[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
MENTAL HEALTH TREATMENT FOR FAMILIES:
SUPPORTING THOSE WHO SUPPORT
OUR VETERANS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 28, 2008
__________
Serial No. 110-73
__________
Printed for the use of the Committee on Veterans' Affairs
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41-373 PDF WASHINGTON DC: 2008
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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 HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania HENRY E. BROWN, Jr., South
SHELLEY BERKLEY, Nevada Carolina
JOHN T. SALAZAR, Colorado VACANT
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
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
February 28, 2008
Page
Mental Health Treatment for Families: Supporting Those Who
Support Our Veterans........................................... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 46
Hon. Jeff Miller, Ranking Republican Member, prepared statement
of............................................................. 46
Hon. Shelley Berkley, prepared statement of...................... 47
WITNESSES
U.S. Department of Veterans Affairs, Kristin Day, LCSW, Chief
Consultant, Care Management and Social Work Service, Office of
Patient Care Services, Veterans Health Administration.......... 39
Prepared statement of Ms. Day................................ 88
______
American Association for Marriage and Family Therapy, Charles
Figley, Ph.D., LMFT, Fulbright Fellow and Professor, College of
Social Work, and Director, Traumatology Institute and
Psychosocial Stress Research and Development Program, Florida
State University, Tallahassee, FL.............................. 14
Prepared statement of Mr. Figley............................. 62
American Group Psychotherapy Association, Inc., Suzanne B.
Phillips, Psy.D., ABPP, CGP, Psychologist-Psychoanalyst, Group
Therapist, Northport, NY, Adjunct Professor of Clinical
Psychology, C.W. Post Campus, Brookville, NY, and Post-doctoral
Faculty, Derner Institute, Postdoctoral Program in Group
Psychotherapy and Psychoanalysis, Adelphi University, Garden
City, NY....................................................... 18
Prepared statement of Ms. Phillips........................... 68
American Legion, Scott N. Sundsvold, Assistant Director, Veterans
Affairs and Rehabilitation Commission.......................... 32
Prepared statement of Mr. Sundsvold.......................... 76
Bannerman, Stacy, M.S., Fife, WA, Author, When the War Came Home:
The Inside Story of Reservists and the Families They Leave
Behind......................................................... 5
Prepared statement of Ms. Bannerman.......................... 51
Connecticut, State of, Linda Spoonster Schwartz, RN, Dr.P.H.,
FAAN, Commissioner of Veterans Affairs......................... 2
Prepared statement of Ms. Spoonster Schwartz................. 47
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 30
Prepared statement of Ms. Ilem............................... 78
Iraq and Afghanistan Veterans of America, Todd Bowers, Director
of Government Affairs.......................................... 28
Prepared statement of Mr. Bowers............................. 86
Leousis, Peter, Principal Investigator, Citizen Soldier Support
Program National Demonstration, and Deputy Director, H.W. Odum
Institute for Research in Social Science, University of North
Carolina at Chapel Hill........................................ 3
Prepared statement of Mr. Leousis............................ 57
Mental Health America, Ralph Ibson, Vice President for Government
Affairs........................................................ 16
Prepared statement of Mr. Ibson.............................. 64
Paralyzed Veterans of America, Fred Cowell, Senior Health Analyst 24
Prepared statement of Mr. Cowell............................. 82
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chairman,
National PTSD and Substance Abuse Committee.................... 26
Prepared statement of Mr. Berger............................. 84
SUBMISSIONS FOR THE RECORD
National Military Family Association, Inc., Barbara Cohoon,
Deputy Director, Government Relations, statement............... 90
Salazar, Hon. John T., a Representative in Congress from the
State of Colorado, statement................................... 95
MENTAL HEALTH TREATMENT FOR FAMILIES:
SUPPORTING THOSE WHO SUPPORT
OUR VETERANS
----------
THURSDAY, FEBRUARY 28, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Berkley, Hare, Miller,
and Moran.
Also Present: Representative Kennedy
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call this hearing to order. I
want to thank everyone for coming. We will have some votes this
morning. We are supposed to get done at noon. So to try to
speed the process up, I will be extremely brief and ask
unanimous consent that if any Members have opening statements,
that they be submitted for the record.
We are here today to talk about mental health treatment for
families of veterans. This is a very important issue. One that
this Committee looks to address. These are issues that we hear
a lot about when we go back home to our districts and talk to
Guard and Reserves and active military. I think it is very
important that whatever this Congress and this Committee does
we not only look at veterans, but we also look at the family
and the community. I want to thank all the witnesses here today
for coming. I really appreciate that. And look forward to your
testimony.
As I mentioned earlier, I request my full remarks be
submitted for the record.
[The prepared statement of Chairman Michaud appears on
p. 46.]
Mr. Michaud. Mr. Hare, do you have an opening statement?
Mr. Hare. No.
Mr. Michaud. Okay. Without any further ado, on our first
panel we have Linda Schwartz, who is Commissioner of Veterans
Affairs for the State of Connecticut; Stacy Bannerman, who is
from Fife, Washington; and Peter Leousis, who is Deputy
Director and Principal Investigator for Citizen Soldier Support
Program National Demonstration.
And without objection, we will make sure that your full
testimony is submitted for the record. I would ask Ms. Schwartz
to begin her testimony.
STATEMENTS LINDA SPOONSTER SCHWARTZ, RN, DR.P.H., FAAN,
COMMISSIONER OF VETERANS AFFAIRS, STATE OF CONNECTICUT; STACY
BANNERMAN, M.S., FIFE, WA, AUTHOR, WHEN THE WAR CAME HOME: THE
INSIDE STORY OF RESERVISTS AND THE FAMILIES THEY LEAVE BEHIND;
AND PETER LEOUSIS, PRINCIPAL INVESTIGATOR, CITIZEN SOLDIER
SUPPORT PROGRAM NATIONAL DEMONSTRATION, AND DEPUTY DIRECTOR,
H.W. ODUM INSTITUTE FOR RESEARCH IN SOCIAL SCIENCE, UNIVERSITY
OF NORTH CAROLINA (UNC) AT CHAPEL HILL
STATEMENT OF LINDA SPOONSTER SCHWARTZ, RN, DRPH, FAAN
Ms. Schwartz. Good morning, Mr. Chairman, and thank you
very much for letting me speak. It is a very important subject
as you know. I am retired from the Air Force. I was medically
retired because of injuries I received as a reservist. And that
was probably my first trip to this place, this room, looking
for justice.
And I think we are all coming today here for justice. It is
no secret that the military has changed from the time I joined
in 1968. There are more women. There are more married families
and a heavy reliance on our Guard and Reserve has brought the
needs of our returning veterans to every town and city of this
United States.
I am really not going to go into the specific problems. But
I am going to tell you that in Connecticut we realized when we
saw a lot of the disruptions of the family life, when we saw
some of our returning veterans who were having a very difficult
time readjusting, and we realized that there was an increase in
domestic violence, Driving Under the Influence (DUIs), and
breach of peace, and a lot of dangerous behaviors by returning
Connecticut veterans.
Governor Rell charged me to do whatever it takes to ensure
that the families and the returnees received all of the help
that we could possibly give.
I am lucky because in Connecticut the General Assembly in
2004 set aside $1.4 million for a program, which we now call
the Military Support Program. This was to be opened for all
families of the Reserve components, pre-, during, and post-
deployment. And we actually have learned over time that the
more important thing is that we not only included the spouses
and the children, we included significant others, the parents,
and the siblings, immediate family members.
We have a 24/7 toll-free number that is manned by a real
person. When anyone is in need of help and we have done a lot
to actually advertise the program. The way it works is if
someone calls the toll-free number, we have taken this model
building on some of the experience Connecticut had after 9/11,
we have trained mental health professionals throughout the
community.
We called it ``Military 101.'' And it was 16 hours of
training. All of the clinicians had to go through this
training. And they are actually certified through the
Department of Mental Health and Addiction Services of the State
of Connecticut.
So if someone is in need and they call this toll-free
number, if it is not a mental health issue, they are referred
to the appropriate agency. But morning, noon, and night, if
they should call this number, they are given the name of three
clinicians within their immediate geographical area who have
agreed to take these calls and have agreed to engage in
treatment with these families.
And if everything else, all other funding sources are not
available, we pay for that care for those individuals from the
fund that was set aside by our General Assembly.
The best thing about this is that we call back after
receiving a call within 7 to 10 days to see how things are
going. If they haven't actually engaged in treatment, we
certainly encourage them to do that.
Additionally, what we have done is the idea that continuity
of care. I did cite in my written statement to you a study that
was done in your own home State of Maine, which illustrated
that returning veterans are more likely to engage in mental
healthcare with their families, because the stigma that we all
hear about kind of subsides because the military member is
doing it for their family, not necessarily for themselves.
However, they are engaged in treatment.
We have had--March 1, 2008, in the 10 months that we have
been in business, we have had over 360 calls and made 180
referrals of families who are now in treatment.
I think that in addition to that we have had done a lot of
other activities for example, we are doing a survey of our
returning veterans. And now one of the other things is that the
outreach for these veterans is a very, very important thing
that my Governor has tasked me to do.
But along with that, maybe because she was the member of a
military family, she certainly realizes the importance that the
family provides, the support that they provide, to our troops
in the field.
And that concludes my testimony.
[The prepared statement of Ms. Schwartz appears on p. 47.]
Mr. Michaud. Thank you.
STATEMENT OF PETER LEOUSIS
Mr. Leousis. Mr. Chairman and Members of Subcommittee,
thank you for the opportunity to speak this morning. I am the
Principal Investigator of the Citizen Soldier Support Program
National Demonstration.
This program was funded by Congress to develop model
approaches for mobilizing and engaging communities to support
citizen soldiers and their families.
Before I begin, I want to thank the North Carolina
Congressional delegation and the UNC Board of Governors for
their support of this work. I also want to emphasize that while
we have been laying the groundwork for this initiative for many
months, the elements are just getting underway. We will have a
much better picture of our impact in 6 months.
Our focus is on the National Guard and Reserves. In North
Carolina, most citizen soldiers don't live near a military
installation. And their families don't often think of
themselves as military families.
To date, more than 10,000 citizen soldiers in North
Carolina have served in Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF). And most of them came home to
communities and towns that might not even be aware of their
service and sacrifice.
We know that most families are resilient. But repeated
deployments and reintegration can be as challenging for
families as it is for veterans.
And there is evidence that exposure to combat has an even
greater affect on the Reserve component than it does on the
active component. Clearly, the mental health needs of returning
veterans affect the entire family. The issue is not whether
many families will face mental health challenges, but how we
can make sure they get the services they need where and when
they need them. Mental Health treatment should be made
available to the entire family when it is clinically
appropriate.
The initiative I am overseeing focuses on rural communities
and communities without ready access to U.S. Department of
Veterans Affairs (VA) medical facilities and Vet Centers. And I
have some maps that I want to show you very quickly this
morning.
The first map shows that every county in the State has
either Guard or Reserve members. The green indicates the
highest concentration. The red is the lowest concentration.
The second map shows the Vet Centers and VA medical
facilities in North Carolina. Those circles are 20-mile
radiuses. In other words, about a 30-minute driving distance to
each one of those facilities or Vet Centers.
Our initiative is focused on those little dots that you see
out there in the counties. Those are licensed clinical social
workers, of course, the greatest concentrations are in the
urban areas where the Vet Centers and the medical facilities
are.
But virtually every county in the State has licensed
clinical social workers and other mental health providers who
can also work with these families and provide services outside
of VA medical facilities.
In fact, our approach is targeting those folks who live
outside of those circles. It is guided by three principles. The
first is that we have to complement the work that others are
doing. And that includes the VA. One of our very close
collaborators has been Dr. Harold Kudler at the Mental Illness
Research, Education and Clinical Center. That is located in
Durham at the VA medical center there.
Another principle is that we need to take a systems
approach. Our efforts are focused on leveraging existing mental
health training and delivery systems to enhance the delivery of
services throughout the State.
The third principle is that there is no silver bullet. We
need to take a variety of different approaches and move forward
on many different fronts at the same time.
We have five components. The first is to provide evidence-
based, best practice behavioral health training for healthcare
professionals who are in counties outside of those circles.
That includes primary care physicians and mental health
providers, because often times the physicians are the gateways
to mental health services.
Second, we are working on a demonstration to provide
specialized mental health services to returning vets and
families using an integrated care model that combines
healthcare and mental healthcare in family health clinics in
rural underserved counties.
The goal is to be self-sustaining within 3 years through
TRICARE, third party payers, and Medicaid.
The third component is to expand TRICARE participation
throughout the State to physicians and mental health providers.
We are also working very hard to recruit those folks into the
system and to recruit the hospitals, the major hospitals, in
the State.
Fourth, we want to address the critical shortage of
clinicians in medically underserved rural counties through a
tuition loan forgiveness program for psychiatric nurse
practitioners to get that care out there in the communities.
And then finally, we have online information for consumers,
for the families, and military servicemembers through our NC
Health Info website, and information for providers through the
AHEC Digital Library. AHEC is the Area Health Education
Centers.
Our goal is to implement these strategies in North Carolina
and to help other States replicate those that are successful.
That concludes my remarks, Mr. Chairman. Thank you very
much.
[The prepared statement and referenced maps of Mr. Leousis
appear on p. 57.]
Mr. Michaud. Great, thank you. And I am very glad that you
are the first one to use this new technology we have----
Mr. Leousis. I understand.
Mr. Michaud [continuing]. And glad that it works.
Mr. Leousis. It works very well.
Mr. Michaud. Ms. Bannerman.
STATEMENT OF STACY BANNERMAN, M.S.
Ms. Bannerman. During the few hours it takes for this
hearing to conclude, another veteran will commit suicide. Most
likely a veteran of the Guard or Reserves who make up more than
a half of veterans who committed suicide after returning home
from Iraq and Afghanistan.
There will be at least seven family members left behind to
deal with the adjustment, loss, anger, and grief. And they will
do so alone. Forced to live with the pain of their preventable
loss for the rest of their lives.
I am currently separated from my husband, a National Guard
soldier who served 1 year in Iraq. And just as we are finding
our way back together, we are starting the countdown for a
second deployment. Two of my cousins by marriage have also
served in Iraq, one with the Minnesota Guard, a 22-month
deployment, the longest of any ground combat unit. And my other
cousin, active duty, was killed in action.
When the home front costs and burdens fall repeatedly on
the same shoulders, the anticipatory grief and trauma,
secondary, intergenerational and betrayal, is exponential and
increasingly acute. Guard families experience the same
stressors as active-duty families during all phases of combat
deployment. But we have nowhere near the same level of support,
nor do our loved ones when they come home.
The nearly three million immediate family members directly
impacted by Guard and Reserve deployments struggle with issues
active-duty families do not.
The Guard has never before been deployed in such numbers
for so long. Most never expected to go to war. During Vietnam,
some people actually joined the Guard in order to dodge the
draft and avoid combat. Today's Guard and Reservists are
serving with honor and bravery each and every time they are
called.
But when the Governor of Puerto Rico called for a U.S.
withdrawal from Iraq at the annual National Guard conference,
more than 4,000 Guardsmen gave him a standing ovation.
These factors are crucial to understanding the mental
health impacts of the war in Iraq on the families of Guard and
Reserve veterans and tailoring programs and services to support
them.
At least 20 percent of us have experienced a significant
drop in household income during our loved one's combat
deployment. And that is an added stressor. Some veterans lost
their jobs as a direct result of deployment. Some of us
relocate. We go to food shelves. Where we once shared parenting
responsibilities, we are the sole caregiver. And we have no on-
base childcare center.
