centers. However, they do not have immediate access to
adequate medical care. This being the case, the VA should create a
streamlined process for face-to-face medical evaluations for those with
pre-existing personality disorder discharges.
We owe these veterans a second chance to get much needed help for
their service-connected injuries.
This concludes my prepared statement. I would be pleased to answer
any questions.
Prepared Statement of Jonathan Town, Findlay, OH
On January 20, 1961 a Veteran who was being sworn in as our
president said during his inaugural speech ``Ask not what your country
can do for you, ask what you can do for your country''. Since January
2001 over 22,000 people have answered this call and served in the
United States armed forces only to be chaptered out of the military
with a Personality Disorder discharge. It has become a debate if it was
done to save the military money or to help out with military war time
and deployment strength. Regardless of the reason, it is an outrage
that these servicemembers, including myself and their families have
been put through this.
I would like to tell you my story. I served 4\1/2\ honorable years
at Fort Knox, Kentucky as an administration specialist. I was then
given orders for ``Permanently Change of Station'' to Korea. After
arriving in Korea I was told that the unit I was assigned to had just
received its deployment orders to Iraq. In August, 2004 the ``STEEL''
battalion (which I now was part of) deployed to Ramadi, Iraq. On
October 19, 2004, I was running mail for our battalion when incoming
rounds started exploding across the street from where my vehicle was
parked. While running for shelter in our S-1 shop's office, a 107mm
rocket exploded 3 feet above my head leaving me unconscious on the
ground. After regaining consciousness, I was taken to the battalion's
aid station where I was treated for various wounds including a severe
concussion, shrapnel wound in my neck and bleeding from my ear. I was
given quarters for the rest of the day and went back to work the next
day. This is when everything started to go downhill health-wise for me.
Throughout the next 9 months, while continuing to serve my country, I
battled severe headaches, bleeding from my ear, and insomnia. We
finally got the word that we were headed home and I thought I would
finally be able to get some assistance for the medical issues I was
going through. After a few days back in the United States, I realized a
new battle for me was taking place. My ability to adjust to loud
noises, large groups of people, and forgetting what had happened to my
unit and myself while we were in Iraq was going to be yet another
battle.
About 45 days after coming back stateside to Fort Carson, Colorado
I was finally able to see a psych doctor. The first few meetings with
the doctor were good and it seemed like he actually cared about helping
me get through my issues if it were possible. Then word came down that
our unit was going to be redeployed. The next time I went to see the
doctor he informed me that he was going to push a personality disorder
chapter and explained why. The doctor said ``You have the medical
issues that call for a medical board but the reason I am going to push
this chapter is because it will take care of both your needs and the
Army's. You will be able to receive all of the benefits that you would
if you were to go through a medical board; get out of the military; and
focus on your treatment to get better. For the military they can get a
deployable body in to fill your spot''. I told him that if this is what
he thought was best for the military and my family that he could do
what he needed to do. I never realized that everything that was said to
me during that day were all lies.
I went through the ``final out process'' to leave the military. The
day that I was signing out I was told by the ``final out'' personnel
that I would not receive any severance pay or benefits and that I
actually owed the military $3,000. I do not know everyone in this room
but I think that if you where to work your heart out for a company or
agency only to be told that you owed them money when you went to leave
you would obviously think something is wrong. If it weren't for my
family taking us in and supporting us both financially and emotionally
and for new friends helping us, I don't know where my family and I
would be right now. The last 9 months have been spent trying to get
assistance both medically and financially through the Veterans
department; getting the word out to the public about what is happening
to my fellow servicemen and myself; and trying to get my family and
myself back on our feet. I'm now receiving treatment and disability pay
from the VA. I am fortunate because there are many, many injured
military personnel that still have not gotten to this point.
I think the government should fix the Personality Disorder
discharge issue and the time it takes a servicemember to receive the
start of their disability from the time they leave the armed forces.
The Chapter 5-13 Personality Disorder discharge should be completely
taken out of any DOD regulation or if the military really wants a way
to get servicemembers out of the service (that do not have over 6
months of active service or have not been deployed overseas) then it
needs to be written that way in the regulations. It is 100% wrong to be
able to use this discharge for any servicemember that has been on
active service for a substantial amount of time; who has fought in a
war or who has served in a war zone for their country.
An idea I have heard about I could fix how long a servicemember has
to wait till they finally start receiving disability after leaving the
armed forces. The servicemember starts his or her disability paperwork
and process at the station where the he or she is currently stationed 2
months prior to getting out of the service. The servicemember should
not be able to final out from their branch of the military until he or
she is either granted or denied their disability claim. By going
through this route, it will allow the servicemember to receive their
first disability check immediately after their last paycheck from the
armed service. The Department of Defense should work ``hand in hand''
with the Veterans Department to assist the soldiers in need.
In closing I want to state that I did not have a personality
disorder before I went into the Army as they have stated on my
paperwork. I have post traumatic stress disorder and traumatic brain
injury now due to injuries from the war. I shouldn't be labeled for the
rest of my life with a personality disorder and neither should my
fellow soldiers who also incorrectly received this label. I would like
to ask the Committee and panel Members to thoroughly think about the
ideas I have mentioned to fix some of the issues we as veterans are
facing. Please help those who have helped their country.
Thank you.
Prepared Statement of Joshua Kors, Reporter, The Nation
and Contributor, ABC News
Good morning. I've been reporting on personality disorder for the
last 10 months, and I'm here today to talk about the 22,500 soldiers
discharged in the last 6 years with that condition.
A personality disorder discharge is a contradiction in terms.
Recruits who have a severe, pre-existing condition like a personality
disorder do not pass the rigorous screening process and are not
accepted into the Army.
The soldiers I interviewed this year passed that first screening
and were accepted into the Army. They were deemed physically and
psychologically fit in a second screening as well, before being
deployed to Iraq, and served honorably there in combat. In each case,
it was only when they came back physically or psychologically wounded
and sought benefits that their pre-existing condition was discovered.
Discharging soldiers with a personality disorder prevents them from
being evaluated by a medical board and getting immediate medical care.
This can be life-threatening for our soldiers. A good example is Chris
Mosier, who served honorably in Iraq, where he watched several of his
friends burn to death in front of him. After that, he developed
schizophrenic-like delusions. He was treated at Ft. Carson for a few
days, then discharged with a pre-existing personality disorder. He
returned home to Des Moines, where he left a note for his family saying
the Iraqis were after him there in Iowa, then shot himself.
Surgeon General Gale Pollock agreed to review a stack of
personality disorder cases. After 5 months, she produced a memo saying
her office had ``thoughtfully and thoroughly'' reviewed the cases,
including Jon Town's, and determined all of them to be properly
diagnosed. With further reporting, I discovered that as part of that
``thoughtful and thorough'' 5-month review, Pollock's office did not
interview anybody, not even the soldiers whose cases she was reviewing.
Some of those soldiers said they called the Surgeon General's office
offering information about their ailments. Their efforts were rebuffed.
The one thing the Surgeon General's office did do was contact a
doctor at Ft. Carson, where many of the personality disorder diagnoses
were made, and ask him whether his doctors got it right the first time.
That doctor said yes, his staff's original diagnoses were correct, and
Pollock shut down the review at that point.
The Surgeon General's office denied that for many months, insisting
that the review was conducted by a panel of health experts who were not
involved in the original diagnoses. This wasn't a case of one man
reviewing his own work, they said. But eventually it did come out that
the only reviewer was Col. Steven Knorr, who as Chief of Behavior
Health at Ft. Carson, oversaw many of the personality disorder
diagnoses and, in his capacity as a psychiatrist, was reportedly
involved in creating many of them as well.
When the problems with Walter Reed became public, the Pentagon took
two actions: it accepted the resignation of Surgeon General Kevin
Kiley, and it hired the public relations firm LMW Strategies with a
$100,000 no-bid contract to put a positive spin on those problems. This
past week, as these personality disorder discharges became public, VA
Secretary Nicholson stepped down. And today Surgeon General Pollock
will sit before you.
As a journalist, it's not my role to make any recommendations, but
I do want to share with you the hopes of the wounded veterans I spoke
to this year, which is a hope that someone be held responsible, and
that officials go back through the 22,500 cases and seek out the
thousands of Jon Towns who are waiting there, struggling right now
without benefits or the media spotlight.
Personality Disorder Discharges (2001-2006)
----------------------------------------------------------------------------------------------------------------
Year Army Air Force Navy Marines
----------------------------------------------------------------------------------------------------------------
2001 805 Unavailable 1,389 443
----------------------------------------------------------------------------------------------------------------
2002 734 1,523 1,733 460
----------------------------------------------------------------------------------------------------------------
2003 980 1,496 1,316 328
----------------------------------------------------------------------------------------------------------------
2004 988 1,307 1,253 414
----------------------------------------------------------------------------------------------------------------
2005 1,038 928 1,176 475
----------------------------------------------------------------------------------------------------------------
Nov. 2006 1,086 1,085 1,076 442
----------------------------------------------------------------------------------------------------------------
Totals: 5,631 6,339 7,943 2,562
----------------------------------------------------------------------------------------------------------------
Source: Department of Defense
* Navy numbers are for fiscal, not calendar, year.