During deployment, we may attempt to cope by drinking more,
eating less, taking Xanax or Prozac to make it through. We
cautiously circle the block when we come home, our personal
perimeter check to make sure there are no Casualty Notification
Officers.
Our kids may act out or withdraw, get into fights, detach
or deteriorate, socially, emotionally, and academically. And
there are no organic mental health services for the children of
Guard and Reservists, even though they are more likely to be
married than active-duty troops.
When our soldiers come home, they are given a perfunctory
set of questions. And then they are given back to us. Fifty
percent of Guard and Reserves who have served in Iraq suffer
post-combat mental health issues. And the government has known
for decades, decades, decades. The VA has done nothing about
it. And I question--I question commissioning reports and
conducting studies if we are not going to apply what we have
learned.
Perhaps rather than forking out another $5 or $10 million
for a study, that money could be used to fund a community-based
center that would provide our families and veterans 3 years of
the free services they are desperately begging for but that
aren't available.
We should commission the people who have their doctorates
in deployment. The military families and veterans, they know
what is needed, what helps, and what the emerging issues are.
I knew the suicide rates of citizen soldiers who served in
Iraq were going to be off the charts when I started hearing
from their family members more than 2 years ago.
And although it stands to reason that the branch of service
with the highest rates of post traumatic stress disorder (PTSD)
would be the same one with the highest rates of suicide, the
Department of Veterans Affairs had to do a formal analysis to
determine that citizen soldiers are more likely to kill
themselves as war veterans. A Military Citizens Advisory Panel
could likely have saved lives, dollars, and years of pain.
After a loved ones return from deployments that have all
the precursors for post-combat mental health issues, we are
given a pamphlet and told to ``give it time.'' And while we are
reading and waiting, we are losing our veterans, our marriages,
our health, and our families.
For one military family living with a combat veteran who
wrote, ``Back in May, Kyle suffered a PTSD disassociative state
of mind and held me at knife point. He had me and my family
sitting on the floor and was speaking to us in Arabic for an
hour and a half.''
The veteran's unresolved traumatic re-enactment resulting
in domestic violence is the nucleus of intergenerational
trauma, which the children and grandchildren of these veterans
are going to be living with forever.
The VA's mental health professionals preach to the wives
about resilience. But they aren't the ones being woken up at
three in the morning because their husband has shot the dog, or
is holding a gun to your head, or a knife at your throat.
Expecting the wife and family member to treat the veteran
violates the professional standard prohibiting family members
from treating their own. It places the burden of care on the
family. It creates a highly unfair and unethical expectation
that we are trained mental health providers. It excuses the VA
from fulfilling its responsibilities to our veterans. And it
discounts our reality, while placing an immoral burden on our
veterans, our family members, who are likely already suffering
undue mental health and financial consequences.
Another issue before I make the recommendations that the
Committee requested that I provide at this hearing. Another
critical, critical issue is the one of betrayal trauma. When
the Veterans Administration repeatedly proves to us that we
can't trust them to take care of our loved ones, we feel
betrayed. When our loved ones 5 years into this war still don't
have the equipment, they need, we feel betrayed.
And there is no dictionary large enough to describe what
you feel when you learn that your loved one has fought, died,
been wounded, is on the ground or on alert to return to fight
in a war that was launched on 935 lives.
Mental health experts refer to what is going on with
military families, particularly in the Guard and Reserve, as
betrayal trauma. That is what occurs when the people or
institutions we depend on for survival, the VA, and the
Pentagon, the U.S. Department of Defense (DoD), when they
violate us in some way.
And I assure you when it is life and death and your loved
one on the line, and when they are fighting for country and
Constitution, military service is no mere contract. It is a
covenant. And it has been betrayed.
Now in order to genuinely care for our Guard and Reserve
veterans, we must attend to the need of families who are left
behind and serve as the first line of support.
However, right now within the Veterans Administration,
treatment is tied to the veteran. Military spouses can't access
services at the VA until their soldier has acknowledged his or
her trauma, registered with the appropriate agency, provided
paperwork or given permission for the spouse to receive
assistance or attend a support group, which may or may not be
available at the time.
The majority of affected loved ones, the siblings, the
parents, the significant others, are beyond the scope of
services. Guard and Reserve families often don't have private
insurance. We can't afford the copays. We are unable to find
adequate mental health providers who have the experience,
training, and awareness to address the particular needs of our
community during a time of war. And those inadequacies put the
health, well-being, and future of all military family members
and their veterans at risk.
A few brief recommendations----
Mr. Michaud. Yes, because----
Ms. Bannerman. Yes, sir.
Mr. Michaud [continuing]. I was ready to--this is twice the
amount of time.
Ms. Bannerman. Thank you. I appreciate that immensely.
Mr. Michaud. So if you could go through as quickly as
possible.
Ms. Bannerman. Very brief.
Military Citizens Advisory Panel, the real support for
citizen soldier veterans and loves ones can't be achieved
without the perspectives of those who are directly affected by
combat.
I would recommend that the experiences, and the
perspective, and the realities of the people who have--the
people who have the doctorates in deployment are brought into
the policy program and oversight processes of the Veterans'
Affairs Committee.
I would recommend peer-to-peer support groups. I would
recommend that you look at implementing an adopt a family
program that would involve community members in taking a Guard
or Reserve family member under its wings for all phases of
combat deployment.
I would recommend, particularly in the rural areas, 40
percent of our veterans live in rural areas, that you conduct
home visits.
I would recommend that the VA fund community-based weekend
retreats. Our citizen soldiers work full time when they come
home. We need weekend retreats, or we need experiential
programs. We need non-clinical services. We need night
services.
And please, please develop and implement a family systems
theory programming and services. Please, thank you.
[The prepared statement of Ms. Bannerman appears on p. 51.]
Mr. Michaud. Well, thank you very much. And thank you also
for writing the book entitled ``When the War Came Home: The
Inside Story of Reservists and the Families They Leave
Behind.''
I haven't had a chance to read the book. But I definitely
will. So I want to thank you for your interest, in this area as
well. It is very helpful.
Mr. Hare. I have a couple of quick questions. Commissioner
Schwartz, you had mentioned about the Connecticut Military
Support Program. Knowing what States are going through with
budgetary shortfalls and the way the economy is, how does
Connecticut plan to continue to fund this program, or do you
plan on continuing to fund the program?
And my second question is, is there any way the VA can help
support what Connecticut's doing for this particular program?
Ms. Schwartz. Let me say, sir, that I give that credit to
the foresight of the General Assembly. We sold the site, which
had been a psychiatric hospital. And a portion of the money
that was realized from that was set aside well in advance. Yes,
they do intend to continue to support it, because we have found
that our families--I hope you can hear me.
We have found that--you know this as well as I do, families
in distress on the home front, can now electrically transmit
immediately through emails and cell phones the distress that
they are in. This actually does affect mission readiness.
The most important thing about it is that we are proactive,
in addition to this, I have commissioned a study of recently
returned veterans, a survey that is being conducted by Central
Connecticut State University out of funding they have received.
And it is going to just recently returned veterans, because I
would like to make a point. Many people would not like to hear
this point, but the truth of the matter is that our veterans
who are returning today are not--are not joining the veteran
service organizations. They are into the peer-to-peer support
groups.
Student groups throughout Connecticut, I have actually been
working with university presidents to have at least an office
for the veterans to drop in, because we have many veterans in
our college campuses who are finding that they just don't fit.
And as a veteran of the Vietnam War, I know that feeling
well. So I want to do whatever I can to assure that doesn't
happen again. That is my charge. And that is my daily goal.
Getting back to what can VA do, I want to just say your
State, my State, all the States of the union, put together--$4
billion is what our States invest in the care of veterans
throughout America. That is second only to a very small second,
but second only to the Federal VA.
I am sure you have heard this before, but let me say it
again. We need to know when these folks are coming home. There
is no--there is no vehicle for us to be informed when they are
coming home. But they are Reservists who are not attached to a
unit. National Guard has a great safety net, because at least
we know who they are.
But as you may know, my Congressman, Joe Courtney, has
sponsored legislation to require that VA and DoD inform the
States when people are coming home.
Let me also say that there are some things the VA cannot
do. You just heard a litany. VA cannot possibly respond in the
time that they need to do that. And that is why working with
the States, because I am accountable not only to my Governor,
but to the citizens of my State. And all of my counterparts
across the country care, they are vitally interested in this.
And I think that VA needs to see us as a natural partner.
When you put the resources of Connecticut together with the
resources of the VA in Connecticut, we have--we have developed
a continuum.
Right now we are working on the issue of so many of our
veterans returning facing jail time. And we are working on an
alternative to incarceration, which includes VA.
Mr. Michaud. Thank you very much.
Mr. Leousis, can you speak to the unique mental health
challenges that members of the Guard and Reserves and their
families have, particularly those who live in rural areas?
Mr. Leousis. Yes, sir. Well there is a lot of research that
indicates, as I said, that first of all, Guard and Reservists
are affected at roughly twice as much. There was an article
published in the ``Journal of the American Medical
Association'' last year that said returning Reservists and
Guardsmen have roughly 42 percent mental health issues.
It definitely affects their families. And what we are
finding is that they live too far from VA centers, or the vets
medical facilities, or the Vet Centers to get the kind of
treatment or services they need once they become eligible for
those services.
So our goal is to train providers in those rural areas who
then will go into a directory that will be available not just
through NC Health Info, which is information for consumers for
the families themselves, but also go into a directory working
with the local medical--the North Carolina Medical Society so
that primary care physicians would also have information about
who they can refer those families to when they show up at their
offices.
Mr. Michaud. Okay. And the program--Citizen Soldier Support
Program--engages community support for members of the National
Guard and Reserves. Are there any plans to expand this program
to other States?
Mr. Leousis. Yes, there are. What we would like to do is
stand up a national center at the university that I work at.
But the goal would be to take the successful demonstrations and
practices that we are developing in North Carolina. And then
working with other States and people like Colonel Schwartz in
Connecticut, develop a strategy that is tailored to
Connecticut, not to North Carolina, but that takes a lot of the
principles.
Over 40 States have AHEC systems. AHEC stands for Area
Health Education Centers. And those are training systems that
exist in States to reach mental health and healthcare
providers.
Mr. Michaud. Thank you. Congressman Hare.
Mr. Hare. Thank you, Mr. Chairman.
Ms. Bannerman, thank you so much for coming. And I thank
all the panelists. I had an opportunity in my office to meet
with the parents of Tim Bowman who committed suicide when he
got back. And his mother was telling me something that I think
about almost every day. She said when he--before he came home
or when he was coming home, they were given less than 5 minutes
of things to look out for, things that they may encounter.
And, you know, here sits the parents of this wonderful
young man and taking the blame for something. ``We should have
seen it. But we didn't see it. Didn't know what to look for.''
I wonder if--you know, if maybe you could just from your
perspective, you know, because you mentioned a word I think
that is incredibly important. It is also the families of these
people, because if you come home suffering post traumatic
stress disorder. I have had people come up to me. And the
little kids will say, ``Why is my dad hitting my mom?'' or
``Why is he doing the things that he is doing?''
So I wonder maybe if you could talk a little bit about
maybe some things you would suggest we could do to help the
families of people, because it is not just the servicemember
that needs the help, it is the families who are greatly
affected by whether, you know, it is post traumatic stress or
whether the person takes their life. And, you know, to keep a
family or to help--try to help them get through this terrible
time or things to look out for.
Again, this mother told me--she said, ``Congressman, I
should have seen this. I should have done something about it.''
And I said, ``Well, if you don't know what to look for, how can
you--you know.''
I am just wondering maybe to get some thoughts from you on
that.
Ms. Bannerman. Thank you for asking me Congressman.
Virtually every family member I have spoken with who has lost
their veteran due to suicide or divorce has said, ``I thought
that if I loved him enough I could fix him.''
When we are just given a pamphlet, and then sent home, and
there is no kind of follow up, chances are good that pamphlet
goes in a drawer somewhere. If the person reads through it
once, then it goes into a drawer. And that is about the end of
that.
What would have been hugely beneficial, one, I think that
the VA should be--start making efforts to reach out to families
or begin tracking our soldiers at the midpoint of their
deployments. I don't understand this business of waiting until
they have been home forever. It just seems like forever to us.
That is all.
And I think also one of the things that would be huge is if
our families--again, especially Guard and Reserve, you know,
when you are active family, you have somebody living next door
to you on base who is going through the same thing or who has
been through it.
If we had just heard from a combat veteran, if we had just
heard from military families who have lived through
deployments. If they had come to us, rather than this public
relations outreach specialist from the VA, with the pamphlet,
if we heard from a combat vet and military family members, that
would have been huge.
If there had been follow up done, you know, at regular
periodic intervals. We know that post-combat trauma manifests
in different ways and kind of at different stages. And there
should be check ins.
In my husband's case, when he got home, there wasn't a
comprehensive mental health screening done until he had been
home for more than 8 months. There had been no follow up for
him whatsoever. The regular active-duty people, they have
weekly kind of mental health check in stuff. It is mandatory.
The Guard has got nothing.
And then they didn't call him with the results of his
mental health screening until almost 10 months after they did
it. So that is oh gee, a year and a half that went by from the
time he got home until the time they called him and said,
``Yeah, we got your test results, and you have some symptoms of
PTSD. And we suggest you get counseling.'' That was it.
Mr. Hare. Not to interrupt you, but in my home State of
Illinois, it is my understanding that all Guardsmen are tested,
or screened for PTSD. But yet, many places across the country
they are not. And for that person to actually step forward and
say, you know, I think I have this problem. They may need--
first of all, they may not even know they have a problem. It
may not manifest itself for months or years.
There has to be a much better way. We have to do a much
better job it would seem to me of screening every person when
they come. And that and then following that up with talking to
their families too, because this is not just for the veteran.
This is for their entire family that is affected by this.
Ms. Bannerman. Minimize the delays as much as possible. And
also, I think one of the things too is a whole lot more needs
to be done to shift the language. I mean, we are talking about
this like it is kind of--it is a mental problem. And it is a
heart problem. It is a soul problem----
Mr. Hare. Mm-hmm.
Ms. Bannerman [continuing]. A lot of it, you know? And we
have so pathologized combat-related mental health issues, that
of course there is this stigma when, in fact, the reality is
that a healthy person after being in combat--combat situations,
unlike any other for longer than ever, a sign of health is that
they come back and they have difficulty reintegrating.
And so it is also about the framing of it. And it is about
the language. And it is about having much more. Don't just put
these guys from combat to cul-de-sac in 48 hours.
Mr. Hare. Right. Well, listen I thank you so much. I look
forward to reading your book.
Ms. Schwartz. I would just like to say something.
Mr. Hare. Sure.
Ms. Schwartz. The U.S. State of Illinois, you have a
wonderful Director of Veterans Affairs. And she----
Mr. Hare. Tammy Duckworth. Yeah, she does a great job.
Ms. Schwartz. Yes. And she has instituted a traumatic brain
injury (TBI) screening that is something that we all--for all
returning Guardsmen. And it is true that they do.
I personally have been to the demobilizations (DMOBs)
myself. But, you know, the euphoria of the troops coming home,
they are in the best shape they have been in in months.
And so when you do a screening like VA, or when you look at
the TBI screening that they are doing now with some concerns
that there is no validity to this test, that screening--the
most important thing you could take away from it is the
screening at the--immediate DMOB is not working.
But what we find is 30 days after they come home, that is
when reality sets in.
Mr. Hare. Mm-hmm.