TOTAL (2001-Nov. 2006): 22,475
Total for 2001: 2,637 (which includes the Air Force's one
unavailable year)
Total for 2002: 4,450
Total for 2003: 4,120
Total for 2004: 3,962
Total for 2005: 3,617
Total for 2006: 3,689
__________
[GRAPHIC] [TIFF OMITTED] T7475A.001
__________
Press Release / March 27, 2007
``Post Traumatic Stress Disorder (PTSD) is real. The Army's
leadership--up and down the chain of command starting with the Acting
Secretary of the Army and the Vice Chief of Staff of the Army--are
actively involved in getting the entire Medical Evaluation Board and
Physical Evaluation Board process right. The Army has no greater
obligation to its returning `Wounded Warriors' than to provide them
with the absolute best medical care possible; and if we come up short,
then the Army will react immediately to remedy the problem.
Leaders from the Office of the Army Surgeon General had the cases
Mr. Robinson brought to them thoroughly evaluated and reviewed. While
we cannot address individual medical cases in this venue, it was
determined that the behavioral health providers did thorough
assessments and appropriately referred the soldiers for substance abuse
and behavioral health treatments. A more detailed response is being
provided to Mr. Robinson.
The behavioral health officers at the Army hospital at Fort Carson
reviewed the Chapter 5-13 cases in soldiers who were diagnosed with
PTSD. The data demonstrated that there were no soldiers separated under
Chapter 5-13 in the last 4 years who should have undergone a medical
evaluation board. It should be noted that a personality disorder
diagnosis does not necessarily mean that a medical evaluation board is
needed. It indicates that a soldier has personality traits that are not
compatible with military service.
Soldiers who are separated under Chapter 5-13 receive honorable
Discharges and, if they have served 6 or more years on active duty,
they are eligible for separation pay. Additionally, it is Army policy
not to separate a soldier for a personality disorder under Chapter 5-13
if that disorder amounts to a disability. If the disorder amounts to a
disability, the soldier should be separated under the disability
evaluation procedures of AR 635-200.
Further, it is certainly possible that there are cases where
soldiers with symptoms of Post Traumatic Stress Disorder or Traumatic
Brain Injury are not diagnosed or treated. We are grateful each time
someone raises a concern. Nothing is more important than insuring that
these men and women are provided the best possible health care.
We understand that many wounded and injured soldiers, who have
supported the Global War on Terror, as well as their families, continue
to endure hardships. The Army is committed to providing the best
possible medical care for the men and women who have volunteered to
serve this great nation and has recently launched the Wounded Soldier
and Family Hotline: 1-800-984-8523.
The purpose of the hotline's call center is twofold: to offer
wounded and injured soldiers and family members a way to seek help to
resolve medical issues and to provide an information channel to senior
Army leadership so they can improve how the Army serves the medical
needs of our soldiers and their families.''
Lieutenant Colonel Bob Tallman, Spokesman for the U.S. Army
Prepared Statement of Paul Sullivan
Executive Director, Veterans for Common Sense
Chairman Filner and Members of the Committee, thank you for
inviting Veterans for Common Sense to testify about ``PTSD and
Personality Disorders: Challenges for the VA.'' VCS is a non-profit
organization based in Washington, DC focusing on issues related to
national security, civil liberties, and veterans' benefits.
My testimony focuses on offering solutions to the many
unconscionable, outrageous, and intentional actions taken by the
Department of Veterans Affairs and by the Administration to prevent our
Iraq and Afghanistan war veterans from receiving prompt medical care
and disability compensation for PTSD. My testimony is based on more
than 15 years' of experience as a veterans' advocate and as a VA
project manager.
There are two common sense standards VA should meet. First, when a
war veteran needs mental healthcare, our Nation must provide it
immediately from a certified mental healthcare professional so the
veteran can avoid a broken family, lost job, drug abuse, alcoholism,
crime, homelessness, and suicide.
Second, when a veteran needs disability compensation for a mental
health condition, our Nation must provide it immediately, without
endless bureaucratic hassles, so the veteran can put food on the table,
pay the rent, and take care of his or her family.
When the Department of Defense discharges a servicemember who
fought honorably in combat for a personality disorder, then the
military is breaking its own rules. DoD regulations state that if a
servicemember was in combat, then the military is generally prohibited
from using a personality disorder diagnosis.
DoD's actions have serious consequences. A veteran discharged for a
personality disorder is usually denied access to VA healthcare and
disability benefits based on VA regulations that prohibit providing
services for a pre-existing condition.
In light of the military's inappropriate discharges, what can
Congress and VA do now to begin to resolve this fiasco? VCS will
describe the scope of PTSD among Iraq and Afghanistan war veterans, and
then VCS will offer solutions. More than 1.6 million of our fellow
Americans have deployed to the two war zones.
As of December 2006, about 686,000 are now veterans eligible for VA
healthcare and benefits. A staggering 36 percent, or 229,000 veterans,
were already treated at VA medical facilities. Of those treated, more
than one-third, or 84,000 veterans, were diagnosed and treated for a
mental health condition, including more than 20 percent, or 45,500, for
PTSD.
As of June 2007, more than 202,000 Iraq and Afghanistan war
veterans have already filed disability compensation claims against VA.
Of the 157,000 claims approved by VA, more than 19,000 veterans are
service-connected for PTSD. The PTSD claims will continue to rise as
the number of PTSD patients rise, especially when the deployed veterans
exhaust their 2 years' of free healthcare.
When all of our troops return home, at the current rate, VA faces
nearly 600,000 potential mental health patients, including 320,000
diagnosed with PTSD. The number will grow as hundreds of thousands more
of our servicemembers deploy for a third or fourth combat tour in an
escalating war that surrounds our troops with 360-degree combat 24
hours per day, where our troops switched from being the predator to
being the prey. The number of claims will also continue to rise,
including those for PTSD.
VCS urges Congress to adopt nine new policies so that more of our
war veterans with PTSD don't fall through the cracks--the period of
time between when a servicemember discharges from the military and the
new veteran begins receiving all of his or her healthcare and
disability benefits.
Failure to reduce the stigma and delay in providing healthcare and
benefits will most likely result in a social catastrophe among many of
our returning Iraq and Afghanistan war veterans--including broken
families, lost jobs, stigma, drug abuse, alcoholism, crime,
homelessness, and suicide. Many of these consequences are preventable.
Please act now and take advantage of this quickly closing window of
opportunity.
Proposed Solutions to Personality Disorder and PTSD Crisis
First, VCS urges Congress to order the Department of Defense to
immediately stop discharging war veterans with a personality disorder
diagnosis. If the military allowed the servicemember to enlist, then a
personality disorder diagnosis should be given only in cases of fraud
after providing the servicemember with full due process. Congress
should also order the military to conduct a review of all personality
disorder discharges for veterans deployed since September 11, 2001.
Congress should also order VA to review applications for healthcare and
disability compensation where VA denied access based on a personality
disorder.
Second, Congress should order DoD and VA to establish a policy to
reduce the stigma against people with mental health conditions.
Military studies confirm this stigma hinders many of our war veterans
from seeking mental healthcare. America can and should welcome our
veterans home with full and prompt access to mental healthcare.
Third, VCS urges Congress to demand full enforcement of Public Law
105-85, the law requiring all servicemembers to be examined for
physical and mental health conditions before and after deployment. This
law implements a critical lesson learned from the gulf war, when the
military failed to examine our troops before and after deployment. The
military's negligence resulted in a lack of information about gulf war
illnesses among more than 100,000 Desert Storm veterans that still
stump scientists today.
Fourth, Congress can enact legislation creating a presumption of
service connection for PTSD for veterans who deployed to a war zone
since September 11, 2001, who are diagnosed with PTSD. A deployment
since September 11, 2001, should be considered as combat under 38 USC
1154. A presumption makes it easier for VA to adjudicate the claim, and
results in faster medical treatment and faster disability compensation
payments for veterans. Congress should also explore automatically
approving all VA claims at a modest rate within 30 days, for a period
up to 1 year, for deployed veterans' claims. VCS supports this bold
recommendation initially made by Harvard Professor Linda Bilmes.
Fifth, Congress should enact legislation significantly expanding
VA's highly successful Vet Centers and allowing VA readjustment
counselors to provide mental health services to active duty
servicemembers, either at existing facilities or at new offices on
military bases. This expanded service might first be targeted at
military installations that have shortages of mental healthcare
providers and bases expecting large redeployments from the war zones.
This way, the supply of mental health professionals can meet expected
and significant surges in demand. Congress should also consider
allowing families to participate in the readjustment counseling process
at Vet Centers.
Sixth, Congress should enact S. 1606, which was added to the
National Defense Authorization Act in the Senate. This bill directs DoD
to streamline policies and reduce the number of veterans falling
through the cracks. The most important part of the bill, in our view,
is the provision mandating that DoD provide free medical care for
veterans discharged for a medical condition at less than 30 percent.
Based on the series of government Accountability Office reports over
the past 10 years, this legislation should be amended to mandate that
DoD provide VA immediate access to full military and medical records
immediately after a veteran's discharge so that VA can expedite medical
treatment and claims processing.
Seventh, Congress should enact S 1354, which directs VA to define
the war zones, collect data, and prepare cost and benefit use reports
about the Iraq and Afghanistan wars. This proposal mandates ``truth in
government'' so Congress and the public are fully and regularly
informed about the human and financial costs of the two wars. This
proposal will also tremendously improve VA planning and budgeting.
Without consistent and timely reports for the expanding Iraq and
Afghanistan war population, VA may once again fall $3 billion short and
be unable to provide medical care to veterans.
Eighth, in a related matter, VCS urges Congress to enact S 849 so
that VA and DoD comply with all Freedom of Information Act requests in
a complete and timely manner. VA routinely delays or denies our FOIA
requests about the Iraq and Afghanistan wars. VA's stonewalling unduly
hinders VCS from providing fact-based advocacy. VCS used DoD and VA
documents obtained under FOIA to assist Harvard Professor Linda Bilmes
with estimating the cost of the two wars for VA at between $350 billion
and $700 billion over 40 years. VCS also obtained obscure DoD reports
confirming the two wars caused more than 65,000 casualties, defined as
a person who is dead, wounded, injured, or ill (DoD and the press
routinely mislead the public by providing the incomplete count of
25,000 casualties). VCS also publicized the fact that VA statistics
reveal that National Guard and Reserve are half as likely to file VA
disability claims than Active Duty. However, the National Guard and
Reserve are twice as likely to have their claim denied.
Ninth, Congress and VA should consider a package of PTSD-related
reforms:
VA should set clear timeliness standards to screen and
provide care for PTSD.
VA should outsource current demand for PTSD treatment to
the private sector, so veterans receive timely care, until such time as
VA can hire permanent staff.
VA must accept a PTSD diagnosis from private professional
psychiatrists. If VA disputes the non-government diagnosis, then VA
should approve the PTSD claim until the claim decision is final so that
the veteran receives prompt medical care.
VA must update the outdated and incomplete PTSD rating
schedule to take into consideration quality of life issues raised
recently by the Institute of Medicine. The rating schedule should be
veteran-friendly and be based upon the latest medical and scientific
findings.
VA must require all claims adjudicators to receive prompt
and intensive training on PTSD claims. This high-priority item should
be accomplished quickly because of the escalating claims backlog and
the reasonable expectation of hundreds of thousands of more PTSD
claims.
VA must be held accountable when VA makes mistakes. When
a veteran wins a case based on appeal or remand, then VA should be
required to pay back interest and penalties. Without accountability, VA
will continue to inappropriately delay and deny veterans PTSD claims.
Background Describing VA's Crisis
Sadly, Mr. Chairman, the current VA political leadership failed our
veterans as the VA claims backlog grew 50 percent in the past 3 years.
In a bitter irony, VA handed out $3.8 million in cash bonuses to top VA
political leaders while the overall situation deteriorated at VA. More
veterans are waiting much longer to receive disability compensation
payments. In response to the outcry over the bonuses, VA said it wanted
to retain top executives who could earn more outside government. In our
view, bonuses are for exemplary performance only. Public service is an
honor, not an ATM machine.
Due to the current poor political leadership, VA's doctors and
claims staff are unable to provide either immediate treatment or prompt
payments because of inappropriate interference by VA political
appointees. In effect, VA's political appointees locked VA's doors and
blocked access to healthcare and disability benefits. If not for the
intervention of Congress in May to appropriate $1.8 billion in
emergency funds to hire more doctors and claims adjudicators, VA's
crisis would continue worsening.
In early 2005, while working at VA, I briefed political appointees
and executives at VA headquarters about the sharply escalating mental
health and PTSD disability claims among Iraq and Afghanistan war
veterans. I personally advised several VA executives, including Ruth
Whichard, Mike McLendon, Jack McCoy, Ronald Aument, Lois Mittelstaedt,
and several others, that the claims situation was worsening as the two
wars deteriorated and the number of eligible veterans continued
growing. I advised them, in writing, that more claims processors be
hired to meet the steeply rising demand, especially the even faster
rise in mental health and PTSD claims. I provided several e-mails
documenting these briefings to your staff in March 2007.
After my briefings, top VA political appointees shamefully broke
faith with our veterans. Instead of hiring more physicians and claims
processors to meet the growing demand, top VA political appointees
fought against our war veterans and locked the doors.
At one briefing in 2005, a political appointee since fired for his
role in the lap top theft scandal, Mike McLendon, revealed that the
Bush Administration was fighting against our war veterans. At one
meeting, McLendon said there were too many PTSD claims, the veterans
were filing them too soon after returning home, our veterans were too
young to be filing claims, and it costs VA too much money to assist
them. McLendon went further with a factually incorrect and highly
offensive statement that if our returning Iraq and Afghanistan war
veterans simply ``believed in god and country, then they would not come
home with PTSD.'' I immediately advised my supervisor about this
incident, and I also advised your staff about it in early 2006.
After my several briefings to political appointees in 2005 warning
them of the current problem, VA launched a systematic effort to block,
hinder, restrict, and otherwise prevent our newest generation of combat
veterans from receiving the mental healthcare they need and that they
earned. In effect, VA locked the doors to cover their refusal to
prepare for the surge in returning Iraq and Afghanistan war veterans
with PTSD.
VA's Four Anti-PTSD Policies Adopted in 2005
VA ordered a re-evaluation of 72,000 previously approved
PTSD claims rated at 100 percent. If implemented, VA's policy would
have further increased the 600,000 claim backlog by shifting VA claims
adjudicators away from working on new claims to work on already
approved claims. Luckily, Congress intervened and stopped VA from
implementing this outrageous policy. In the one thousand PTSD claims VA
reviewed, VA found zero cases of fraud.
VA instituted a ``second signature'' requirement for
approving new claims for PTSD at 100 percent. This VA policy would have
also increased the backlog by requiring additional work for each claim
by a second VA employee. Luckily, veterans groups raised the alarm and
VA suspended this policy. Congress should legislate a termination of
this policy.
VA contracted with the Institute of Medicine for the
stated purpose of validating the diagnosis of PTSD. VA's hidden purpose
was to narrow the definition of PTSD so that fewer veterans would
qualify for VA healthcare or VA disability benefits, thus blocking
future claims and saving VA money. Luckily for our veterans, IOM
validated the serious nature of PTSD.
VA again contracted with IOM for the stated purpose of
validating PTSD disability payment amounts. VA's hidden purpose was to
reduce the amount of money paid to veterans suffering from PTSD, thus
saving VA money. Fortunately for veterans, IOM responded with a report
saying VA should consider quality of life issues when determining a
veteran's level of disability.
When viewed together, these four anti-PTSD policies sent a signal
to veterans, veterans' groups, and Congress that VA would fight against
PTSD claims filed by Iraq and Afghanistan war veterans. We will never
know how many veterans stopped fighting VA and then needlessly suffered
from broken families, lost jobs, alcoholism, drug abuse, crime,
suicide, and homelessness.
Under the guise of saving taxpayer money, VA's 23-page claim form
and Byzantine claims process serve to inappropriately reduce the number
of eligible and entitled veterans receiving assistance for mental
healthcare and disability benefits, especially for PTSD.
As a result of these and other anti-veteran policies recently
adopted by VA, VCS was given no other choice than to file suit against
VA in Federal Court this week. VCS hopes to bring attention to the
plight of our returning war veterans with mental health conditions,
especially those misdiagnosed with personality disorder and thus denied
VA healthcare and disability benefits.
America must not repeat the social catastrophe after the Vietnam
War and gulf war, where veterans faced enormous road blocks when
seeking healthcare and disability benefits. Veterans are citizens, too,
deserving of full civil rights, equal access, and due process when
dealing with our government when we return home from war.
Allow me to close with this very sharp warning that the U.S. 9th
Circuit Court of Appeals issued last week in its ruling against VA for
resisting payments to Vietnam War veterans suffering from chronic
lymphocytic leukemia due to Agent Orange poisoning.
``What is difficult for us to comprehend is why the Department of
Veterans Affairs . . . continues to resist the payment of desperately
needed benefits to Vietnam War veterans who fought for their country
and suffered grievous injury as a result of our government's own
conduct. . . .
``These young Americans who risked their lives in their country's
service and are even today suffering greatly as a result are deserving
of better treatment from the Department of Veterans Affairs than they
are currently receiving. . . .
``We would hope, that this litigation will now end, that our
government will now respect the legal obligations it undertook in the
consent decree 16 years ago, that obstructionist bureaucratic
opposition will now cease, and that our veterans will finally receive
the benefits to which they are morally and legally entitled.''
[Attachments to Mr. Sullivan's testimony are being retained in the
Committee files and include the following:]
1. VA Benefits Activity, Veterans Deployed to the Global War on
Terror, Prepared by VBA Office of Performance Analysis & Integrity,
June 25, 2007;
2. VA Facility Specific OIF/OEF Veterans Coded with Potential PTSD
Through 2nd Qt FY 2007;
3. Analysis of VA Health Care Utilization Among U.S. Southwest
Asian War Veterans, Operation Iraqi Freedom, Operation Enduring
Freedom, VHA Office of Public Health and Environmental Hazards, April
2007;
4. Study by Linda Bilmes, John F. Kennedy School of government,
Harvard University, entitled ``Soldiers Returning from Iraq and
Afghanistan: The Long-term costs of Providing Veterans Medical Care and
Disability Benefits,'' January 2007 http://www.mofo.com/docs/pdf/
PTSD070723.pdf; and
5. Complaint filed against VA written by Gordon Erspamer, Esq., of
Morrison & Foerster: http://www.mofo.com/docs/pdf/PTSD070723.pdf
Prepared Statement of Tracie Shea, Ph.D.