Ms. Schwartz. And the DoD has said, oh, come back in 90
days. But it is really 30 days. I know some States, Minnesota
is one of them, has been successful negotiating with DoD to be
able to do this at 30 days.
But I think when you have to negotiate with DoD, that is a
tall order. And that somebody needs to really think about
bringing them back at 30 days, not the 90 days.
Mr. Hare. Great. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. Mr. Moran.
Mr. Moran. Thank you, Mr. Chairman. Just one question as a
follow up to either one of our witnesses that I have heard
testify.
Is there some justification for this 90 days? What is the
explanation for why it is not being done at the most
appropriate time?
Ms. Schwartz. I think that in the beginning they felt that
they were doing--that 90 days was just actually implemented a
couple of years ago. They felt like it----
Mr. Moran. It used to be longer?
Ms. Schwartz. Yes. And the issue was that, you know, they
have been at war. Give them some downtime.
But I think experience has shown, and it is across the
board, that 30 days is the mark. And we need to be looking at
them at 30 days. That is when, as I said, reality sets in. And
readjustment issues start to surface. That is when you can pick
up on some of these mental health issues before they become a
crisis.
Mr. Moran. Thank you very much. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. Ms. Berkley.
Ms. Berkley. Thank you, Mr. Chairman. I have a statement
that I would like to submit for the record.
[The prepared statement of Congresswoman Berkley appears on
p. 47.]
Mr. Michaud. Your statement will be made part of the
record.
Ms. Berkley. I also want to thank our witnesses for being
here and helping to educate us further. So thank you for your
time and attention to what is a very serious and increasingly
more prevalent issue.
Mr. Michaud. Thank you. Once again I would like to thank
our first group of panelists very much for your testimony. It
has been very enlightening. I look forward to working with you
as we move forward on this issue. I now would like to invite
the second group to please come forward.
Our second panel includes Charles Figley, who is a Ph.D.
from the American Association for Marriage and Family Therapy
(AAMFT); Ralph Ibson, who is Vice President of Government
Affairs for Mental Health of America; and Suzanne Phillips, who
is here on behalf of the American Group Psychotherapy
Association (AGPA).
I want to thank all three of you for coming today as well.
We do have your written testimony, and it will be submitted for
the record. We ask that you stay within the 5 minutes.
We still have a couple panels to come. So if we can try to
stay within that 5-minute time frame, it would be appreciated.
So without further ado, Mr. Figley.
STATEMENTS OF CHARLES FIGLEY, PH.D., LMFT, FULBRIGHT FELLOW AND
PROFESSOR, COLLEGE OF SOCIAL WORK, AND DIRECTOR, TRAUMATOLOGY
INSTITUTE AND PSYCHOSOCIAL STRESS RESEARCH AND DEVELOPMENT
PROGRAM, FLORIDA STATE UNIVERSITY, TALLAHASSEE, FL, ON BEHALF
OF AMERICAN ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY; RALPH
IBSON, VICE PRESIDENT FOR GOVERNMENT AFFAIRS, MENTAL HEALTH
AMERICA; AND SUZANNE B. PHILLIPS, PSY.D., ABPP, CGP,
PSYCHOLOGIST-PSYCHOANALYST, GROUP THERAPIST, NORTHPORT, NY,
ADJUNCT PROFESSOR OF CLINICAL PSYCHOLOGY, C.W. POST CAMPUS,
BROOKVILLE, NY, POST-DOCTORAL FACULTY, DERNER INSTITUTE,
POSTDOCTORAL PROGRAM IN GROUP PSYCHOTHERAPY AND PSYCHOANALYSIS,
ADELPHI UNIVERSITY, GARDEN CITY, NY, ON BEHALF OF AMERICAN
GROUP PSYCHOTHERAPY ASSOCIATION, INC.
STATEMENT OF CHARLES FIGLEY, PH.D., LMFT
Mr. Figley. Dear Mr. Chairman and other Members of the
Subcommittee, on behalf of the American Association for
Marriage and Family Therapy, I would like to thank you for
shedding light on the need for the Department of Veterans
Affairs to expand VA mental health services to include family
members of veterans in addition to veterans themselves.
We are honored to participate in this important dialog. And
by holding today's hearing, which is Mental Health Treatment
for Families: Support Those Who Support Our Veterans, access to
family oriented mental health services will finally be formally
addressed, so we can begin to help heal the clandestine wounds
increasingly affecting those closest to returning
servicemembers.
As background, the AAMFT is a national non-profit
professional association representing the interests of over
52,000 marriage and family therapists across the United States.
And it was started in 1942.
Family therapists are the only mental health profession
required to receive training in family therapy and family
systems. Not only are marriage and family therapists (MFTs)
licensed in 48 States and this District of Columbia, but each
licensed or certified MFT must meet strict professional
requirements including a minimum of a master's degree, even
though 30 percent have a Ph.D., in marriage and family therapy
or equivalent degrees with substantial course work in MFT. In
addition, MFTs must complete at least 2 years of a post-
graduate clinical supervision internship.
At the end of 2006, the President signed into law a
sweeping veterans' bill that finally added marriage and family
therapists as eligible providers of mental health services
under the VA. It is Public Law 109-461.
As one of the 5 core mental health professions, designated
by the Heath Resources and Services Administration, family
therapists are trained to treat disorders commonly faced by
veterans, including clinical depression, post traumatic stress
disorder, among others. Despite our ongoing collaboration with
the leadership of the VHA and the law having been in effect
well over a year, our 52,000 U.S. family therapists are still
awaiting implementation into the VA system as we can begin to
aid our Nation's veterans, as we have served active-duty
military for over 30 years.
Family therapists have been eligible to provide medically
necessary mental health services to active military personnel
and their families under the CHAMPUS and TRICARE program for
decades, as well as recognized by the Department of Defense.
Additionally, family therapist interns serve veterans in VA
facilities, but presently cannot continue this care as licensed
MFTs since our VA implementation is incomplete.
So why are we so anxious to get to work at the VA? The
impact of mental illness on our veterans and their families is
striking. Recognition of the need to expand VA mental health
services to include families is growing as an impact of mental
health disorders among veterans of OIF and OEF manifest,
following their mustering out of the military.
A 2004 study, that I am sure you are aware of, demonstrated
the significant mental health consequences of the wars in
Afghanistan and Iraq. This publication in the ``New England
Journal of Medicine,'' cites the estimated risk for PTSD from
service in Iraq Wars as 18 percent, while the risk of PTSD from
Afghanistan is 11 percent.
According to a less well known study in the ``Journal of
Marital and Family Therapy'' in October of 2006, ``domestic
violence rates among veterans with post traumatic stress
dirorder are higher than those in the general public.
Individuals who have been diagnosed with PTSD who seek couple
therapy with their partners constitute an underrepresented and
understudied population.''
Additionally, servicemembers deployment length is
intrinsically related to higher rates of mental health problems
and marital problems.
Data within the U.S. military report, the ``Mental Health
Advisory Team (MHAT) IV,'' my journal had a special issue just
last month on this, shows that there are at--has been at least
72 confirmed soldier suicides in Iraq since the beginning of
OIF as late as 2006.
As with previous MHAT reports, this also finds suicide
rates at 28 percent higher compared to the average Army rates
for those not deployed. For servicemembers, deployment length
and family separation were the top non-combat deployment
issues.
Marital concerns were higher than in previous surveys among
these OIF troops. And like other concerns, they were related to
deployment length. Those in Iraq were more than--who are more
than 6 months, which includes the Army and Marine Corps for
example, were at least 1\1/2\ times more likely to be assessed
as having mental health problems. In addition, those troops
were more likely to have--I understand--the marital concerns,
reporting problems of infidelity, and were almost twice as
likely in planning--in planning for a marital separation and
divorce.
And the data goes on and on. So let me just come to a
conclusion. What about the Reservists and National Guard that
was noticed--noted on the last panel?
The obvious problems of hampering veterans access to mental
health services is a shortage of qualified mental health
providers in rural communities. This is where marriage and
family therapists come in.
Once you have a way of addressing the staffing problems is
through the increased access to mental health services provided
by practitioners who are widely present in rural communities.
These are, again, family therapists.
Our own data show that 31 percent of all rural counties
have at least one family therapist, demonstrating our strong
MFT representation in rural America. Improving access is
critical, particularly since the National Rural Health
Association reports on the average distance between a VA care
facility and the veteran is 63 miles.
This is unacceptable travel time for those who have already
traveled the world on behalf of--in pursuit of U.S. safety and
security. Our servicemembers deserve more and to help and make
a seamless transition out of active duty and into veteran
status.
[The prepared statement of Mr. Figley appears on p. 62.]
Mr. Michaud. Thank you very much. Mr. Ibson.
STATEMENT OF RALPH IBSON
Mr. Ibson. Good morning, Mr. Chairman and Members of the
Subcommittee. Thank you for holding this truly important
hearing.
Military deployment, particularly for a Guardsman and
Reservist, can be enormously stressful as many witnesses have
already testified this morning. The strain that war places on
families and marriages does not necessarily end with a
homecoming.
The post-deployment period can also be a time of difficult
readjustment. As one writer put it, ``In many instances, a
traumatized soldier is greeting a traumatized family, and
neither is recognizing the other.''
Clinicians have described adjustment reactions among OIF/
OEF veterans that include feeling anxious, having difficulty
connecting to others, experiencing sleep problems, strains in
intimate relationships, as well as problems with impulse
control and aggressive behavior.
These understandable reactions impair the process of
reintegrating an individual back into family life. Clearly, the
family has a profoundly important role in a veterans
readjustment and recovery. But family members who have been
scarred by the trauma of the deployment experience and who
sometimes suffer anxiety and depression themselves, may not
have the capacity to provide that needed support.
It is critically important certainly that veterans get the
counseling and treatment they need. And that they receive that
help early to avoid problems becoming chronic or worsening.
But if the veteran is to be truly helped, we cannot ignore
the mental health needs of those family members whose support
is so critical.
Let me emphasize that current law already reflects the
importance of providing mental health services to family
members of veterans.
Section 1782(a) of Title 38 specifically directs using the
word ``shall.'' It directs VA to provide counseling and mental
health services to immediate family members when those services
are necessary to support the treatment of a service-connected
condition.
Given that service-connected status is a key element in
that provision, it is important to acknowledge that Congress
has already established what amounts to presumptive service-
connected status for all OIF/OEF veterans for healthcare
eligibility. And it just recently extended that presumption--
that effective presumption--from 2 to 5 years.
So what is the practice in VA today? The VA is a national
healthcare system. But when it comes to meeting the needs of
veterans with mental health problems, which for many does
include addressing the family's mental health, getting needed
support depends entirely on where the veteran lives. If one can
get to a Vet Center, family counseling is probably available.
But what about the veteran living a considerable distance
from the closest Vet Center? A few, I emphasize a few, VA
medical centers provide an excellent program of family support
services that includes consultation, education, and psycho-
education.
But it is our experience that most medical centers and
clinics do not offer such programs. It is difficult to square
that patchwork with language in Title 38 that, as I noted, says
the Secretary ``shall provide consultation, professional
counseling, training in mental health services as are necessary
in connection with treatment of a service-connected
condition.''
Only a handful of facilities appear to be providing any of
those services. And notwithstanding that clear language, we are
not aware of any VA medical centers or clinics that provide
mental health treatment as required by law to family members of
veterans for treatment of a service-connected condition.
If VA is treating an OIF/OEF veteran for PTSD that has not
been adjudicated as service connected, current law limits
provision of family services to instances where the veteran has
been hospitalized. That limitation appears to us to make no
sense, particularly given VA's transformation a decade ago from
a hospital-based system to one that is heavily reliant on
ambulatory treatment. Continuation of hospitalization as the
test seems anachronistic and contrary to good medical practice.
We see no sound rationale for providing family services in
Vet Centers on the one hand and restricting them in the medical
centers. And we urge the Committee to amend section 1782.
Finally, it appears to us tragic that with the prevalence
of PTSD among returning veterans, the Department has not heeded
the advice of its own experts.
And I think it goes very much to Congressman Hare's earlier
question. The VA Special Committee on PTSD some 2 years ago
stated, ``VA needs to create a progressive system of engagement
and care that meets veterans and families where they live.''
And as Ms. Bannerman spoke earlier, the emphasis should be on
wellness, rather than pathology, on training rather than
treatment.
Finally, the PTSD Committee went on to say, ``Because
virtually all returning veterans and their families face
readjustment problems, it makes sense to provide universal
interventions that include education and support for veterans
and their families, coupled with screening and triage for the
minority of veterans and families who will need further
intervention.''
That concludes my summary.
[The prepared statement of Mr. Ibson appears on p. 64.]
Mr. Michaud. Great, thank you very much. Ms. Phillips.
STATEMENT OF SUZANNE B. PHILLIPS, PSY.D., ABPP, CGP
Ms. Phillips. On behalf of the American Group Psychotherapy
Association----
Mr. Michaud. Could you turn your microphone on, please?
Ms. Phillips. On behalf of the American Group Psychotherapy
Association, I thank you for the opportunity to testify for the
needs of veterans and their families.
In the aftermath of 9/11, the American Group Psychotherapy
Association faced the needs of a traumatized population by
running an extensive number of groups for bereaved spouses,
children, families, schools, communities, churches,
corporations, and first responders.
In all, AGPA ran 600 groups, meeting the needs of over
5,000 people. The curriculum we used, the protocols we
developed have been published. And they have already been
translated to the needs of other populations such as the
victims of Hurricanes Katrina and Rita, and more recently the
California fires.
I am here to propose that many of those group programs are
particularly relevant to the needs of veterans and their
families.
Trauma, assault, connections and social ties. We have found
that group interventions are particularly viable, not only
because they are cost effective, but because they reduce
barriers of care.
Groups normalize, destigmatize, they validate. They offer
the opportunity to bear witness, to support resiliency, as well
as to restore connections.
Too often the collateral damage from war is the destruction
of the marriages and families of our veterans. Thirty-eight
percent of the marriages of Vietnam veterans were dissolved
within 6 months of their return from Southeast Asia.
We have heard today already of the difficult homecomings of
our veterans from Iraq and Afghanistan. Homecoming is a
complicated process. It is difficult to reverse battle mind
mentality. It is difficult to move on when others have been
lost.
In fact, many of our veterans bring home the war in terms
of physical wounds and psychological scars. Their marriages and
their families are at risk. But they are also their greatest
resources. Research tells us that it is the close social ties,
the marriages and the families that are the most potent
anecdote to the despair and isolation that unfold from combat
trauma.
One of the programs that was particularly effective after
9/11 that is relevant to vets was the Couples Connection
Program that we ran in partnership with the Counseling Office
of the Fire Department of New York. After 9/11, the Fire
Department of New York had lost 343 of their men. Firefighters
are much like military. In fact, many of them are Reservists
and Guardsmen. They have the same code. You go in together, you
come out together, and you leave no man behind.
As a result, for months they stayed on the pile looking for
traces of lost brothers. By the time the pile was closed on
June 2002, many of their marriages and families were
devastated. It was in response to this that we ran the Couples
Connection Program over 15 times for the next 2 years relative
to the delayed response of PTSD.
These programs involved 25 couples at a time in group
experiences that normalized PTSD, addressed survivor guilt,
masked depression, and the isolation and helplessness of those
who wait on the home front, as well as the necessary steps back
to marriage and intimacy.
Another very relevant program was the family program called
Going on After Loss. This program did a great deal to restore
stability in families, as well as to address trauma and the
need for new role definitions. This could very easily be
translated into families going on after war, particularly with
wounded parents.
The program ran parallel family, children, and parents
groups. It emphasized communication, coping skills, and new
beginnings.