Psychologist, Post Traumatic Stress Disorder Clinic
Veterans Affairs Medical Center Providence, RI
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning Mr. Chairman, I am honored at the opportunity to
provide testimony to the Committee on issues related to Post Traumatic
Stress Disorder (PTSD) and Personality Disorders.
Mr. Chairman, I come before this Committee, not as a representative
or spokesperson for the Department of Veterans Affairs (VA) but as a
mental health researcher who has conducted extensive research on
Personality Disorders. My thoughts and opinions, which I will share
with you today, are my own and should not be taken as VA's views or
policy.
As a psychologist on the clinical staff of the Post Traumatic
Stress Disorder Clinic at the Veterans Affairs Medical Center in
Providence, Rhode Island for the past 17 years, I have assessed and
treated hundreds of veterans. I also conduct research on personality
disorders and on PTSD as part of my academic role as professor of
Psychiatry and Human Behavior at the Warren Alpert Medical School,
Brown University. Of note to the topic of today's hearing, I was a
member of the Subcommittee responsible for the revision of the
Personality Disorders section for the 4th edition of the Diagnostic and
Statistical Manual for Mental Disorders (DSM-IV).
The Committee has requested my testimony regarding PTSD and
Personality Disorders in the context of servicemembers and veterans. My
comments will focus on requirements set forth in VA and used at all
VAMC facilities for an adequate assessment and diagnosis of personality
disorder. With regard to the use of appropriate procedures, I will
speak to my personal experience conducting assessments as a
psychologist at the VA in Providence.
Definition of Personality Disorder
A Personality Disorder is defined by the DSM-IV as an enduring
pattern of inner experience and behavior that deviates markedly from
the expectations of the individual's culture, manifested in cognition
(ways of perceiving or interpreting events, others' behavior), affect
(range, intensity, lability, appropriateness of emotional response),
interpersonal functioning, or impulse control. For a diagnosis to be
made, several requirements must be met:
1. The enduring pattern is inflexible and pervasive across a broad
range of personal and social situations. This means that problematic
behaviors should be evident in multiple situations.
2. The pattern of behavior is stable and of long duration, and its
onset can be traced back at least to adolescence or early adulthood.
3. There is evidence of significant distress or impairment in
functioning associated with the enduring pattern of behavior.
4. The pattern of behavior is not better accounted for as a
manifestation or consequence of another mental disorder.
5. The pattern is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition (e.g. head trauma).
Distinguishing Between Personality Disorder and PTSD in Servicemembers
Following Stressful Event
There are several implications of these requirements for
determining a diagnosis of personality disorder following deployment.
Since the onset of personality disorders by definition occurs by late
adolescence or early adulthood, there typically should be evidence of
the behavior pattern prior to adulthood. A history of solid adjustment
and good psychosocial functioning prior to adulthood would not be
expected in an individual with a personality disorder.
It is critical to rule out other mental disorders that may be
responsible for the maladaptive behaviors in making a clinical
diagnosis of personality disorder. Following an extended event
characterized by traumatic stressors, it is particularly important to
determine if problematic behaviors are due to PTSD. The DSM-IV
explicitly states ``When personality changes emerge and persist after
an individual has been exposed to extreme stress, a diagnosis of Post
Traumatic Stress Disorder should be considered'' (p. 632). Exposures to
severe or prolonged trauma can result in behaviors that look like
features of personality disorders. PTSD criteria include irritability
or outbursts of anger, feeling of detachment or estrangement from
others, and restricted range of affect (unable to experience feelings
such as love). In addition, the DSM-IV describes several associated
features of PTSD that may be present, including self-destructive and
impulsive behavior, social withdrawal, feeling constantly threatened,
and impaired relationships with others.
The recognition of possible personality changes following severe or
prolonged stress is apparent in the International Classification of
Diseases (ICD-10), which includes a diagnostic category of ``Enduring
personality change after catastrophic experience.'' This diagnosis is
used in cases of persistent change in personality following extreme
stress, including prolonged exposure to life-threatening situations,
characterized by two or more of the following features newly present
after the trauma:
1. A hostile or distrustful attitude toward the world.
2. Social withdrawal.
3. A constant feeling of emptiness or hopelessness.
4. An enduring feeling of ``being on edge'' or being threatened
without any external cause, as evidenced by an increased vigilance and
irritability.
5. A permanent feeling of being changed or being different from
others (estrangement).
These features may be present in individuals exposed to extreme
trauma. Again, such features overlap with many of the criteria for
Personality Disorders. The critical distinction is whether they
represent change in personality following exposure to severe traumatic
stress. Although I have focused here on the distinction between
Personality Disorders and PTSD, it is important to recognize that these
conditions can co-exist. A person able to function in spite of a mild-
to moderate personality disorder can develop PTSD after trauma. An
additional consideration I have not discussed is Traumatic Brain Injury
(TBI), which is sometimes associated with behavioral changes that may
look like features of personality disorders, for example, aggression,
poor impulse control, or suspiciousness. For individuals with exposure
to head injury (including closed head injury), neuropsychological
testing may be indicated to rule out brain injury as a cause of such
behaviors.
Assessments at the VA
VA psychologists conduct assessments for service connected
disability applications. These ``compensation and pension'' exams
follow established guidelines, and cover psychosocial functioning and
symptoms of mental disorder present prior to, during, and following
military service. Military experience, including exposure to traumatic
events, is assessed, and the timing of the onset of symptoms in
relation to military service is determined. Most of the exams that I
personally have conducted have been to establish service connection for
PTSD. These require detailed questioning of symptoms of PTSD and other
mental disorders, including timing of onset. If there is a pattern of
maladaptive behavior existing prior to military service, it is
important to determine whether there has been a change in connection
with military service. Diagnoses reflect a personality disorder if
present but, in my personal experience, this has been rare. As noted
above, a personality disorder can also co-exist with PTSD. In my
experience, these exams take about 60 minutes on average, but can take
longer in more complicated cases.
Also of note is that VA policy now requires screening of all OEF /
OIF veterans for TBI. Positive responses to the screen are followed up
with more detailed assessments by neuropsychologists.
Summary
To summarize, events characterized by repeated exposure to
traumatic stress can result in symptoms and behaviors that appear, on
the surface, to resemble personality disorder. A clinical diagnosis of
personality disorder should be made only when it can clearly be
established that the behavioral patterns and associated psychosocial
impairment or distress were present by late adolescence or early
adulthood, existed prior to stressful events, and cannot be better
explained by the experience during an event of traumatic stress or
brain injury. In addition to a comprehensive psychological assessment
of the individual, consultation with family members or others with
knowledge of the individual prior to service is advisable when
considering a personality disorder diagnosis. The significance of an
accurate diagnosis cannot be underestimated.
Thank you for this opportunity to testify. I will be pleased to
answer any questions you may have.
Prepared Statement of Dean G. Kilpatrick, Ph.D.
Distinguished University Professor
Director, National Crime Victims Research and Treatment Center
Medical University of South Carolina, and Member
Committee on Veterans' Compensation for Post Traumatic Stress Disorder
Institute of Medicine and National Research Council
The National Academies
Good morning, Mr. Chairman and Members of the Committee. My name is
Dean Kilpatrick and I am Distinguished University Professor in the
Department of Psychiatry and Behavioral Sciences and Director of the
National Crime Victims Research and Treatment Center at the Medical
University of South Carolina. Thank you for the opportunity to testify
on behalf the Members of the Committee on Veterans' Compensation for
Posttraumatic Stress Disorder. The committee was convened under the
auspices of the National Research Council and the Institute of
Medicine. These institutions are operating arms of the National Academy
of Sciences, which was chartered by Congress in 1863 to advise the
government on matters of science and technology. The work of the
Committee was requested by the Department of Veterans Affairs, which
provided funding for the effort.
Our Committee recently completed a report entitled PTSD
Compensation and Military Service that addresses some of the topics
under discussion in this hearing. I am pleased to be here today to
share with you the content of that report, the knowledge I've gained as
a clinical psychologist and researcher on traumatic stress, and my
experience as someone who previously served as a clinician at the VA.
I will begin with some background information on posttraumatic
stress disorder. Briefly described, PTSD is a psychiatric disorder that
can develop in a person after a traumatic experience. Someone is
diagnosed with PTSD if, in response to that traumatic experience, he or
she develops a cluster of symptoms that include:
reexperiencing the traumatic event as reflected by
distressing recollections, memories, nightmares, or flashbacks;
avoidance of anything that reminds them of the traumatic
event;
emotional numbing or feeling detached from other people;
hyperarousal as reflected by trouble sleeping, trouble
concentrating, outbursts of anger, and having to always be vigilant for
potential threats in the environment; and
impairment in social or occupational functioning, or
clinically significant distress.