AGPA was very aware of the impact on caregivers after 9/11
and provided many group programs and training to deal with the
secondary post traumatic stress dirorder and vicarious
traumatization that affects spiritual caregivers and clinicians
dealing with families and those who have been traumatized.
This is very relevant to our VA clinicians as well as non-
clinical staff who are dealing with so many returning vets.
Initiatives are already in place with the DVAs in San Antonio
and Houston to provide training for psychiatric nurses and
ancillary staff dealing with our veterans.
Much like dealing with family members, when you support and
train the system that surrounds veterans, you enhance the
possibility of their recovery.
In terms of trying to connect across a distance, AGPA
provided a great deal of training by means of telephone contact
and online panels. At one point as we were running our online
panels for trauma training, we had over 2,500 participants
worldwide checking in.
This has potential----
Mr. Michaud. If you could please sum up.
Ms. Phillips. In terms of the programs that we could
present, we know that the families and the spouses of our
veterans are their best resources. By including them directly
in programs, we make possible the reconnections that really
bring them home.
That concludes my testimony.
[The prepared statement of Ms. Phillips appears on p. 68.]
Mr. Michaud. Great. Once again, I want to thank all three
panelists very much for your enlightening testimony. And I will
be submitting some questions for the record, if you could
respond.
[No questions were submitted.]
Mr. Michaud. Mr. Miller.
Mr. Miller. Thank you very much, Mr. Chairman. I apologize
for being late. I was in an Armed Services hearing on the Army
budget.
Mr. Ibson, I came in during your testimony I believe. One
of the comments you made was that Congress should have no
hesitation of amending current law to allow family members of
Operation Iraqi Freedom and Operation Enduring Freedom veterans
to get counseling services that would enable them to better
support the veteran in his or her treatment.
For clarification, do you support, advocate opening
treatment just so they can deal with the veteran and their
issue, or are you advocating furthering the process to allow
family members to receive mental healthcare as well?
Mr. Ibson. Well, current law certainly links the provision
to services to family members to a nexus for the treatment of
veterans.
I think one could certainly look at the extraordinary
trauma of the deployment and post-deployment period on that
family member and liken it to service connection. That that
trauma is as much linked to war as is the veteran's experience
in service.
I could understand lines the Committee might feel it
appropriate to draw. But certainly at a minimum, we would see
nexus to the veteran's treatment as a critical point. And the
failure to make that bridge for veterans who have not yet been
adjudicated service connected seems troublesome.
Mr. Miller. But you do acknowledge that it could be very
problematic to expand care to family members that may have
preexisting issues and see how that could mushroom into a
tremendous cost for the VA system, and in some ways even hamper
the ability to provide healthcare to the veteran?
Mr. Ibson. But, again, with the analogy to establishing
service connection, whether or not there is a preexisting issue
when the experience of military service aggravates an
underlining disorder, we make no distinction with respect to
the veteran.
And I think in the spirit of furthering the veteran's well-
being, it behooves us, at least from our perspective, to ensure
that the family member can get needed services and be
supported.
Mr. Miller. So you recommend that if a family member has
childhood issues that they are being treated for then the VA
should be responsible for treating those issues because they
are in fact a family member of a returning veteran.
Mr. Ibson. That is not the point I was trying to make, sir.
Mr. Miller. Well that is the point I am trying to make.
Mr. Ibson. I understand.
Mr. Miller. That is what I am saying. You see how the nexus
could be drawn. You are now providing--I understand aggravating
or mitigating circumstances. I think we would all agree, but I
am just saying can you see how broad it then becomes? It
becomes a system whereby we are treating individuals who
clearly could be, clearly who have no nexus, no connection to
the veteran's mental health.
Mr. Ibson. The art of line drawing is always challenging,
sir. And in the final analysis, my judgment would be, or my
recommendation would be that the Committee look to what can
serve the reintegration, recovery, readjustment of that
veteran.
Mr. Miller. Do you subscribe that is not what this
Committee does already?
Mr. Ibson. No. I don't mean to suggest that at all, sir.
Mr. Miller. Thank you. Another question, you stressed that
VA needs to create a progressive system of engagement and care
that meets the needs of the veterans and their families where
they live.
Can you give me some ideas of how that is accomplished in
our rural areas, as most all of us, maybe except Ms. Berkley.
Do you have any rural areas in your district? Obviously,
veterans do not always live where the care is most readily
available.
Mr. Ibson. Yes, sir. And I think this Committee has already
taken a historic stand on that point in marking up, and moving
to the floor, and passing in the House the Chairman's Bill H.R.
2874, provisions of which would direct the VA to mount a
national program to train returning servicemembers to function
as peers, to do outreach, and engagement, and support.
And I think, again, it speaks to the issue that Mr. Hare
and that you are raising. That it allows for an opportunity to
work with community providers who under H.R. 2874 would be
encouraged to employ such trained peers to reach the many, many
veterans, particularly the National Guardsmen and Reservists,
who are remote from the VA.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. Mr. Figley, if I could
get an opinion from you here. Do you think the VA fully
understands the importance of involving the families, and
spouses, children, and parents in mental health treatment for
the veteran?
Mr. Figley. No.
Mr. Hare. Okay. Okay then.
Mr. Figley. You wanted me to be brief. I am trying to be
brief.
Mr. Hare. Pardon me. Well there went my 5 minutes in a
hurry. No. Well, what do they need to do? You know, I
understand that. So what would you suggest that they do to
change that no into a yes at some point?
Mr. Figley. Well it really starts with what I was trying to
emphasize--one of the major messages that Congress passed a law
that allowed and authorized the VA to have marriage and family
therapists to address the mental health issues of these
returning veterans.
And this group, our group, is the most qualified in the
world really to deal with these kinds of issues. And for
various reasons, I mean, I am not sure why, that has not
happened. So my sense is that there is a lack of commitment
there.
But if that happens, if there are lots of marriage and
family therapists running around, they will constantly say why
aren't you talking--why aren't you focusing on a family system,
particularly with this group of veterans who are concerned
about--you know, we have basically false positives and false
negatives in terms of assessing for PTSD and other things.
And so if you focus on the impact on the family, then it is
a very different kind of situation. If you tell your commanding
general I am going for marriage counseling, that is very
different than going for counseling as an individual.
Mr. Hare. Well we have heard this point. And I hear this a
lot too. You know, the veteran--the servicemember on a Monday
is in Iraq, and on Thursday is at their kid's soccer game.
Mr. Figley. Right.
Mr. Hare. It is here 1 day. And you are back this next day.
And it would seem to me that, you know, the Chairman's talked
about an idea, and I just kind of want to run it by the panel,
of before this person is released back in that they have what
you call almost a debriefing boot camp, or for lack of a better
title where there is some time spent for the veteran, to
understand the programs that are available, to understand, to
be screened, and the things to look out for.
But also on the family side, to somehow pull that family
in, because they clearly don't understand. And as I said
before, this mother of the young man who committed suicide, she
had no idea what to look for. And he obviously had some serious
problems that weren't--you know, that he didn't get the help
for.
So I am trying to figure out, what do you think of that
idea or that concept? How do we ultimately pull the families in
to be a part of this? This is a family thing. This is just not
solely related to that person who has served.
And especially I think as someone said earlier, sometimes
these are people who are on their second, third deployment when
they are coming back. For heaven's sake we--you know, if there
is not a problem, if they don't think there is a problem there,
there is. And we just have to be able to identify it, and find
it, and be able to help them.
Mr. Figley. Yes. I am sure the other panelists will add to
this. It should start long before they are deployed. There
should be an orientation for families, as well as the troops
that are being deployed about the common and expected kinds of
reactions and what to do about it and resources established.
The National Guard and Reserves are the ones that I worry
about most, because your analogy of coming back, they are in a
community that understand this.
Mr. Hare. Yes.
Mr. Figley. But those that go back to their own rural
community, sometimes don't even know if they have gone. So,
yes, there should be a comprehensive orientation prior to
deployment, during, and following deployment to educate and to
constantly monitor and provide assistance.
Ms. Phillips. One of the first steps in recovery from
trauma is establishing safety. We found that psycho-educational
groups for families that, in fact, as you say Mr. Hare, informs
them of what to expect so that it demystifies some of the
symptoms, it reduces the anxiety in the children. These are--
the psycho-educational piece also offers a way to screen for
higher levels of care.
So in terms of groups, even apart from services to family,
training groups and psycho-educational input seems to be not
only preventive but really reinforce further recovery.
Mr. Hare. Thank you very much. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. Ms. Berkley.
Ms. Berkley. I don't really have any questions of the
panel. I think my question is and when I had an opportunity to
review the information for today's hearing, and looking at all
of the services that the VA provides, is it--you know, Congress
people are very keen on passing more laws. And, you know, we
hear from a panel and we go my gosh, we have to introduce a
piece of legislation allow--having family counselors do this or
that.
But I am wondering if it is not a matter of passing the
laws? Do the laws exist? Is the flexibility there? Is it a
function of the VA not having the resources to carry out
Congress' wishes?
And that--I mean, when I look at this, we are providing
education, counseling, community referrals, caregiver training
and support, respite care, homemaker/home health program, adult
day care, home-based primary care, palliative, hospice care,
Fisher Houses of course.
I am wondering what it is that I can do as a Member of
Congress in recognizing that the needs are extraordinary. And
recognizing that I have no rural areas in my district. And I
don't have the problem of being in such an isolated area that
you can't get any care. I have a problem of being in a very
populated area and not getting any care.
But I don't--as I sit up here feeling so helpless and
concerned that yet another law isn't going to solve any problem
and isn't going to save a single veteran from a mental health
issue or ease the hardship of a family that is going to have a
family member who served and is suicidal or has committed
suicide. And we have--you know, I have had a few servicemen in
Nevada that have committed suicide after their service to this
country. It is a heartbreaking thing. What can we do up here?
Mr. Figley. What you are doing right now. This is a
historic--in my opinion, this is a historic session, because
what you are suggesting, not just to the VA but to all Federal
programs, and we have State representatives as well, of
changing the paradigm, focusing on the family. Recognizing the
family members are veterans too. That they have served their
country through these multiple deployments. And there is so
much evidence to show how our military is being worn out by the
deployments. The families are being worn out as well. And we
have an obligation to take care of them.
Ms. Berkley. I couldn't agree with you more. Some of my
Nevada National Guard Army people are on their fourth
deployment since 9/11, not necessarily in Iraq, but a year away
from home. Fourth, which just I think indicates how stretched
our services are.
I have family members that--and these are National Guard.
They are not kids usually. They are adults. Families while
there--while mostly husbands, not always, but mostly husbands
are serving, you have women that are losing their homes, they
are moving their children into their parents' home. This is
something--they haven't lived at home since they were 18. And
now they are moving back with adult children of their own. They
are having a hard time making ends meet. And this is what our
National Guard people are coming home to, a family in crisis
that needs counseling of its own separate and apart from
dealing with somebody that has just gotten back from Iraq.
And that is a concern of mine, providing the necessary
services, mental health and otherwise, to people that--you are
right. They are on the frontline. They may not be in Iraq, but
I will tell you something, they are sacrificing plenty on
behalf of this country.
And it is--and I am talking to, you know, women in their
30s and their 40s that are having a very, very tough financial
time. And the kids are, you know, messed up obviously. And
there is not a father figure in the house. And they have--we
are going to be stuck with the problems of this war for many,
many decades to come. And I think it is time that we recognized
that and start planning for a future that might be quite a bit
different for thousands--hundreds of thousands of Americans
than they anticipated.
Mr. Ibson. Just to add to Mr. Figley's remarks, I think he
is quite right that the leadership this Committee will play is
a tremendously important part in moving forward.
At the same time, there are gaps in VA's authority with
respect to provision of family services. I would be happy to
work with you or the staff to develop a piece of legislation if
you would like.
I think it is very clear that there are anachronistic
statutory limitations that unless a veteran is service
connected for PTSD or a mental health condition, the entry
point for family members into the system is very limited. And I
think that amending the law is certainly a step the Committee
could take to help those veterans and their families.
Mr. Michaud. Once again, I would like to thank this panel
for your testimony today. It has been very helpful. I look
forward to working with you as we move forward on this very
important issue. So thank you very much.
We have just been called for votes. So we will not have
time to take the third panel. We will recess. But I would like
to introduce the third panel. It will be Scott Sundsvold who is
representing the American Legion; Joy Ilem, the Disabled
American Veterans (DAV); Fred Cowell, from the Paralyzed
Veterans of America (PVA); Dr. Thomas Berger from the Vietnam
Veterans of America (VVA); and Todd Bowers from the Iraq and
Afghanistan Veterans of America (IAVA).
So I would invite the third panel to come forward when we
begin. And once again, thank you very much. We will be in
recess until further notice. It shouldn't take too long, we
have three votes. So thank you.
[Recess.]
Mr. Michaud. Once again, I apologize for the interruption.
Let's begin. We will start with Mr. Cowell. We have your
testimony. It will be entered into the record. So if you can
begin.
STATEMENTS OF FRED COWELL, SENIOR HEALTH ANALYST, PARALYZED
VETERANS OF AMERICA; THOMAS J. BERGER, PH.D., CHAIRMAN,
NATIONAL PTSD AND SUBSTANCE ABUSE COMMITTEE, VIETNAM VETERANS
OF AMERICA; TODD BOWERS, DIRECTOR OF GOVERNMENT AFFAIRS, IRAQ
AND AFGHANISTAN VETERANS OF AMERICA; JOY J. ILEM, ASSISTANT
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND
SCOTT N. SUNDSVOLD, ASSISTANT DIRECTOR, VETERANS AFFAIRS AND
REHABILITATION COMMISSION, AMERICAN LEGION
STATEMENT OF FRED COWELL
Mr. Cowell. Mr. Chairman and Members of the Subcommittee,
the Paralyzed Veterans of America appreciates this opportunity
to present its views and recommendations concerning how the VA
can best assist veterans with mental illness by providing
counseling and educational services to their families.
The prevalence of mental illness is high among soldiers
currently serving and veterans who have returned from service
in Iraq and Afghanistan.
Combat exposure, coupled with extended and frequent
deployments, are associated with an increased risk for post
traumatic stress dirorder and other forms of mental illness. VA
reports that Operation Iraqi Freedom and Operation Enduring
Freedom veterans have sought care for a wide array of possible
co-morbid medical and psychological conditions, including
adjustment disorder, anxiety, depression, post traumatic stress
dirorder, and the effects of substance abuse.
VA has also reported that of the 299,000 separated OIF/OEF
veterans who have sought VA healthcare since fiscal year 2002,
a total of 120,000 unique patients had received a diagnosis of
a possible mental health disorder. Almost 60,000 enrolled OIF/
OEF veterans had a possible diagnosis of PTSD. Almost 40,000
OIF/OEF veterans have been diagnosed with depression. And more
that 48,000 reported non-dependent abuse of drugs.
However, soldiers and veterans are not the only individuals
being affected. For every unique OIF/OEF veteran who is
fighting mental illness, there is also a veteran's spouse or a
family member who is also directly affected.
Veterans' spouses and other family members provide the
majority of care and support for veterans who have chronic
mental illness.
Caregiving is a job that cannot be neglected, and in many
cases it cannot be delegated. Family caregiving is physically
and emotionally draining and has a financial impact as well.
The National Family Caregivers Association (NFCA) notes that
caregivers often feel isolated, and report that their lives are
not normal, and no one can possibly understand what they are
going through.
In a NFCA survey, 61 percent of caregivers report
depression and 51 percent sleeplessness. Additionally, spouses
and family members must make sacrifices at work to attend to
duties at home.
It is PVA's belief that VA's treatment of veterans with
mental illness will produce more positive outcomes if veterans'
spouses, appropriate family members, and other caregivers
receive detailed counseling and education services from VA
professionals.
Spouses, family members, and other caregivers need access
to a comprehensive VA counseling and education services program
that offers a systemwide, uniform curriculum of information.
But also one that is flexible enough to be condition specific.
Spouses and family members need to know about mental
illness and need information about the specific condition
affecting their loves ones.
These caregivers also need to understand how to recognize
the warning signs of potential crisis situations. The
importance of medication management assistance and the need for
regular attendance during ongoing professional treatment and
counseling sessions.
They need access to a peer support program where they can
share and discuss common problems and find solutions from
experienced caregivers. They also need VA's physician and
counselor contact information when they feel the need to seek
professional advice. Perhaps a family hotline can help bridge
the gap when weekend assistance is needed and for those times
when a VA medical health expert is not on duty.
They need to have a fundamental understanding of how VA
services work. This aspect of the curriculum should include
information on the scope of VA medical and financial benefits
that are available to the veteran.
Additionally, Mr. Chairman, any VA program must find ways
of assisting with the caregiver's personal problems as well.
Counseling and education only goes so far. If the veteran's
family unit is to remain stable, then avenues of assistance
such as referrals for treatment for spouses and family members
must also be available.
At the very least, VA must provide a mechanism where the
problems of caregivers can be heard and advice given.
Mr. Chairman, PVA knows firsthand the benefit of counseling
and educational services for spouses and family members of
veterans with spinal cord injury.
Caregivers of veterans with spinal cord injury play a
primary role in the successful rehabilitation, activities of
daily living, and of his or her reintegration into civilian
life. Perhaps the PVA's spinal cord injury system of care
program for family counseling and education could be a model,
if modified, to serve families of veterans with mental illness.
PVA believes Congress should formally authorize and VA
should provide counseling and educational and support services
to family members of severely injured and mentally ill
veterans.
These services should include education on mental illness,
relationship and marriage counseling, VA benefit counseling,
and related assistance for the family coping with the stress
associated with caring for a severely injured or ill veteran.
Finally, Mr. Chairman and Members of the Subcommittee, we
thank you for holding this important hearing and recognizing
the pressing needs of veterans' families as they struggle to
assist and support veterans with mental illness.
The VA has great expertise in treating veterans with mental
illness. And PVA believes that this cadre of VA mental health
professionals could easily assemble a comprehensive counseling
education program that can be there for veterans' families.
This concludes my remarks, Mr. Chairman.
[The prepared statement of Mr. Cowell appears on p. 82.]
Mr. Michaud. Thank you very much, Mr. Cowell. Mr. Berger
who is from the Vietnam Veterans of America.
STATEMENT OF THOMAS J. BERGER, PH.D.
Mr. Berger. Mr. Chairman and other distinguished Members of
this Subcommittee, Vietnam Veterans of America or VVA
appreciates the opportunity to present our views on the need
for the Department of Veterans Affairs to provide mental health
assistance and treatment within VA medical centers for family
members of veterans.
And, again, we would like to thank you for your leadership
in taking point on the mental healthcare of our veterans'
families and in seeking the views of veterans' service
organizations on this very important and timely issue.
As you are well aware, one of the recommendations of the
Dole-Shalala Commission was to ``significantly strengthen
support for families.'' This will not be an easy task. But VVA
believes this hearing can serve as the opening dialog on this
very serious concern.
As more and more troops return home damaged emotionally and
mentally as well as physically, their families must contend not
only with the shock of seeing the physical desolation of their
loved ones, but come to grips with the new reality of their
lives, which have changed dramatically, and not for the better
in many cases.
Take for example a 35-year-old soldier or Marine with two
children who returns home with what is diagnosed as Traumatic
Brain Injury or TBI. His or her impairment affects the future
of the entire family. His or her spouse and children have to
deal with his or her inability to concentrate, the mood swings,
depression, anxiety, even the possible loss of employment.
As you can imagine, the economic and emotional instability
of a family can be as terrifying and as real as any difficulty
focusing or simply waking up in the middle of the night and
crying.
In cases of severely brain-damaged casualties, spouses,
parents, and siblings may be forced to give up careers, forsake
wages, and reconstruct homes to care for their wounded
relatives rather than consign them to the anonymous care at a
nursing home or assisted living facility.
VVA believes that the mental health stresses of war may be
even greater for the families of those serving in the National
Guard or Reserves. In that deployment of these individuals
often results in dramatic losses of income along with numerous
legal and family complications affecting the children,
including domestic violence or substance abuse.
In addition, unlike family members of active-duty military
who often have an established support system available to them
on the base as we have heard earlier, family members of Guard
and Reserve troops must often struggle to create their own
systems of support.
You will hear cries that the VA medical facilities, with
the notable exception of the VA Vet Centers operated by the
Readjustment Counseling Services, are not authorized to provide
mental healthcare treatment for the families of veterans.
You will also hear that neither the military DoD or the VA
has the organizational capacity or the personnel resources to
provide such.
There are other issues about the intensity and drains of
vitally needed services and family support that will be hard to
sustain, as well as significant issues regarding the complexity
of other medical and specialized needs.
However, in calendar year 2007, thanks largely to the
leadership of this Committee, along with others in our
Congress, along with the Speaker of the House, more than $11
billion was infused into the VA system, mostly for healthcare.
Unfortunately, this is only a start, albeit a very good
start, toward restoring and building the organizational
capacity needed to properly take care of veterans and every
generation who have earned the right to healthcare by virtue of
their service to the country in uniform.
VVA believes that many of the logistical and organizational
challenges that I have mentioned or alluded to can be overcome
through legislation that authorizes partnerships between the VA
and professional mental health organizations such as the
National Council for Community Behavioral Healthcare, which
represents over 1,400 community-based mental health programs,
as is already suggested in H.R. 2874, the ``Veterans'
Healthcare Improvement Act of 2007,'' and its companion bill in
the Senate, S. 38, the ``Veterans' Mental Health Outreach and
Access Act of 2007.''
A model of such a collaborative partnership involving the
VA, the Maine National Guard, sir, and the Community Counseling
Center, a local behavioral healthcare provider, has been in
operation since 2006 in Portland, Maine, and has achieved
positive, very positive, results.
The example of what is happening in Connecticut, as we
heard from Commissioner Schwartz this morning, is yet another
model of the type of creative partnerships and very effective
and useful work that can be done when VA does not insist on
having total bureaucratic control over all of the activities in
healthcare delivery in which they play some role.
This distinguished panel can make a difference by promoting
the process of healing of veteran and family members in a way
that has never been done before, as Mr. Figley has strongly
suggested, if there is cooperation across the jurisdictions of
Congress.
I thank you. That is the end of my testimony.
[The prepared statement of Mr. Berger appears on p. 84.]
Mr. Michaud. Thank you very much, Mr. Berger. Mr. Bowers
who is with the Iraq and Afghanistan Veterans of America.
Thanks for coming today. Thanks for your service.
STATEMENT OF TODD BOWERS
Mr. Bowers. Thank you, Mr. Chairman. Mr. Chairman, Ranking
Member, and distinguished Members of the Committee, on behalf
of the Iraq and Afghanistan Veterans of America, and our
thousands of members nationwide, I thank you for the
opportunity to testify today regarding mental health needs of
military families.
I would like to point out that my testimony today does not
reflect the views of the United States Marine Corps in which I
still currently serve as a Reservist. I am here testifying
today in my civilian capacity as the Director of Government
Affairs for the Iraq and Afghanistan Veterans of America.
In my 10-year career as a Marine Reservist, I have had the
honor of serving in Iraq twice. When I returned home from my
tours, I realized that combat deployments are hard on members
of the Armed Services, but they are even more difficult for
military families.
My family was no different. During my second tour in Iraq,
I was wounded when a sniper's bullet impacted the scope on top
of my rifle. Fragments of that bullet are still lodged in my
face today as a constant reminder of how lucky I was that
October day in Fallujah.
The circumstances surrounding my injury were so fantastic
that I knew my parents would eventually hear about the
incident. My command and myself, felt it was important that I
contact my family via satellite phone to inform them of what
had happened. While this was the correct decision, I knew that
the impact on my loved ones would be tremendous. Over the phone
I told my mother, ``You can hear my voice. I am alright.''
But the incident that physically wounded me, wounded my
mother much worse. She had a difficult understanding--difficult
time understanding what had happened. In her own words, she
never knew why someone would want to shoot her Todd, although
she may take that back the way I acted in high school
sometimes.
While I was completing my tour in Iraq, my mother needed
help at home. My family lives far from the reserve center that
I deployed from and was not involved in any formal family
counseling groups. Her only contact with fellow military
families was via email or phone.
As she struggled to cope with the knowledge of my injury,
my mother was more than alone, she was lost. She sought
assistance through the only means she was aware of, the mental
health counseling covered by her own health coverage.
For 1.6 million veterans of Iraq and Afghanistan, the
stresses of deployment really hit home. As the Committee knows,
rates of psychological injuries among new veterans are high and
rising. According to the VA Special Committee on post traumatic
stress dirorder, at least 30 to 40 percent of Iraq veterans, or
about half a million people, will face a serious psychological
injury, including depression, anxiety, or PTSD.
Data from the military's own Mental Health Advisory Team
shows that multiple tours and inadequate time at home between
deployments increases rate of combat stress by 50 percent.
These deployments, the Mental Health Advisory Team has
concluded, also puts families at a tremendous strain. Twenty-
seven percent of soldiers and Marines in Iraq are reporting
marital problems.
It is not only marriages that are being tested. More than
155,000 children have parents currently deployed in support of
the wars in Iraq and Afghanistan, and 700,000 children have had
a parent deployed at some point during the conflicts, according
the American Psychological Association. According to the
Pentagon, almost 19,000 children have had a parent wounded, and
2,200 children have lost a parent in Afghanistan or Iraq.
Much of the difficulties that these families will face will
be knowing where to reach out to receive help. This is often
connected to the stigma that we have seen with mental health
issues. This doesn't just resonate within the military. It also
resonates among military families. That is why I am very proud
to announce that IAVA has partnered with the Ad Council, the
non-profit organization responsible for some of America's most
effective and memorable public service campaigns, including ``A
Mind is a Terrible Thing to Waste,'' ``Only You Can Prevent
Forest Fires,'' and ``Friends Don't Let Friends Drive Drunk.''
This summer, the Ad Council and IAVA will launch a multi-
year campaign to destigmatize mental healthcare for
servicemembers and more importantly their families. The
broadcast, print, web, and outdoor ads will encourage those who
need it to seek mental healthcare and inform all Americans that
seeking help is a sign of strength rather than weakness. We are
very excited to partner with the Ad Council to help get troops,
veterans, and their families the care that they need and that
they deserve.
Mental health and support for veterans' families are also
key components of our 2008 legislative agenda. One of our six
legislative priorities this year is new funding to combat the
shortage of mental health professionals.
The VA must be authorized to bolster its mental health
workforce with adequate psychiatrists, psychologists, and
social workers to meet the demands of the returning Iraq and
Afghanistan veterans and their families, including funding for
Vet Centers to alleviate staffing shortfalls.
While IAVA applauds the VA initiative to hire new Iraq and
Afghanistan veterans as outreach Coordinators, as of April
2007, VA numbers show that more than half of the 200-plus Vet
Centers need at least one or more psychologists or therapists.
IAVA also supports the creation of a new VA program to
provide family and marital counseling for veterans receiving VA
mental health treatment. For the many military and veteran
families, unlike my family--for the many military and veteran
families who, unlike my family, are among the 47 million
uninsured Americans, this may be their only access to mental
healthcare that they need to cope with the effect of the wars--
that the wars have had on their families.
I thank you for providing me the opportunity to testify
before you this afternoon. All of the data and IAVA
recommendations I have cited today are--can be located in our
mental health report and our legislative agenda, which I have
brought copies for you all today.
Thank you.
[The prepared statement of Mr. Bowers appears on p. 86. The
IAVA report entitled, ``Mental Health Injuries, the Invisible
Wounds of War,'' January 2008, will be retained in the
Committee files. The report can be downloaded from the IAVA Web
site at: http://www.iava.org/documents/Mental_Health.pdf.]
Mr. Michaud. Thank you very much, Mr. Bowers. Ms. Ilem,
from the Disabled American Veterans.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you Mr. Chairman and Members of the
Subcommittee.
The Disabled American Veterans being invited to testify
today regarding the mental health needs of family members of
veterans.
Service-related polytraumatic injuries and post-deployment
mental health issues exact a severe toll, not only on the
veteran, but on military and veteran family members as well.
Many severely wounded and disabled veterans require
continuous and intensive family caregiver support for many
years and for some, a lifetime. In most cases, a spouse,
parent, or other family member assumes the role of primary
caregiver, often leaving behind jobs, college, or other
personal and professional goals and responsibilities.
With the wars in Iraq and Afghanistan, the demographics,
family dynamics, and expectations of disabled veterans and
their families have changed. And so too should VA benefits and
services.
The changed conditions in these families, including the
impact of post-deployment readjustment problems, and the
physical and emotional demands of long-term caregiving, warrant
a new program to care for and comfort these families and
provide relevant and specialized support and counseling
services when they need them.
While we are pleased that VA has initiated a variety of
caregiver assistant pilot programs, VA currently lacks a
comprehensive program of caregiver assistance, counseling, and
related services to ensure these families receive adequate
support.
Therefore, we recommend that VA expeditiously develop a
systematic policy based on the best-practices garnered from
these pilot initiatives.
Family support is critical to a disabled veteran's
successful rehabilitation. Therefore, we should provide the
training and services necessary so they do not become
overwhelmed by the impact of readjustment issues on the family
and responsibilities in caring for these extraordinary
veterans.
It is important that these family members are properly
educated and trained to deal with the symptoms of and how to
live with someone who has experienced a devastating injury or
illness, while at the same maintaining their own good mental
and physical well being.
Like previous generations of veterans, our newest war
veterans are returning with not only serious physical injuries
such as amputations and Traumatic Brain Injury, but also post
traumatic stress dirorder, depression, anxiety, and substance
abuse disorders, and other post-deployment mental health
problems.
If left untreated, these conditions can destroy marriages
and ultimately separate families and even result in
homelessness. The absence of a personal caregiver or attendant
for seriously disabled veterans would mean even higher costs to
the government to assume total responsibility for their care.
And more importantly, would lower the quality of life for the
very veterans for whom VA was established.
Likewise during this transitional period, caregivers
themselves are at risk for stress-related mental health
disorders and adverse physical effects. For this reason, we
support and recommend that Congress authorize a full range of
psychological and social support services as an earned benefit
to family caregivers of severely injured and ill veterans.
At a minimum, this benefit should include relationship and
marriage counseling, family counseling, technical training, and
related assistance for the families coping with post-deployment
mental health issues or with the stress and emotional
consequences of caring for a severely injured or permanently
disabled veteran.
For many younger, unmarried disabled veterans, their
parents must once again assume the role of caregiver. They too
face the same dilemmas of spouses of severely injured veterans.
And we believe Congress should also address the needs of these
parents who are now primary caregivers for their severely ill
or injured children, as well as other designated family members
who assume this full-time role.
We also believe VA should establish a national program to
make a variety of respite services available to all severely
injured veterans who need it. Alternative VA respite care
programs should be established with age appropriate settings
and strong rehabilitation goals suited to the needs of a
younger veteran population.