PTSD is one of an interrelated and overlapping set of possible
mental health responses to combat exposures and other traumas
encountered in military service. Although PTSD has only been an
official diagnosis since the 1980's, the symptoms associated with it
have been reported for centuries. In the U.S., expressions including
shell shock, combat fatigue, and gross stress reaction have been used
to label what is now called PTSD.
Our committee's review of the scientific literature and VA's
current compensation practices identified several areas where changes
might result in more consistent and accurate ratings for disability
associated with PTSD.
There are two primary steps in the disability compensation process
for veterans. The first of these is a compensation and pension, or C&P,
examination. These examinations are conducted by VA clinicians or
outside professionals who meet certain education and licensing
requirements. Testimony presented to the Committee indicated that
clinicians often feel pressured to severely constrain the time that
they devote to conducting a PTSD C&P examination--sometimes to as
little as 20 minutes--even though the protocol suggested in a best
practice manual developed by the VA National Center for PTSD can take 3
hours or more to properly complete. The Committee believes that the key
to proper administration of VA's PTSD compensation program is a
thorough C&P clinical examination conducted by an experienced mental
health professional. Many of the problems and issues with the current
process can be addressed by consistently allocating and applying the
time and resources needed for a thorough examination. The Committee
also recommended that a system-wide training program be implemented for
the clinicians who conduct these exams in order to promote uniform and
consistent evaluations.
The second primary step in the compensation process for veterans is
a rating of the level of disability associated with service-connected
disorders identified in the clinical examination. This rating is
performed by a VA employee using the information gathered in the C&P
exam. The Committee found that the criteria used to evaluate the level
of disability resulting from service-connected PTSD were, at best,
crude and overly general. Our Committee recommended that new criteria
be developed and applied that specifically address PTSD symptoms and
that are firmly grounded in the standards set out in the Diagnostic and
Statistical Manual of Mental Disorders used by mental health
professionals. As part of this effort, the Committee suggested that VA
take a broader and more comprehensive view of what constitutes PTSD
disability. In the current scheme, occupational impairment drives the
determination of the rating level. Under the Committee's recommended
framework, the psychosocial and occupational aspects of functional
impairment would be separately evaluated, and the claimant would be
rated on the dimension on which he or she is more affected. The
Committee believes that the special emphasis on occupational impairment
in the current criteria unduly penalizes veterans who may be capable of
working, but significantly symptomatic or impaired in other dimensions,
and thus it may serve as a disincentive to both work and recovery.
Determining ratings for mental disabilities in general and for PTSD
specifically is more difficult than for many other disorders because of
the inherently subjective nature of symptom reporting. In order to
promote more accurate, consistent, and uniform PTSD disability ratings,
the Committee recommends that VA establish a specific certification
program for raters who deal with PTSD claims, with the training to
support it, as well as periodic recertification. Rater certification
should foster greater confidence in ratings decisions and in the
decisionmaking process.
To summarize, the Committee identified three major changes that are
needed to improve the compensation evaluation process for veterans with
PTSD:
First, the C&P exam should be done by mental health
professionals who are adequately trained in PTSD and who are allotted
adequate time to conduct the exams.
Second, the current VA disability rating system should be
substantially changed to focus on a more comprehensive measure of the
degree of impairment, disability, and clinically significant distress
caused by PTSD. The current focus on occupational impairment serves as
a disincentive for both work and recovery.
Third, the VA should establish a certification program
for raters who deal with PTSD clams.
Our committee also reached a series of other recommendations
regarding the conduct of VA's compensation and pension system for PTSD
that are detailed in the body of our report. I have provided copies of
this report as part of my submitted testimony.
Thank you for your attention. I will be happy to answer your
questions.
Prepared Statement of Sally Satel, M.D.
Resident Scholar, American Enterprise Institute
Thank you for the invitation to appear before the Committee. I am a
psychiatrist who formerly worked with disabled Vietnam veterans at the
West Haven VA Medical Center in Connecticut from 1988-1993. Currently,
I am a resident scholar at the American Enterprise Institute. I have
been interested in applying the lessons we learned in treating Vietnam
veterans to the new generation of service personnel returning from Iraq
and Afghanistan.
Background
A particularly unsettling story appeared on ABC News on July 12
called ``Used Up and Spit Out--The Personality Disorder Discharge.''
The segment portrayed two young men who had served in Iraq with
military distinction but then suffered what appeared to be, in one
case, posttraumatic stress disorder, and in the other, a traumatic
brain injury inflicted by a close-range rocket blast as well as post
traumatic stress disorder. Ultimately, both soldiers were given a
``separation because of personality disorder'' discharge (Chapter 5-13)
from the Army.
In the wake of these and other reports of Chapter 5-13 discharges,
lawmakers, veterans' advocates, and military families have wondered if
the military is using personality disorder discharges to avoid covering
the healthcare needs of servicemembers. Without question, to use the
diagnosis of personality disorder to deny proper care and benefits to
men and women who have served honorably and were injured in their
service is a grave clinical error, not to mention a deep injustice.
Relevance to the Department of Veterans Affairs
Understandably all eyes are on the Department of Defense because
that is the jurisdiction in which Chapter 5-13 discharges originate.
Yet the matter of personality disorder separation has implications for
the Department of Veterans Affairs as well. Just as it is a serious
mistake to diagnose a soldier who became mentally impaired as a result
of military service as suffering, instead, from a personality disorder
(and discharge him on that basis), overlooking opportunities to
identify significant behavioral problems among soldiers--at enlistment
or early in training or after deployment--imposes an equally
significant challenge for the VA. Why? Because it is these individuals
who are particularly vulnerable to developing psychiatric impairment
under the strain of combat stress. Upon discharge, they may turn to VA
mental health facilities for long-term treatment that may have been
prevented with proper screening or more effectively resolved with
immediate care within the service.
A Brief Word on Personality Disorders and the Military
What is a personality disorder (PD)?--Personality disorders are
defined by the Diagnostic and Statistical Manual as enduring
maladaptive patterns of behavior and cognition that leads to clinically
significant distress or impairment in social, occupational, or other
important areas of functioning. The early signs are usually evident in
adolescence or early adulthood.
Does military service cause PD? No, but it might intensify
underlying maladaptive traits and PDs and these can make the soldier
unfit for duty. This scenario, it seems to me, would form an
appropriate foundation for the use of a Chapter 5-13.
Can stress injury look like PD? Yes. In addition to the anxiety
features that characterize a stress reaction, behavioral problems such
as misconduct and disobedience can accompany it. At any given point in
time such a serviceman or woman might appear to have a PD but if review
of his or her enlistment record (e.g., evidence of criminal activity)
and, especially, review of training file reveal solid performance, most
likely the soldier is wrestling with a stress reaction, perhaps full-
blown PTSD.
Can a soldier have both PTSD and PD? Yes. However, presumably an
individual with both conditions was once judged mentally fit to assume
active duty. Such judgments were made first at the time of enlistment,
then throughout training, and eventually before deployment. If a
soldier progressed that far and had been considered mentally fit along
the way, it is only logical to conclude that whatever deterioration he
suffered was due to his military service. This calls into question the
judgment that he is now mentally unfit because of a pre-existing
personality disorder ``that is so severe that the soldier's ability to
function effectively in the military environment is significantly
impaired.'' \1\
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\1\ AR 635-200 Active Duty Enlisted Administrative Separations
http://gidischarges.org/odpmc/army/index.html, accessed July 23, 2007.
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*Thus, if many soldiers are being discharged late in their tours of
duty, diagnosed with PD through Chapter 5-13, two questions must be
considered: First, are the PD diagnoses accurate in the first place?
The media and lawmakers have focused on this important question.
Secondly, if they are indeed accurate, are enlistment and ongoing
screening procedures adequate to identify these problems earlier?
Adequacy of screening?--A soldier unfit for duty because of a PD
can often be identified in the training or early deployment phases of
duty. Boot camp and related activities are emotionally intense and
demanding crucible. As such they act as a natural ``stress test,''
unmasking a person's innate problems with coping and impulse control--
difficulties that the he or she could otherwise compensate for in
civilian life. Individuals' tendencies to become hostile, aggressive,
resistant to authority under pressure, suspicious of others' motives,
and disruptive to unit cohesion will likely assert themselves in the
context of these environments, to the notice of those around including
command and especially peers.\2\
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\2\ Fiedler E, Oldmanns T, Turkheimer E. ``Traits associated with
personality disorders and adjustment to military life: predictive
validity and self and peer reports.'' Military Medicine. 169 (3)
(2004), pp. 207-211.
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Thus, the time to intercept these individuals in order to treat or
discharge them as unfit for duty, as the military deems appropriate, is
at intake, during training, before they are deployed, or early in the
in the deployment period. Yet it is my understanding that the Pentagon
has lowered standards to meet quotas and that an increased number of
so-called moral waivers have been granted so that recruits with felony
records and other significant evidence of behavioral problems can
enlist.\3\ Those waivers may be officially overlooking exactly the
behaviors that are symptoms of personality disorders.
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\3\ Badkhen, Anna. ``Army Relaxes Its Standards to Fill Ranks:
Critics say push to meet quotas may let unstable recruits join up.''
San Francisco Chronicle. June 11, 2006.
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There is a modest literature on screening. I will mention just two
interesting reports. A 2003 report called Reducing the Threat of
Destructive Behavior by Military Personnel, which was commissioned by
the Deputy Assistant Secretary of Defense, documents a meaningful
correlation between pre-service history (e.g., arrests, convictions,
disciplinary problems, and especially, failure to finish high school)
and in-service criminal behavior, destructive acts, and attrition.
The report identified two main areas of concern regarding initial
selection and continuing evaluation procedures of military personnel
``(1) lack of effective prescreening procedures to identify
military entrants with criminal records and other behavioral
adjustment problems, and
(2) inadequate management practices that have allowed the
retention on active duty of military personnel who have shown a
pattern of substandard behavior.''
A 4-year followup study by Eli Flyer, for the Naval Post Graduate
School, and John Noble of the Navy Recruiting Command found that Navy
recruits who did not complete high school had a significantly higher
attrition rate during their initial tour compared to graduates.\4\
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\4\ Flyer, Eli and Noble, John. Development and Validation of a
Biographical Questionnaire to Screen GED/Non-High School Graduate
Applicants for Navy Service: Four-Year Follow-Up Findings. On file with
author. Note: 50% of drop outs were within the first year of active
duty. The researchers asked 7,000 Navy recruits to complete an eight-
item questionnaire about pre-enlistment behaviors (e.g., difficulty
taking orders, previous suicide attempts, having run away from home,
having visited a mental health professional). Those who did not
complete high school (about 1,000 of the recruits). Non-graduates with
the most pre-enlistment problems (the bottom quartile) and had an
attrition rate of 72 percent compared to graduates who had an attrition
rate of 52 percent; while grads in the top three quartiles had a mean
attrition rate of 33 percent. Also note, there is a well-documented
relationship between cognitive factors such as educational attainment
and IQ and development of stress reactions and PTSD which can lead to
attrition. Failure to finish high school may partly reflect this
phenomenon. For review see Gilbertson MW, Paulus LA, Williston SK,
Gurvits TV, Lasko NB, Pitman RK, Orr SP. ``Neurocognitive Function in
Monozygotic Twins Discordant for Combat Exposure: Relationship to
Posttraumatic Stress Disorder''. Journal of Abnormal Psychology. 115
(3) (2006), pp. 484-495; For relationship between educational level and
active duty stress casualties, see Helmus TC, Glenn RW. ``Steeling The
Mind: Combat Stress Reactions and their Importance for Urban Warfare.''
RAND. Document MG-191-A, 2005.
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The controversy surrounding Chapter 5-13 discharges would suggest
need for a re-evaluation of screening protocols currently used by DoD.
Misapplication of the Chapter 5-13 discharge sets up a kind of
Catch-22 for the DoD. First the military deems a recruit sufficiently
mentally fit to be sent into training and then into a war zone, but
then when psychiatric problems arise it turns around and claims that
those problems were there all along_problems that should have shown up
earlier in their tour of duty.
Patients with PTSD and Personality Disorder Who Seek Care at VA
Facilities
Co-occurrence--PD and PTSD, especially chronic PTSD, are common in
treatment seeking populations.\5\ It is generally difficult to parse
the relationship because there are few longitudinal, prospective
studies. The vast majority of studies are cross-sectional, or snap-
shot, analyses making it difficult to infer temporal order.
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\5\ Richman H, Frueh BC. ``Personality disorder symptomatology
among Vietnam veterans with combat-related PTSD.'' Anxiety. 2(6)
(1996), pp. 286-295; Southwick SM, Yehuda R, Giller EL Jr.
``Personality disorders in treatment-seeking combat veterans with
posttraumatic stress disorder.'' American Journal of Psychiatry. 150
(1993), pp. 1020-1023; Bollinger AR, Riggs DS, Blake DD, Ruzek JI.
``Prevalence of personality disorders among combat veterans with
posttraumatic stress disorder.'' Journal of Traumatic Stress. 13(2)
(2000), pp. 255-271; T. Keane, D. Kaloupek. ``Comorbid Psychiatric
Disorders in Posttraumatic Stress Disorder: Implications for
Research.'' Annals of the New York Academy of Sciences. 821(1) (1997),
pp. 24-34.
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Possible explanations of co-occurrence:
1. PD can predispose to PTSD--This is a plausible inference to
draw from the considerable volume of data showing that traits and
predispositions associated with PDs (borderline and antisocial types,
in particular) are the same ones that enhance risk for developing PTSD
after traumatic experience. These dispositions and traits include
childhood conduct disorder, neuroticism (a tendency to react to
adversity with depression or anxiety), impulse control problems, early
family instability, and exposure to traumatic events (which are more
common in children and teens with behavioral difficulties and adults
with antisocial personality).\6\
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\6\ Brewin CR, Andrews B, Valentine JD. ``Meta-analysis of risk
factors for posttraumatic stress disorder in trauma-exposed adults.''
Journal of Consulting and Clinical Psychology. 68(5) (October 2000),
pp. 748-66; Ozer E, Best SR, Lipsey TL, Weiss DS. ``Predictors of
posttraumatic stress disorder and symptoms in adults: a meta-
analysis.'' Psychological Bulletin. 129(1) (2003), pp. 52-73; Breslau
N, Davis GC, Andreski, P. ``Risk factors for posttraumatic stress
disorder-related traumatic events.'' American Journal of Psychiatry.
152(4) (1995), pp. 529-35; King DW, King LA, Foy DW, Gudanowski DM.
``Prewar factors in combat-related posttraumatic stress disorder:
structural equation modeling with a national sample of female and male
Vietnam veterans.'' Journal of Consulting and Clinical Psychology.
64(3) (June 1996), pp. 520-31; Jang KL, Stein MB, Taylor S, Asmundson
GJG, Livesley WJ. ``Exposure to traumatic events and experiences:
aetiological relationships with personality function.'' Psychiatry
Research. 120 (2003), pp. 61-69; Schnurr PP, Vielhauer MJ.
``Personality as a risk factor for posttraumatic stress disorder.'' In
Risk Factors for Posttraumatic Stress Disorder. Ed: R. Yehuda.
Washington, DC: American Psychiatric Press, 2000
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2. PTSD can ``look like'' PD--The symptoms of PTSD such as
anxiety, nightmares and sleep deprivation can lead to irritability,
intense anger, aggression, substance abuse, and emotional instability--
symptoms commonly associated with borderline personality disorder and/
or asp. One could call this pseudo-personality disorder. It should
remit if the underlying stress reaction is treated and resolves. If
PTSD becomes chronic, however, these dysfunctional attributes may
persist.
3. Living with chronic PTSD can induce personality changes--An
analogy can be made to chronic pain patients insofar as it is unknown
whether many of the psychopathological features observed in chronic
pain patients (e.g., anger, manipulativeness, suspiciousness,
interpersonal hostility to comply, emotional instability) are the
consequence of chronic pain and its related difficulties, or whether
pre-existing psychopathology predisposed some individuals to develop
chronic pain.\7\
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\7\ Weisberg, JN. ``Studies Investigating the Prevalence of
Personality Disorders in Patients with Chronic Pain.'' In Personality
Characteristics of Patients With Chronic Pain. Eds: Gatchel R, Weisberg
N. Washington, DC: American Psychological Association, 2000.
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Thus, there are three potential pathways by which veterans can
manifest symptoms of PTSD and features of personality disorders at the
same time: maladaptive personality features (1) were present before
military service, (2) are a byproduct of the trauma and should resolve
when the stress reaction remits, (3) are a response to living with
PTSD.\8\ In the absence of prospective studies or baseline information
on individuals it is difficult to distinguish between these scenarios.
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\8\ Axelrod S, Morgan CA, Southwick SM. ``Symptoms of Posttraumatic
Stress Disorder and Borderline Personality Disorder in Veterans of
Operation Desert Storm'' American Journal of Psychiatry. 162 (2005),
pp. 270-275.
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4. PTSD aggravates features of PD--In civilian settings, we
frequently observe that when patients with longstanding personality
disorders encounter stressful experiences such as physical illness,
pain, bereavement, divorce, or on the job tension, they often fail to
adapt and behave more erratically, impulsively, etc.
5. PD alone: see below.\9\
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\9\ No PTSD or other Axis I Mental Disorder: There may be
situations in which a veteran has no diagnosable features of PTSD but
seeks treatment because he is struggling with problems at home or on
the job because of a severe personality disorder.
a. Exacerbation of maladaptive personality traits due to service:
It is possible that war stress alone intensified a pre-existing
personality disorder. Although veterans with severe PD may not be
particularly sympathetic, one could argue that the military should have
been better attuned to the fact such men and women can be too
psychologically fragile to handle the great pressure of the combat
environment and that more intensive screening at enlistment and during
the first term was warranted.
b. No change in intensity of PD traits: It is always possible that
some veterans seeking care at the VA will be as maladapted to civilian
life after their service duty as they were when they first entered the
service. In other words, they were made no worse as a result of their
military service. Granted, such a scenario may not occur too often, yet
for the sake of completeness it is worth considering. The first
question it raises is why such men and women were permitted to enlist
in the military or to deploy in the first place--an issue discussed
earlier. Nonetheless, since they did indeed serve in Iraq or
Afghanistan, the VA has responsibility for their mental health needs.