We note that one of the new caregiver pilot programs offers
24 hour in-home respite care to temporarily relieve caregivers
for up to 14 days a year. This kind of in-home service may be
an optimal setting for many severely disabled veterans and
their families.
Mr. Chairman, we believe that VA must continue to adapt its
services to the particular needs of this new generation of
disabled veterans. Likewise, these programs should be improved
and available for the previous generations of veterans with
similar disabilities.
Finally, we are hopeful with Congress' support that VA will
make a change from a system that focuses primarily on the needs
of a veteran patient to one that also fully embraces the
challenges of family caregiving.
That concludes my statement. Thank you.
[The prepared statement of Ms. Ilem appears on p. 78.]
Mr. Michaud. Thank you, Ms. Ilem. Mr. Sundsvold.
STATEMENT OF SCOTT N. SUNDSVOLD
Mr. Sundsvold. Mr. Chairman, the American Legion
appreciates this opportunity to share its views on mental
health treatment for families of veterans.
Mr. Chairman, in order to ensure this Nation's veterans
receive a complete continuum of care, families of those injured
must receive the most appropriate treatment to understand,
accommodate, and transition with the veteran.
When military personnel are deployed, the families are the
most tangible source of trust and disclosure. They are affected
by the letters, emails, and phone calls from those deployed.
Although they are not the actual personnel deployed, their love
and care for those who are in the way of danger may indeed
cause permanent stress related issues. When their loved one
returns from deployment, there is yet another possible
stressor, the transition from military duty to civilian life.
The National Defense Authorization Act of Fiscal Year 2006,
directed the Secretary of Defense to establish a task force to
examine issues related to mental health and the Armed Forces
and create a report containing an assessment of and
recommendations for improving the effectiveness of mental
health services provided to members of the Armed Forces.
The report introductions spoke on this Nation's involvement
in the Global War on Terrorism and the unforeseen demand on
military members and their families. It was also stressed that
DoD must expand its capabilities to support the psychological
health of its servicemembers and their families.
In June 2007, the Defense Health Board Task Force on Mental
Health released the report titled ``An Attainable Vision.''
This report derived from the Task Force's visits throughout
military community at 38 installations worldwide. According to
the Task Force, the military health system lacked the fiscal
resources and personnel to fulfill its mission to support
psychological health.
Mr. Chairman, these findings also imply that if the
treatment was insufficient during the military member's term of
service, the veteran's issues do not vanish upon entry into the
civilian community. And they often affect the family as well.
The findings and recommendations reported by the Task Force
suggest an elevation of family involvement in mental health
treatment. When transitioning from military to civilian life,
veterans and their families full continuum of care should not
be stifled.
Currently, the VA does not have the authority to include
veterans' family members in treatment for mental health
concerns. The American Legion is in agreement with the
statement of the Secretary of Defense, Robert M. Gates, who
stated, ``Care for our wounded must be our highest priority.''
This statement includes those affected both mentally and
physically.
According to the Task Force report, the cost of mental
illness extends beyond discharge from military service. There
was also a recognized need for extensive family involvement in
the long-term process of rehabilitation and community
integration, which include close involvement of families in the
recovery process, as well as a greater responsiveness in the
treatment of family members' needs.
In 2007, the American Legion conducted site visits of
various Vet Centers throughout this Nation to include Puerto
Rico. During these visits, it was reported that successful
services provided ranged from marriage counseling to reunion
debriefings.
However, no mental health services for family members were
provided. Also offered were family therapists for veterans
suffering from mental illnesses, ensuring that the veteran's
immediate support network is prepared to care for and cope with
the veteran's mental health issues, but no mental health
support for the veteran's immediate family members.
The success of services provided within VA and their
satellite facilities as they relate to veterans and their
families should be extended to include mental health treatment
for family members to fully ensure a complete and successful
transition into the community.
Mr. Chairman, to ignore the need for mental health support
of family members invalidates the meaning of full continuum of
care. The American Legion urges Congress to appropriate
sufficient funds for the VA to ensure comprehensive mental
health services are available to the veteran and their family
members.
Mr. Chairman, the American Legion sincerely appreciates the
opportunity to submit testimony and looks forward to working
with you to improve the lives of America's veterans and their
families. Thank you.
[The prepared statement of Mr. Sundsvold appears on p. 76.]
Mr. Hare. Thank you. Thank you all very much for coming by
this afternoon. Obviously, the first priority is care for
veterans. But it is clearly evident that the care for veterans
also means ensuring that the veteran's support system, their
family, is prepared to take care of them. And particularly
given the prevalence of mental health issues, post traumatic
stress dirorder, and TBI coming out of OEF and OIF, the need
for providing counseling treatment and education for families
and caregivers is clear.
I would like to know, from all of you, if you wouldn't
mind, in your opinion, what is the best way that this Committee
can adequately address meeting the needs of veterans but also
integrating mental health services for their families? Is it,
you know, clarifying existing language that we have or don't
have? Is it creating programs? If so, how far should these
programs go?
In essence, what I would like to know from all of you is
what do we need to do here to better address this problem so we
can move toward helping veterans and their families?
Mr. Berger. Mr. Hare, I will jump right in. It may be time
to do a joint hearing with the authorizing and/or
Appropriations Committees that oversee the funding for all
these different kinds of things, because as you have heard,
sir, when we speak about the issues involving the veteran and
his or her family, they are very complex. There are many of
them.
Funding for these kinds of things is handled under a
variety of Committees. And that I would suggest that this
Committee could initiate some joint hearings with the
Appropriations Committees that oversee the Federal dollars that
go to these community mental health programs for example and
that sort of thing. To see if there can be incentive funds made
available to better serve the families of the returnees, as
well as the families of those families while the servicemember
is deployed.
Mr. Hare. Ms. Ilem.
Ms. Ilem. I would think that there is a couple of things
that the Committee could do. I mean, first VA has indicated
they recently established eight caregiver pilot programs
throughout the country that had some very interesting, very,
you know, alternative ideas and options for--especially for
caregiver support.
I would ask VA, you know, how are those programs going. I
would think they just got--you know, they are probably just
getting stood up and getting hired in terms of, you know, that
the staffs for those programs.
But definitely there would have--you know, there would be a
lot to be gained to see the oversight of those programs and
what comes out of them, how successful they are, what is the
patient satisfaction, what is, you know, the success of those
programs? So that they could develop something that is
consistent throughout the system and available to all veterans
who need it.
On the mental health, for post-deployment issues, I see
that on there--on the panel would be Dr. Batresand obviously
the Vet Centers have been very critical in terms of family
involvement.
But I would also ask that you ask VA what are really the
numbers and the data in terms of the mental health that is
provided in connection with services for our veterans
rehabilitation for post-deployment issues in the medical
centers and within their more traditional mental health
programs as well to get an idea where the real gap in services
are.
Mr. Hare. Mr. Sundsvold.
Mr. Sundsvold. Mr. Chairman, in 2006, the American Legion
passed a resolution asking that the VA provide more oversight
on the strategic spending of the mental healthcare money that
is given. And we can provide a copy of that resolution to that
effect.
Mr. Hare. Mr. Bowers, did you have something?
Mr. Berger. Yes. Mr. Chairman, I think a number of things
that the Committee could do. I think we need to review the
extension of authority that is available for families of
veterans. Obviously, we believe that the treatment and care of
the veteran must come first as you pointed out. But, obviously,
we live in unique times. And the consequences of what is
happening to veterans of OIF/OEF are devastating for families.
The Vet Centers are certainly the frontline of treatment
for our veterans and what limited services are available to
families. We think, you know, a uniform, systemwide criteria or
curriculum should be developed that provides a comprehensive
set of services to families.
The VA needs to be clear about what they can provide. And,
obviously, an expansion of counselors, and psychologists, and
social workers need to be developed and expanded to serve the
Vet Centers.
We also think that VA should look into developing mobile
support clinics that can reach out into rural areas and bring
mental health services to veterans in those areas and their
families.
Mr. Hare. Thank you. Mr. Bowers.
Mr. Bowers. I would just agree with the rest of my
panelists that the Vet Centers have been incredible for OIF and
OEF veterans. The only fault being that they are relatively
short staffed right now and having a hard time keeping up with
the demand.
Over the past few weeks, we have been doing focus groups
around the country to meet with veterans and most importantly
veterans' families. These have been interesting, 2-hour
sessions that we spend with them to find out what difficulties
they faced when they came home. The one thing that is apparent
from all the families is that lack of communication of what
resources were available was the number one issue.
They found out way too late about services and programs
that were available at the VA after the fun was smoking. So it
made things very difficult for these families. So that is a
line of communication of what is out there is going to be
extremely helpful in the future.
Mr. Hare. Thank you, Mr. Bowers. I couldn't agree with you
more. As I said earlier, I met with the parents of a young man
who committed suicide. And they had no idea what to look out
for. I think they said they had maybe 5 minutes--a 5-minute
briefing--your son is coming back.
They feel that somehow they failed their son, except they
didn't know what they were looking for. So I couldn't agree
with you more on the need to give the families the opportunity
to know so they can help that person when they do get home.
Let me thank you all. At this time I would like to
recognize my colleague, Congressman Kennedy, who has taken time
out to come and be with us this afternoon. I would be happy to
yield to the gentleman.
Mr. Kennedy. Thank you very much. I appreciate it very
much. And I thank all the witnesses for coming and testifying
on this critical issue. There is nothing more important than
making sure we don't turn our backs on those that were there
for us and the families that were there for them.
And they are secondarily there just as much as the veteran
themselves, because they are making the same sacrifices as our
veteran. And I fail to see the difference in the sacrifice our
families are making. I think we should be looking at the
veteran and their family as a whole unit. So far as the
services we should provide, we should be providing them to the
whole family. I am glad to see this hearing focusing just that.
I would like to see us make sure we track the impact on the
secondary effect of post traumatic illness on the children,
because I am really concerned in the years ahead, especially
for the Guard and Reservists, what impact these second, third,
fourth deployments are going to have on these children.
And, you know, we have anecdotal evidence from Vietnam and
so forth the effects on these children. We know from other
studies and child studies that children who grew up in
households where there is detachment, disturbances, emotional
problems and the like, that they are at much higher risk for
various other problems. And clearly, you would imagine any
child is growing up under the stresses and strains that these
children are forced to grow up in are going to be faced with
enormous challenges.
And we, as a country, ought to be preparing ourselves to
make sure that they don't face those challenges. And the best
way to do it is to head them off rather than wait for them to
arrive.
Just to talk about making people more aware of everything,
I got a great briefing the other day from a group that made a
film. They did some documentaries about suicide and prison. But
they have made documentaries now on--docudramas I should say,
on returning veterans. And what it does is to highlight the
process that veterans have gone through in a very powerful way.
So as to bring more understanding on the part of people who
aren't cognizant of the challenges they are facing.
And what these videos are meant to do are to educate
judges, because a lot of these judges don't have any idea.
Healthcare workers, educators, teachers, for example, in my
State. You know, teachers and kids who come from the base, they
don't have to worry, because the teachers know what is going
on. But kids who come from schools outside the base, they don't
know the Guard kids from regular kids. And they need to know
what is going on with these kids.
And so having some understanding of what is going on, and
having these scenarios of what it is like, having these
scenarios painted out in these docudramas, is probably very
helpful. And having these stories told, I think, are really
important for the understanding and appreciation of all those.
In addition to, as was just pointed out by Chairman Hare,
the parents of these families need materials on PTSD outlining
the symptoms and the signs. So we need to do a much better job
at getting these materials out to the families, getting them
out to the providers, getting them out to anyone who is going
to be touching these veterans.
I would like to ask all of you to comment, because one of
the things that in many of my tours around the VA hospitals and
Vet Centers I have been constantly impressed with is that
veterans want to get their care with other veterans
principally. And the Vet-to-Vet Program has been the most
welcoming to most vets that I have found, because they like
nothing better than a peer to talk to.
But it has been--we haven't brought it to scale. In other
words, we have seen it effective in one place in the country
and another place in the country. But we haven't really brought
it to scale, because we have such a huge problem out there in
terms of the demand for services for mental health. But we
haven't had the capacity to meet that demand within the VA.
And what I am thinking is why not take all those vets that
are out there homeless and jobless, get them in there doing
some work counseling other vets by training them up, giving
them some skills, and getting them to help their fellow vets,
because there is nothing more empowering than one veteran
sharing and supporting and helping another vet. It is mutually
beneficial. It is beneficial to the vet who is helping. And it
is beneficial to the vet that is being helped. It is that
miraculous miracle that comes from peer support.
I wonder if you could think of whether we should put
together some curricula in our community colleges or what kind
of professional development you think we should be doing to
train up and give our vets some kind of certificate to get them
into this kind of quasi-consulting role for their fellow vets?
Mr. Berger. Certainly, sir, peer counseling, peer support
programs are very important. They serve a very important social
function as well as the trust issues involved with that sort of
thing.
But at the same time, on the clinical side of things, as a
mental health professional, they cannot be used to substitute
for evidence-based clinical programs. And so I would be
careful. Okay.
Mr. Kennedy. Well, there is no question about that. What I
am just--there is nothing out there now. I have been
absolutely--I am absolutely disheartened by the lack of
outreach by the VA. I know they are doing everything that they
think that they are doing. But the statistics speak for
themselves. The facts speak for themselves.
The sheer numbers of vets returning, and you take a fifth--
whatever number you want, a third, however many. Forty percent
of those who are Guard and Reservists who say they are going
to--have some kind of flash back or some kind of problem.
The fact is, we ought to be reaching out to every single
vet who is returning. It ought to be mandatory for every single
one returning, so that we don't stigmatize a single vet
returning to say, oh, well you are the one who has the mental
health problem. You mean, you have a problem? That is how we
stigmatize them. We ought to have a total 100-percent mandatory
screening for all vets. And if the VA ain't doing it, there is
something wrong with them. Okay?
So we don't have crap going on right now as far as I am
concerned. They aren't doing their job. And I am absolutely
outraged and frustrated by the absolute lack of attention
toward our veterans right now.
So I don't want to hear about how we don't have enough
professional development. We have to get them all
professional--sure, as hell we do. But if we don't have that,
we better get them something. And the best thing I can think is
we better get them something we can get done quickly.
And as far as I can see, we can do this quickly. And that
is get the vets that we got already out there. And get them
trained up quickly. And get them out there talking to one
another, because there is nothing--a miracle about self help
groups. They are pretty effective. And they can be started up
pretty quickly. And until we get that going and get some
outreach going where vets can go and talk to one another, and
then we can start supplementing it with professional
development.
And while the VA is dragging their heals coming up with the
approval process for who can provide clinical support, because
they want to do everything in-house. Oh, sure, they have a
vision here or there. But they are not prepared to take a
national policy saying, okay, here are the criteria. Go at a
community mental health center. Any community mental health
center, any substance abuse center, private, non-profit,
hospital, anywhere in this country. You can provide these
services. At this pay scale, you are hired by the VA. Go out
there. Take care of our veterans. And you find them. And sign
them up. We are going to get paid.
Mr. Hare. Congressman----
Mr. Kennedy. That is the way we ought to have it. And
anything short of that, I think, is them not doing their job.
And right now they are waiting for--they are waiting for our
veterans to come in and sign up. That ain't the way for us to
be waiting for them--for us to be dealing with our vets. I am
sorry.
Mr. Hare. No, no.
Mr. Kennedy. I am just outraged.
Mr. Hare. Listen, let me say, Congressman, I couldn't agree
with you more. And, you know, we will get there. It is going
to--you know, but we need to get there sooner rather than
later.
I want to thank you for coming today, and for expressing
your opinions on this. You are a leader on this in the House,
and I appreciate your being here. We are all better because of
people like you serving in this House. I appreciate your
passion for this.
Let me thank the panel so much for taking time out to come
this morning. I am sorry we were delayed with the votes coming
back, but I appreciate you taking the time to come. So, thank
you all very much.
Our last panel is composed of Kristin Day, who is the Chief
Consultant in Management and Social Work Services, Office of
Patient Care Services for the Veterans Health Administration,
U.S. Department of Veterans Affairs.
Ms. Day, thank you so much for being with us this
afternoon. If you would care to introduce the people you
brought with you. And welcome to the Subcommittee.
STATEMENT OF KRISTIN DAY, LCSW, CHIEF CONSULTANT, CARE
MANAGEMENT AND SOCIAL WORK SERVICE, OFFICE OF PATIENT CARE
SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS, ACCOMPANIED BY IRA KATZ, M.D., DEPUTY CHIEF,
PATIENT CARE SERVICES OFFICER FOR MENTAL HEALTH, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
CHARLES FLORA, EXECUTIVE ASSISTANT TO THE CHIEF READJUSTMENT
COUNSELING OFFICER, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Ms. Day. Thank you so----
Mr. Hare. Could you turn your microphone on please. I am
sorry.
Ms. Day. To my right is Dr. Ira Katz, Mental Health
Service. And to my left is Charlie Flora from the Vet Center
Program.
Mr. Hare. Welcome.
Ms. Day. Sir, before I read my testimony, I would like to
say that on behalf of myself and my colleagues, we have heard
many compelling stories and issues this morning. And we stand
ready to serve any and all who we might be able to help to
resolve some of the immediate problems that they are having.
VA supports caregivers of the wounded, ill, and injured
veterans by providing assessment, counseling, training related
to the caregiver's ability to provide adequate care.
Specifically, this includes education about the veteran's
illness and disability, be it mental or physical, and referral
to community agencies for services that VA is unable to offer.
We conduct visits to assess the adequacy of the home
environment and the need for home equipment or home
modification.
VA provides limited services to family members, which
include members of the immediate family, the legal guardian of
the veteran, or the individual in whose household the veteran
certifies an intent to live.
The law provides, in general, that the immediate family
members of a veteran being treated for a service-connected
disability may receive counseling, education, and training
services in support of that veteran's treatment. We diligently
extend these services under those circumstances. Likewise, if a
veteran is receiving hospital care for a non-service connected
disability, VA is authorized to provide these services, as are
necessary in connection with that treatment, if the services
are initiated during the veteran's hospitalization and their
continuation on an outpatient basis is essential to permit the
discharge of the veteran from the hospital.
Outside our hospital system, VA's Vet Centers also provide
family counseling to family members to promote post-combat
veteran's successful readjustment to civilian life.
The Civilian Health and Medical Program of the Department
of Veterans Affairs is a comprehensive healthcare program in
which VA shares the cost of covered healthcare services and
supplies with eligible beneficiaries. CHAMPVA provides
coverage, provided the dependents are not otherwise eligible
for DoD TRICARE benefits to the spouse or widow or to the
children of a veteran who is rated permanently and totally
disabled due to a service-connected disability, or was rated
permanently--excuse me. Was rated permanently and totally
disabled due to a service-connected disability at the time of
death, or died of a service-connected disability on active--or
on active duty. CHAMPVA provides broad health coverage and
includes a $50 annual deductible and 25 percent co-pay for
services.
Family members of patients in our Polytrauma System of Care
are actively engaged by VA clinicians and staff regarding
treatment decisions, discharge planning, and therapy sessions,
as appropriate, so they can help their loved one learn to be as
independent as possible when he or she returns home. The
designated TBI and polytrauma case manager assigned to each
veteran and active-duty servicemember receives care in VA's
Polytrauma System of Care, coordinates support-efforts to match
the needs of each family.
In October of 2007, VA partnered with the Department of
Defense to establish the Joint VA/DoD Federal Recovery
Coordinator (FRC) Program. VA has hired a Federal Recovery
Coordinator Director, a Federal Recovery Coordinator
Supervisor, and eight Federal Recovery Coordinators as of
December of 2007.
The FRCs are currently located at Water Reed and Brooke
Army Medical Centers, as well as National Naval Medical Center
at Bethesda. Two additional FRCs are currently being recruited
and will be stationed at Brook Army Medical Center in San
Antonio and Balboa Naval Medical Center in San Diego. Vet
Centers provide family counseling for military-related problems
that negatively affect the veteran's readjustment to civilian
life. Family members are usually the first to realize the
effects of possible war-related problems, especially among
National Guard and Reserve members. Effective intervention
through preventive family education and counseling helps many
returning veterans stabilize their post-military family lives.
Veterans who served in a combat theater are eligible for
readjustment counseling, even if they have not enrolled for
healthcare benefits. Vet Centers have full latitude to include
family members in the treatment process, as long as this is
aimed at post-war adjustment for the veteran. Spousal
counseling groups are conducted at many Vet Centers to help
spouses cope more effectively with the veteran's war-related
problems.
VHA works diligently to support veterans, their families,
and their caregivers. Often without the support of these
dedicated family and friends, many veterans would not be able
to maintain their independence or their preferred community-
based lifestyle.
Thank you again for the opportunity to appear here today.
My colleagues and I would be happy to answer any questions you
may have.
[The prepared statement of Ms. Day appears on p. 88.]
Mr. Hare. Thank you, Ms. Day. From my perspective there is
a severe shortage of mental health professionals within the VA
system, and no cohesiveness in providing mental health services
for veterans and their families. So States like North Carolina
and my home State of Illinois are left to fill those gaps that
we have by establishing their own programs.
What are the VA's plans to increase the number of mental
health professionals in the system? That is one question. You
mentioned the Vet Centers, three of which are in my district.
What does the VA have specifically planned to be able to help
those rural people in rural communities who have just as much
need for mental health and their families but don't have access
to those facilities?
Ms. Day. Dr. Katz, would you like to answer the first
question?
Dr. Katz. Sure. VA currently has approximately 17,000
mental staff members in our system. A number that has been
increased by over 3,800 over the last 2\1/2\ years. It is
really a substantial number and a very substantial enhancement
in mental health services. The budget sent to the Hill from VA
estimated approximately a $320 million increase in mental
health funding between this year and next. That would be both
for staff and for contracting or fee basing of services. All
are related. And all are designed to help us both meet the need
of returning veterans and to enhance care for all veterans. The
funding increase, if it is totally devoted to increasing staff
at approximately 100,000 per staff member, would be a
projection of 3,200 new staff members. Really a substantial
further increase.
Ms. Day. Mr. Flora.
Mr. Flora. With reference to rural veterans, the Vet Center
Program also has a contract for fee program where they--
private-sector providers under contract with VA are reimbursed
for providing readjustment counseling service. And most of
these are located in areas distant from other VA facilities to
serve rural veterans.
Also, outreaching to veterans is a mandated part of the Vet
Center mission. We do travel to veterans that are not able to
come into our facilities and see them in their homes or in
their workplaces.
Additionally, the Vet Centers--all Vet Centers, upon
request from a veteran, will have after hours appointments or
weekend appointments to facilitate veterans that may need--that
are working or that may need to drive in a considerable
distance from their hometowns. Thank you.
Ms. Day. Sir, if I may, I would like to tell you about
three programs.
Mr. Hare. Could you turn your microphone on. I am sorry.
Thank you.
Ms. Day. Is it on?
Mr. Hare. Yes.
Ms. Day. Is that better?
Mr. Hare. Thank you.
Ms. Day. I would like to tell you about three programs. I
have the honor of being the Chief Consultant in a new office
called Care Management and Social Work Service in Patient Care
Services.
And in June of this year, of 2007, we stood up the OEF/OIF
case management team at every VA. And they--we now have 7,000
OEF/OIF servicemembers enrolled in that program. There are
clinicians, Veterans Benefits Administration representatives,
and transition patient advocates. They are on that team. The
transition patient advocates have been tasked with going out
into the community, doing home visits, making remote visit
sites, particularly to the severely injured, so that they will
lessen that sense of isolation.
The social workers on the team, we have almost 6,000 social
workers across VHA now. They are--one of their missions is to
engage the community services at the local level to provide
people who are isolated in rural areas support.
In addition, the new joint program between the Department
of Defense and VA, the Federal Recovery Coordinator Program, is
also in the new office. And the FRCs are VA employees. But they
will be working and providing oversight on care to all severely
injured, regardless of where they get their care.
So if a veteran lives in a rural area and doesn't have
access to VA care, maybe using their TRICARE benefits or some
other benefit, VA will still provide a Federal Recovery
Coordinator for them to help the oversight of their care.
Mr. Hare. Thank you. I would like to ask unanimous consent
that Mr. Kennedy be invited to sit at the dais. You can tell I
am new at this. I failed to do that previously. And I want to
welcome, again, my friend Congressman Kennedy, and recognize
him for any statement or questions that he might have.
Mr. Kennedy. Thank you very much. If you kind of respond
earlier to some of the concerns I had about, you know, 500,000
vets that have come back that haven't touched the VA. Forty
percent of whom, you know, will roughly need mental health
services. And how we are reaching out to them. I mean, frankly
you can't just hire all these people inside the VA and think we
are going to solve the problem. We got to do a better job of
doing the kind of partnering within the existing--you know, we
have to leverage other mental health infrastructure. VA can't
just think that we are going to deal with this.
Most of the mental health--a lot of mental health is going
to be delivered through the workplace and peoples' employer
health plans. A lot of it is going to be dealt with in
community health centers. A lot of it is going to be dealt with
in other venues.
I mean, so I want to know what you are doing to make sure
those connections are going to be made? They are going to be
made properly. Those providers are going to be trained up in
PTSD, so that they are going to be properly equipped to have
some of that. Because a lot of these veterans aren't going to
want to have their records ``found out'' by some government
entity, because they are terrified--they are all terrified
about the stigma of having mental health issues. And they are
not going to go near a government agency to get mental health
treatment.
So, you know, what are we doing to get dollars out where
they are not going to be traced to you, the VA? I mean, the Vet
Centers is one of the places where I want to see a lot of
dollars--more dollars go.
But, you know, I heard about the contracting, Mr. Flora.
But that is not happening frankly. That is not happening. From
my look around the Veteran Integrated Services Networks (VISNs)
in this country, the VA is tightfisted. They don't like to
contract out. Why should they? Every VISN Director is in charge
of their own pot of money. They don't want to contract out. And
furthermore, everyone says, oh, that is a slippery slope to
privatization.
You know, so I want to know what you all are doing to use
existing resources? Why are you waiting so long? You have
turned back money in the past to hire people. Get the workers
that you already have out there. And get them to help support
these veterans. There are veterans suffering today, because
there is not enough--the capacity is out there. But you are
waiting to hire your own people instead of using existing
people that are already out there.
What is the wait? What are you waiting for? Why aren't you
contracting out with people right now to provide these
services? What is the hold up? Why are you waiting to hire
people? Why not hire existing people that are in the community
health centers right now? Why not?
Dr. Katz, why aren't you hiring people in the community
health centers right now across America to provide these
services?
Dr. Katz. I will first respond to what you said about the--
--
Mr. Kennedy. Well answer that for me first.
Dr. Katz. What we are planning to do beginning at the end
of this fiscal year is to define what services should be
available for every veteran. And then to----
Mr. Kennedy. What are you talking about? What are you
talking about what services? You are trying to figure it out
now? Every service should be available to every veteran. Okay?
If someone needs help, get them the help. You know, what is
the--we are at a point of urgency, urgency, urgency. People are
dying. People are falling apart. Families are falling apart.
You have to get the contracts out there. Got to get the help
out there.
We have NASBHC in town, the National Association of
Behavioral Health Clinics. They are dying to reach out. They
have vets coming in every day. They are coming up to me all the
time. I know all this stuff, because I am ushering the whole
charge on mental health parity. I am all over the country on
mental health. I know all this stuff.
All mental health providers around the country are
screaming and yelling at me that they have veterans pouring in.
And you guys are sitting there trying to figure out what plan
you are going to have.
What are you going to do for veterans? Why not start
hooking up with these people and helping pay them so they can
help provide--help you provide the job that you are supposed to
do and help take care of our veterans? Why haven't you done
that?
Dr. Katz. Sir----
Mr. Kennedy. You think it is all up to you to do it? Do you
think it is just--VA is supposed to do it all. Is that what it
is?
Dr. Katz. Sir, what I was going to say was that our goal is
to define specifically what services must be available to all
veterans.
Also to define what services must be provided at medical
centers, large mid-sized and small Community Based Outpatient
Clinics (CBOCs). We recognize that there may be gaps between
the services that must be available to the veteran and the
services that must be provided especially at the smaller CBOCs.
And we will require that where we are not providing the
services near to the veteran, we provide them in some other
way, either by travel to residential care facilities for severe
conditions or by partnerships with community-based providers.
This is where we are moving with mental health
enhancements. We will be focusing on patient-centered care that
must be available to all veterans. We recognize that there are
going to be gaps between what we can provide and what must be
available and we will fill them.
Mr. Kennedy. But I will just stop you for a second. There
are two issues here. You have mental health that needs to come
through the VA. And that is where people will go to the VA for
severe mental health issues that they are going to need real
clinical support with.
And then you have mental health. I have post traumatic
illness----
Dr. Katz. Yes.
Mr. Kennedy [continuing]. From the war. And you have every
vet coming back is going to face some of that. All right, as a
matter of course. And they don't want this--you know, for their
part necessarily to have to go through the cumbersome process
of going through the whole VA, because of the stigma. Frankly
speaking because of the stigma.
And the less cumbersome you make the dollars and
bureaucratic, you make the whole mental health part of your
task. So it is not all about this has got to be a serious
mental illness type thing, PTSD clinic. Okay?
But you make it more, this is hey folks, here are--there is
healthcare out there for you to take care of your post
traumatic illness. And it is available here. And it is
available here in the Vet Centers. And complement services here
and here through here. And your Guard is going to have these
available services.
And you are going to have a plethora of areas, so that you
are not feeling as if you have to come down that narrow hall
and go up to floor seven and knock on that door, 7B, in order
to get your PTSD treatment. That is what I am talking about.
There are two kinds of levels.
Now if you need that seventh floor, you are going to have
that seventh floor. But I am talking about the 500,000 that are
going to need counseling and support out there but a far
spectrum. There is going to be a big spectrum. And we need to
push the dollars out there for 85-90 percent who are going to
need some mental health. But that doesn't mean they are all
going to need to come to the VA for your 3,000 new
psychiatrists.
Mr. Hare. I am sorry to interrupt. Let me just----
Dr. Katz. We fervently believe that what you are
describing, a universally available education and counseling,
is public health and prevention. And if that were available,
fewer people would need the seventh floor, get a diagnosis and
need my services.
It could be a good investment.
Mr. Kennedy. So what are you doing to provide it? Where is
that? What are those programs?
Dr. Katz. We will have to take that and get back to you.
Mr. Hare. Let me just say this. I want to thank you
Congressman for spending some time with us and for your
questions. I share your concern about this too. I want to thank
this panel.
I'll close by saying this I think all of us on this
Subcommittee and all of us across this Nation want to do the
best we can for the men and women who have served this Nation
when they come back, as well as their families.
Ms. Day, you talked about it in your opening statement when
you said you heard some stories today. At the end of the day,
for Tim's family when they were in my office feeling that
somehow what had happened to him was their fault. They didn't
know what to look out for. They didn't know the warning signs.