(But not for granting disability benefits because the problem is not
service-connected).
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VA clinicians are unlikely to misdiagnose PTSD and/or Traumatic
Brain Injury (TBI) as personality disorders. The core symptoms of PTSD
and neuropsychiatric impairment are distinguishable from PD. Sometimes
these diagnoses are made simultaneously in the same individual, and
when they are it can be hard to know which is dominant, especially
prior to a course of treatment. Even so, PTSD and TBI, by definition,
are caused by service and are not pre-existing.
Treatment: Clinicians will be familiar with the scenarios outlined
above and treat patients accordingly with combinations of cognitive-
behavioral therapy, desensitization/exposure therapy,
psychopharmacology, family counseling, and vocational
rehabilitation.\10\ It is essential to treat veterans with PTSD and
severe readjustment problems as early as possible when their conditions
will be most responsive to therapeutic intervention. This can often
make the difference between a time-limited impairment and chronic
mental illness. Patients with both chronic PTSD and features of a
personality disorder can be less responsive to treatment.\11\ A point
worth raising here is the importance of qualified staffing at VA mental
health facilities. Anecdotal reports suggest that many facilities do
not have adequate numbers of clinicians who can perform cognitive-
behavioral therapies. This is a deficit that must be addressed.\12\
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\10\ ``Practice Guidelines for the Treatment of Patients with Acute
Stress Disorder and Posttraumatic Stress Disorder.'' American
Psychiatric Association. Accessed on July 20, 2007. www.psych.org/
psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
\11\ Dunn NJ, Yanasak E, Schillaci J, Simotas S, Rehm LP, Souchek
J, Menke T, Ashton C, Hamilton JD. ``Personality disorders in veterans
with posttraumatic stress disorder and depression.'' Journal of
Traumatic Stress. 17(1) (February 2004), pp. 75-82; Bollinger AR, Riggs
DS, Blake DD, Ruzek JI. ``Prevalence of personality disorders among
combat veterans with posttraumatic stress disorder.'' Journal of
Traumatic Stress. 13(2) (April 2000), pp.255-270.; Rosenheck R.
``Malignant post-Vietnam stress syndrome.'' American Journal of
Orthopsychiatry. 55 (1985), pp. 166-176;Hyer L, Woods MG, Bruno R,
Boudewyns P. ``Treatment outcomes of Vietnam veterans with PTSD and the
consistency of the MCMI.'' Journal of Clinical Psychology. 45(4) (July
1989), pp. 547-542; Mazzeo SE, Beckham JC, Witvliet Cv C, Feldman ME,
Shivy VA. ``A cluster analysis of symptom patterns and adjustment in
Vietnam combat veterans with chronic posttraumatic stress disorder.''
Journal of Clinical Psychology. 58(12) (December 2002), pp. 1555-1571.
\12\ A specific form of exposure-desensitization therapy under
development is called ``Virtual Iraq.'' Studies are in progress. The
therapy was developed with funding from the Naval Research Office and
is considered promising. The veteran wears a virtual-reality helmet and
goggles and headphones. A therapist manipulates virtual situations via
a keyboard to best suit the individual patient during 45-50 minute
sessions. By gradually re-introducing the patients to the experiences
that triggered the trauma, the memory becomes tolerable and feelings of
panic no longer accompany once-feared situations (such a driving on
city streets, being in crowds). http://www.defense-update.com/products/
v/VR-PTSD.htm, accessed July 21, 2007
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Disability Determination--The eligibility standard for disability
payments differs from that of treatment. In order to qualify for
disability on the basis of specific injuries or illnesses, an explicit
causal connection between those afflictions and military service must
be demonstrated.
Last May, the Institute of Medicine released a report entitled PTSD
Compensation and Military Service. It emphasized the need for a
consistent evaluation process across centers and the dire importance of
competent evaluation (quality evaluations often take several hours,
involve extensive review of medical and military records, and,
critically, interviews of collateral sources of information). I agree
with these points.
Summary
Improved behavioral and psychological screening for enlistment is
needed to help predict behavioral adjustment to the military.
VA clinicians are unlikely to misdiagnose PTSD and/or TBI as
personality disorder. The core symptoms of PTSD and neuropsychiatric
impairment are distinguishable from PD.
VA must be equipped with mental health staff trained in state of
the art PTSD treatment. Treatment should be delivered at early as
possible to avert development of chronic syndromes.
In determining disability there should be a consistent, high
quality evaluation process across centers.
Prepared Statement of Ira R. Katz, M.D., Ph.D.
Deputy Chief Patient Care Services Officer for Mental Health
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning Mr. Chairman, thank you for this opportunity to speak
about multiple diagnoses and specifically about the principle that Post
Traumatic Stress Disorder (PTSD) frequently coexists with other mental
health conditions.
Multiple Mental Health Problems
As of the end of the first half of FY 2007, almost 720,000 service
men and women have separated from the armed forces after service in
Iraq or Afghanistan, and over 250,000 have sought care in VA. About
95,000 received at least a preliminary mental health diagnosis. Among
these, PTSD, experienced by over 45,000 or 48 percent is the most
common.
The average veteran with a mental health problem received
approximately 1.9 diagnoses. There could be several reasons. First,
injuries of the mind, like injuries of the body can be non-selective.
Depending upon psychological, physiological, or genetic
vulnerabilities, the same stress and trauma can give rise to multiple
conditions, for example PTSD and depression or panic disorder. Second,
the disorders may occur sequentially. Some veterans with PTSD may try
to treat their own symptoms with alcohol and wind up with a diagnosis
related to problem drinking. Third, some pre-existing mental health
conditions like milder personality disorders may be quite compatible
with occupational functioning, even in the military, but may increase
vulnerability to stress-related disorders like PTSD or depression.
How Does VA Deal With This Problem
VA has intensive programs to ensure that mental health problems are
recognized, diagnosed, and treated. There is outreach to bring veterans
into our system, and once they arrive, there is screening for mental
health conditions. For those who screen positive for mental health
conditions, the next step is a comprehensive diagnostic and treatment
planning evaluation. In this, the question is about what is causing the
veteran's suffering or impairment, and what can be done about it. If
someone screens positive for symptoms of PTSD, we are interested in
whether or not they, in fact have PTSD. But we are also interested in
whether or not they have depression, or panic disorder, or problem
drinking, or other problems. Which do we treat? We treat them all. Or
more significantly, we treat the person, not his or her labels.
Clinical science has advanced dramatically since the Vietnam War.
We now know how to diagnose PTSD, and how to treat it. Accordingly, we
are hopeful that we can prevent the lasting suffering and impairments
that occurred after that war. There is a firm evidence-base for several
classes of treatment for PTSD, both psychopharmacological or medication
based and psychotherapeutic or talk/behavior based. Specifically,
several of the antidepressants that act on the neurotransmitter
serotonin have been found to be effective and safe for the treatment of
PTSD, and many other medications are currently being studied. Two
specific forms of cognitive behavioral therapy, prolonged exposure
therapy and cognitive processing therapy appear to be even more
effective than the medications, and VA is currently developing high
throughput training programs to make them increasingly available within
our medical centers, clinics, and Vet Centers. In addition, there is
increasing evidence for the effectiveness of psychosocial
rehabilitation. For veterans for whom there may be residual symptoms
after several evidence-based treatments, treatment is available to help
them function in the family, in the community, or on the job.
Given That There Are a Number of Effective Treatments, How Do We Decide
Which to Provide?
Actually, the question should be which to offer first and which
comes next. The first treatments are usually offered on the basis of
both the provider's judgment and the patient's preference. However, we
monitor treatments and outcomes, and if the first doesn't work, we
modify it.
What happens when patients have more than one condition? The choice
of what to treat first depends on the severity of the conditions, the
provider's judgment, and the patient's preferences. Plans must allow
for combinations or sequences of treatments, as appropriate following
Clinical Practice Guidelines or other sources of guidance.
There may have been a time in the past when coexisting conditions
may have been barriers to care, when it was hard to treat people with
PTSD and alcohol abuse because PTSD programs required people to be
sober, and substance abuse programs required them to be stable. This no
longer occurs. In fact, there are now evidence based strategies for
beginning PTSD and substance abuse treatment simultaneously. One
approach, called Seeking Safety was developed in the VA, and is being
disseminated broadly.
It may be difficult to diagnose personality disorders in the face
of PTSD or other mental health conditions. For patients with relevant
symptoms, the clinical approach in VA is to treat the PTSD first. A
subsequent step would be evaluate what symptoms or impairments remain,
and to plan treatments accordingly.
The message I want to deliver in this hearing is that treatment for
PTSD can work. For veterans or others with multiple conditions,
treatment may be a multistage process beginning with an evidence based
intervention for the most severe of the patient's conditions, and
continuing in a way that depends upon the outcome. Overall, the message
should be cautiously optimistic.
Thank you for this opportunity to testify. I will be pleased to
answer any questions you may have.
Prepared Statement of Colonel Bruce Crow
Chief, Department of Behavioral Medicine
Brooke Army Medical Center, Fort Sam Houston, TX, and
Clinical Psychology Consultant to the Army Surgeon General
Department of the Army, U.S. Department of Defense
Mr. Chairman, Congressman Buyer, and distinguished members of the
Committee, thank you for the opportunity to discuss the behavioral
health status of the brave men and women in your Army. The Army
leadership recognizes the profound impact the combat environment has on
the mental and emotional well-being of soldiers and their families.
Last week, the Army kicked-off an unprecedented awareness campaign to
educate more than one million Active, Reserve and National Guard
soldiers over the next 90 days about Post Traumatic Stress Disorder
(PTSD) and Traumatic Brain Injuries (TBI). Development and
implementation of this chain teaching program has been one of the
highest priorities for both the Secretary and Chief of Staff of the
Army. The presentation and materials were vetted throughout the Army,
not only in the medical channels, but through the leadership and
soldier focus groups as well.
Coincidentally, today at the Pentagon over 200 General Officers and
Senior Executive Service civilians are participating in this PTSD and
mild TBI Chain Teaching Program. The presentation is a combination of
briefing slides and video clips. Commanders and leaders use an
accompanying script to ensure the material is presented accurately and
consistently throughout the Army. Let me briefly highlight what we are
attempting to achieve:
First, leaders and soldiers throughout the chain of
command, to include the Army Chief of Staff, must take care of
themselves and their buddies. Knowing how to recognize symptoms of PTSD
and TBI and being aware of the available treatment options are the
first steps toward addressing these issues.
Second, seeking mental health treatment should not be
perceived as a sign of weakness. Rather it should send a powerful
signal of strength and personal courage. We are aware that mental
health treatment carries with it a certain stigma. Soldiers must
understand that seeking treatment for PTSD is no different than being
treated for medical conditions such as hypertension. Untreated
psychiatric conditions have an impact on soldier readiness and well-
being. The Army is committed to providing the very best treatment
possible.
Shifting gears, I'd like to briefly address personality disorders,
as I know this has been a topic of much discussion within the media and
the halls of Congress. As the clinical psychology consultant to the
Army Surgeon General, I am deeply distressed to hear that some of our
soldiers feel they have been wrongly separated from the Army for
personality disorders. I have heard some alarming numbers thrown around
in the media and would like to set the record straight. About 70,000
soldiers were discharged from the Active Army in 2006. Of those
discharged, 1,086 were separated for personality disorder, of which 295
of those individuals had served in a theater of combat. To the
uniformed, civilian, and contract health care professionals that care
for these soldiers, the thought of even one soldier being
inappropriately discharged for personality disorder is disturbing. With
that in mind, the Acting Surgeon General, Major General Gale Pollock,
has directed each and every one of those 295 records be reviewed by
behavioral health professionals to verify that appropriate actions were
taken and that all health concerns were considered in the discharge.
That extensive record review is currently underway.
Another misconception is that separating a soldier for personality
disorder is simply an administrative decision made by a member of the
Chain of Command to do away with problem soldiers. Separation on the
basis of personality disorder is authorized only if a diagnosis is made
by a psychiatrist or doctoral-level clinical psychologist with the
required DoD professional credentials and privileges. The disorder must
be so severe that the member's ability to function effectively in a
military environment is significantly impaired. Existing military
clinical quality assurance processes such as routine peer review of
provider records also reduce the likelihood of provider deviation from
the community standard of care. To protect their legal rights, every
soldier pending separation for a personality disorder is afforded the
opportunity to consult with an attorney prior to separation.
Additionally, former soldiers who believe that they were improperly or
unfairly separated may petition the Army Discharge Review Board or the
Army Board for Correction of Military Records for administrative review
of their cases. Legal counselors advise soldiers of this right prior to
their separation.
As mentioned, a Personality Disorder is a diagnosis that must be
made by a psychiatrist or Ph.D. level clinical psychologist. There are
actually ten different specific personality disorders, each with a set
of characteristic behaviors. One common characteristic that is shared
by all individuals with a personality disorder is that they have
extreme difficulty modifying their problem behaviors and generally do
not respond well to psychological treatment. These problem behaviors
are typically disruptive to a military unit and are often associated
with discipline problems. When they are judged to be unlikely to change
or respond to clinical treatment, these behaviors can form the basis of
an administrative separation.
When a soldier is referred by their Commander to a psychiatrist or
psychologist for a personality disorder evaluation, it is typically
because there have been behavior problems that have not responded to
counseling and other remedial efforts by the chain of command. The
psychiatrist or psychologist basically looks for three things: 1)
whether there is a diagnosis of a personality disorder; 2) whether
there is a favorable prognosis for psychological treatment; and 3)
whether there is a diagnosis that should be considered for a medical
evaluation board. If the evaluation concludes that a personality
diagnosis is warranted AND there is poor prognosis for treatment or
change in behavior AND there is no psychiatric diagnosis that would
lead to a medical board, the soldier's commander is informed that the
soldier may be further processed for administrative separation because
of personality disorder.
Although soldiers suffering from a psychiatric disorder, such as
PTSD, can sometimes exhibit behaviors that are similar to individuals
with a personality disorder, the diagnoses can be distinguished by
behavioral health professionals. Psychiatric diagnoses made by military
providers are based on the same criteria used in the civilian health
care sector, and codified in the 4th edition of the Diagnostic and
Statistical Manual (DSM-IV). All psychiatric diagnoses include
observable behaviors coupled with significant psychological distress or
impairments in social or occupational functioning.
I mentioned earlier that the Army's Surgeon General's Office will
conduct a review of nearly 300 records of soldiers who had deployed to
a combat theater and were subsequently separated due to personality
disorder. This review has already been initiated and is being conducted
by a team of senior mental health providers. The team will review
mental health records, administrative records, and medical records to
determine if appropriate procedures were followed and whether
improvements are needed in the way clinical evaluations for personality
disorder are conducted as part of the administrative separation
process. If lessons can be learned that will improve the quality of
these clinical evaluations, we want to know and are interested in
making this information available to our Army behavioral health
providers.
In 2006 the Army diagnosed 9,500 OIF/OEF deployed soldiers with
PTSD, including some who had deployed in previous years. We recognize
that for some soldiers, symptoms will emerge after a period of time,
perhaps years following their combat deployment. Findings from our
Mental Health Advisory Teams tell us that between 15 to 20% of deployed
troops report symptoms of post combat stress. As the war continues and
soldiers incur multiple deployments we expect the number of soldiers
suffering from PTSD and presenting for treatment to rise.
Correspondingly, as these soldiers leave military service, the number
of veterans seeking treatment is also expected to grow. As our
education and training efforts are fully implemented, we hope that the
stigma of seeking care will decrease, which could lead to an increased
demand for services in both the military and veteran populations.
When it comes to diagnosis and treatment of PTSD, the Armed Forces
and the VA have some of the most experienced providers in the world.
Even though our Army psychiatry and psychology training programs
include comprehensive training in PTSD, we are working in collaboration
with the VA's National Center for PTSD to develop additional training
and tools for our behavioral health providers. We have also begun
providing training in PTSD to primary care providers, nurses and social
workers working in our Warrior Transition Units. A pilot program titled
RESPECT-MIL also provides behavioral health training to our primary
care providers and enhances their ability to identify, treat, and refer
patients with mental health concerns. This pilot was so successful at
Fort Bragg that we are pushing it across the Army to 15 additional
installations this year. At the Surgeon General's office we established
a Behavioral Health Proponency Office to oversee and coordinate
behavioral health programs across the entire command.
A major challenge we are facing involves recruiting and retaining
active duty and civilian mental health providers. To address staffing
shortfalls, the U.S. Army Medical Command recently committed over $50
million to hire more than 200 behavioral health professionals to fill
requirements across the Army. By bringing on more providers, we intend
to increase access to mental health services and increase our outreach
capability.
I want to assure the Congress that the Army Medical Department's
highest priority is caring for our Warriors and their Families. Like
most of my colleagues, I am here because I believe in supporting
soldiers for what they do every day in defense of our country and our
way of life. I will do everything in my power to ensure soldiers and
their Families receive the best health care available.
Thank you for holding this hearing and thank you for your continued
support of the Army Medical Department and the Warriors that we are
honored to serve.
Statement of Hon. Jeff Miller
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
It is abundantly clear how prevalent the issue of mental health is
with not only veterans returning from the Global War on Terror. This
Committee has given a great amount of attention to traumatic brain
injury, but equally serious is post traumatic stress disorder.
PTSD has proven to be as dangerous an enemy as any; there is no one
specific symptom defining it. It can derive from a range of causes, and
the disorder itself can act itself out in a range of manners. On top of
that, a veteran might not know that he or she has it, and therefore not
seek treatment. While the medical community strives to diagnose PTSD
among our active and former servicemembers as early and accurately as
possible, it must be understood that it is still a developing science.
I look forward to today's testimony and the input the panel members
will provide. This Committee remains dedicated to seeing that the
Department of Veterans' Affairs provides the best treatment possible to
those in need.