As Congressman Kennedy said, so many veterans come back not
wanting to say I think I have a problem. We need to screen
everybody, and families need to know what this is. We need to
look at them longer. We need to go down the road farther than
we are doing this, because this isn't something that
necessarily manifests itself immediately, as you all well know.
At the end of the day it seems to me that our mission is to
do everything we can, because not all wounds are physical. And
I see them at the Vet Centers. I have a Vet Center two blocks
from my district office in Moline, Illinois. I see the vets
that come in.
And, you know, for their families and for all of us, this
is a moral obligation that we have as a Nation. And I would
really hope that the VA will do everything that they can if it
is--as I said, if it is money, if it is changing whatever the
programs are, adding new programs, we stand ready to do that,
because it is our obligation.
If we don't do this, it is really shame on us, not just as
the Congress, but as a nation.
Thank you very much for coming today and spending time.
Mr. Kennedy. Mr. Chairman, if I could just, there is a--
these videos, there is a set of a whole documentary of
docudramas called ``Together with Valor.'' And they are an
educational series of videos for families, professionals, and
judges that are going to be coming out within the next 2 weeks.
And it is called ``Together with Valor.'' And it also has a
complimentary DVD set. And it is going to be going online.
I just want to make people aware of it. That it will have
resourced all of these things, ``Together with Valor.'' My
office will have more on it. Dan Murphy from my office, and he
will give you the contact person if you are interested.
Mr. Hare. Thank you, Congressman. Thank you all very much.
We will have additional questions submitted for you. With that,
this hearing is adjourned. Thank you all very much.
[No questions were submitted.]
[Whereupon, the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
I would like to thank everyone for coming today. We are here today
to talk about mental health treatment for families of veterans. This is
a very important issue and one that this Committee is looking to
address.
Mental health issues are at the forefront of our agenda, and for
good reason.
Of the approximately 300,000 veterans from Operations Enduring and
Iraqi Freedom who have accessed VA healthcare, over 40% have presented
with mental health concerns, including PTSD, substance abuse and mood
disorders. Veterans' mental health conditions not only affect the
returning veterans, but also have a significant impact on their
families. Living with and caring for veterans with mental health
concerns is stressful and can change the way that families relate to
one another.
While the VA is working hard to care for veterans with mental
health needs, too often families of these veterans are neglected.
Spouses, children and parents of veterans have been affected by this
conflict, yet oftentimes they do not have access to treatment which may
help them. In turn, veterans may have a more difficult time recovering
from their mental health concerns because of family problems.
As we will hear, the VA is currently limited in the authority
Congress has given them to provide treatment to families. I know that
the VA does everything they can to care for the whole veteran,
including the family unit, when possible. But the question is, how can
we do more?
The purpose of this hearing is to hear a variety of perspectives
about how Congress might expand VA's current authority to provide
mental health treatment to families of veterans. We will hear from
leaders of regional and state programs who are currently providing
services to families of veterans. We will also hear about the
importance of the family's mental health to the mental health and well-
being of the veteran. Finally we will hear from the VA about what
services they are currently authorized to provide to families.
The Committee realizes that this is a complex issue. But we also
recognize that it is an important one that deserves serious thought and
consideration.
Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health
Thank you, Mr. Chairman.
Good morning and welcome to our witnesses and other interested
audience members.
I am pleased that we are having this hearing today on what I
consider to be one of the most significant and timely subjects this
Subcommittee has to explore--mental health services for our Nation's
wounded warriors and their families.
A report released in November 2007 by the Institute of Medicine
found that there is a correlation between deployment to a war zone and
several mental health conditions including PTSD, depression, and
marriage and family conflict. Unfortunately, this is not news to those
of us familiar with the myriad of issues facing veterans.
Although valuable mental health services are provided by VA and
DoD, family members still are the first and most important network of
support for veterans and their role in the mental healthcare process
should not be underestimated. Family presence and participation is
essential as veterans readjust to civilian life following a deployment.
Families of soldiers make tremendous sacrifices so that the men and
women they love can defend the country we all love and I want to take
this moment to thank them for their role in supporting America.
Currently VA does provide certain mental health services open to
assist family members. This includes Readjustment and Bereavement
Counseling Services at VA Vet Centers, the VA's Family Mental Health
Learning Program and care for Civilian Health and Medical Program of
Department of Veterans Affairs (CHAMPVA) beneficiaries.
I look forward to hearing from our witnesses and their views on
what else could be done to support the mental health needs of family
members. Meeting the healthcare needs of veterans in the best way
possible will always be our first and greatest priority.
In closing, I would also like to commend the VA on their recent
efforts to improve access to mental healthcare for veterans and to
ensure that such care is safe, timely, and effective.
I look forward to working in a bipartisan manner with Chairman
Michaud and the other members of this Committee to ensure that our
veterans and their families are given the best possible care.
Again, I thank you all for being here and I yield back the balance
of my time.
Prepared Statement of Hon. Shelley Berkeley,
a Representative in Congress from the State of Nevada
Mr. Chairman, Thank you for holding this hearing today on such a
pressing issue. As servicemembers return from combat, it becomes
increasingly important to provide them with the mental health services
they need to readjust to society. While we take care of our veterans,
we must not forget about their families. Along with our servicemen and
women, families are the backbone of the U.S. military. They sacrifice
for this country when a loved one is called to active duty. Too often
marriages and families are under great strain when a servicemember is
on deployment. That risk continues even when he or she returns from
active duty. It is important that spouses and families are educated on
how to help their veteran cope with a mental illness such as PTSD. We
must not overlook the needs and concerns families are facing.
I look forward to working with the Committee and VSOs, the VA, and
others to determine how to best meet the needs of veterans and family
members.
Prepared Statement of Linda Spoonster Schwartz, RN, Dr.P.H., FAAN,
Commissioner of Veterans Affairs, State of Connecticut
Good morning Mr. Chairman and Members of the Committee, my name is
Linda Schwartz and I have the honor to be Commissioner of Veterans
Affairs for the State of Connecticut. I am medically retired from the
United States Air Force Nurse Corps and hold a Doctorate in Public
Health from the Yale School of Medicine. I also serve as North East
Vice-President and Chairman of Healthcare for the National Association
of State Directors of Veteran Affairs. I want to thank you for holding
this hearing and for your concern about the mental health needs of
families and those supporting our deployed troops and returned
veterans.
I served 16 years in the United States Air Force both on Active
Duty and as a Reservist during the Vietnam War, since that time, a
great deal has changed in the composition and needs of America's
military and the Nation's expectations for the quality of life and
support for the men and women of our Armed Forces. For example, now
women comprise approximately 15% of the military force, a stark
contrast to the fact that before the advent of the all volunteer force,
women were limited by law to only 2% of the Active Duty force. Another
striking feature of our military force today is the heavily reliance on
the ``citizen soldiers'' of our Reserve and National Guard and the
increasing number of military men and women on Active Duty who are
married with children. The Department of Defense reports that 93% of
career military are married and the number of married military
personnel not considered career is 58%. As a recent report by the Rand
Corporation observed, ``Today's military is a military of families''. I
would add that the families of many Active Duty, Guard and Reserve
units are no longer housed on military installations and are lacking
the support systems enjoyed by previous generations of military
members.
As America has continued to task Reserve and National Guard units
with greater responsibilities in combat areas the realities of multiple
deployments, loosely configured support systems and traditional
military chain of command mentalities are not solving problems, they
are creating them. Transitioning in and out of family life is not only
difficult for the military member, the family, spouse, children,
mother, father, sister, brothers and/or significant other are also
traumatized as well. This is not happening on a remote site or military
base, this time we read about our neighbor next door, the young woman
who teaches kindergarten, our friend from school or church. In essence
the war has come to every town and city in America only it is invisible
until a crisis or tragedy surfaces to remind us that the cost of war is
also borne by those who wait and watch for the return of our troops.
As Connecticut's Commissioner of Veteran Affairs, I have a unique
position and responsibility to be sure that we do not repeat the
mistakes of the past. As a veteran of the Vietnam War and a nurse who
has dedicated over 20 years to advocacy for veterans, I am acutely
aware of the fact that the veterans returning home now are very
different than the veterans of my generation or my fathers World War II
generation. While they are not encumbered with validating the
legitimacy of post traumatic stress dirorder, they have brought the
issue of Traumatic Brain injury to the forefront. Perhaps it is because
they may have trained with a unit for years and experienced the
intensity of living in the danger of a war zone with their unit, that
they feel isolated in their own homes. During deployments, they longed
for family and friends with visions of a celebrated homecoming only to
find upon their return home that crowds and daily responsibilities are
both overwhelming and frightening. After living on the edge of danger
for the prolonged deployment periods, life in America seem boring and
mundane. Although they care deeply about their families, they are
``different'' and ill at ease in their everyday existence and can't
seem to find their way ``HOME''.
Along with the ``Send Off'' ceremonies and the ``Welcome Homes'',
observers began to realize that families left behind experienced
difficulties and stress every day of the deployment. Due to modern
technology, Internet and cell phones these frustrations and
difficulties at home could instantaneously be shared with the deployed
military member in combat areas which placed an additional burden on
their ``mission readiness''. Along with readjusting to the absence of
the military member and the great unknown of what they would be
encountering during their tour of duty, those of us tasked with working
with these families came to the realization that there were serious
gaps in the system. In addition to the day to day concerns of home
repairs, young spouses managing additional duties in the home,
environment and financial constraints, families were having
difficulties that indicated a need for professional counseling and
treatment to cope with the demands and strains they encountered.
In 2003 when I became Commissioner, there were already Iraq
veterans living at the State Veterans Home at Rocky Hill because living
at home with Mom and Dad was not tolerable after being in combat,
families of deployed Active Duty and Reserve were encountering problems
with no place to turn for help and severely disabled veterans were
coming home to families that had no idea how to care for them. These
realizations prompted our Governor, M. Jodi Rell, to charge me to do
``what ever it takes'' to assure Connecticut was taking care if our
veterans and their families.
The 2005-2006 deployment of over 1000 Connecticut National Guard
with members from each of our 169 towns in the State underscored the
need to decisively address these issues and plan for the future.
Connecticut embarked on three major efforts: a) Survey of Recently
Returned Veterans conducted in conjunction with the Center for Policy
Research at Central Connecticut University; b) Summit for Recently
Returned Veterans; c) Military Support Program spearheaded by the
Department of Mental Health and Addiction Services. All of these
efforts were implemented in 2007. Additionally, Governor Rell has
tasked me with convening and Advisory Group of Recently Returned
Veterans to identify needs, monitor services and programs provided by
the State of Connecticut and recommend changes which will assist and
benefit deployed and returning military and their families.
2006 VA Guide ``Returning from the War Zone, A Guide for Families of
Military Members''
Actually acknowledges that with the return of the veterans from
deployments, the entire family will go through a period of transition.
Along with many suggested activities, there is specific reference for a
need for opportunities to reacquaint families with one another. Part of
the transition is expected to be a process or restoring trust, support
and integrity to the family circle.
While there is an expectation that ``Things have changed'' there is
also the daunting task of beginning the difficult work of transition
from soldier to citizen and reestablishing their identity in the
family, work environment and community. Although the publication does a
fine job of identifying the circumstances and the perils, the
directions are not for family but how family can assist the veterans.
Because services are focused on the military member and/or veteran the
options for family members is limited. VA advises ``Families may
receive treatment for war related problems from a number of qualified
sources: chaplain services, mental or behavioral health assistance
programs.''
An example from our Summit for Recently Returned veterans
illustrates the disparity this creates. We learned from one veteran who
came back in 2004 that his two years of open enrollment in VA had
expired. He felt that two years was too short for coverage because it
was hard for him to go to the VA and keep his job. He felt that
treatment at the VA was preventing him from getting on with his life
which he implied really meant VA was doing the exact opposite of what
it should be doing for veterans and their loved ones. He said that for
him, not attending the VA meetings ``was not about stigma, it's just
that the VA is unhelpful.'' When he did go to the VA for help, his wife
went with him, and they (VA) expressed surprise that she and her
husband had come in as a couple. The wife was told to stay out of it,
that it was ``his problem'' and not hers. She felt cut off. This
spurred a more generalized discussion about how families have no idea
how to interact with their veterans and feel lost. What little the VA
does for veterans, it does even less for their families.
Central Connecticut State University Survey of Recently Returned
Veterans
With the reality that troops being deployed to Iraq, Afghanistan
and the Global War on Terrorism represented a striking departure from
the mobilization of American troops in previous wars, the pro forma
conventional methods and remedies relied on in the past seemed
inadequate for addressing the emerging needs of military and veterans
in the 21st Century. Thus, we embarked on a survey of returning
veterans to ``take the pulse'' of their thinking, needs and
expectations. In order to assess the growing population of returning
``Warriors'' and ``Heroes'' specifically problems they were
encountering, their expectations for services and the goals they had
for their future a mail out survey designed in collaboration with
Central Connecticut State University's O'Neil Center for Public Policy
and the Yale School of Medicine was mailed to 1000 Iraq/ Afghanistan
veterans. We have completed an initial mailing and are finalizing our
second wave of surveys. So far we have learned that 63% of the
respondents were married, 10% were divorced and 25% never married.
Major concerns identified by respondents were: problems with spouses
(41%), trouble connecting emotionally with others (24%), connecting
emotionally with family (11%) and looking for help with these problems
(10%).
Also incorporated in the instrument was a PTSD Scale ``Post
Traumatic Stress Checklist--Military scale developed by VA National
Center for PTSD which indicated that 24% of respondents met the
diagnostic criteria. The most salient results fell under the rubric of
sizable number of veterans experiencing problems in several domains of
interpersonal life issues. Researchers concluded that the data
regarding both family and peer relationships, indicated that a sizable
proportion of veterans report difficulties in these areas. These
problems are undoubtedly exacerbated by the symptoms of PTSD with
nearly a quarter of respondents exceeding the diagnostic threshold.
Domestic Violence
In addressing the issue of mental health treatment for families, I
would be remiss if I did not reference the increasing body of evidence
which links combat veterans, PTSD and violent and abusive traumatic
events in the home. Domestic violence has always been a factor in
military life. It is not new. What is new is the fact that victims are
no longer silent and someone is listening. The American public is not
as tolerant as it was decades ago to the litany of brutal deaths
suffered in military communities or at the hands of a military member
or veteran. While the Pentagon has made efforts to address the issue
and offer support and education to families in the military community,
this war's heavy reliance on citizen soldiers of the Reserve and
National Guard components bring this volatile scenario into every town,
every city and every neighborhood of America.
We know that more of our deployed and activated troops are married
with families than in wars past. The long separations, multiple
deployments and sense of isolation from the very supportive military
community creates confusion, anxiety and anger which increases the
stress and difficulties experienced by families. The NY Times recently
reported ``more than 150 cases of fatal domestic violence or child
abuse in the United States involving service members and new veterans
during the war time period that began in October 2001 with the invasion
of Afghanistan''. Interestingly, not all of these tragedies were
perpetrated by combat veterans. It was noted that ``a third of the
offenders never deployed to war''.
Admittedly, these cases are the extreme. However headlines do not
always capture the slow insidious erosions of trust, disruptions of
anger, violence and abuse that deeply wounds and destroys families The
reality of PTSD in men and women who serve in the Armed Forces also
engenders a link between the symptoms of this condition, family
estrangements and dissolution of family units.
Military Support Program
In 2004 the Connecticut General Assembly enacted legislation
authorizing the Department of Mental Health and Addiction Services
(DMHAS) to provide behavioral health services, on a transitional basis,
for the dependents and any member of any reserve component of the armed
forces of the United States who has been called to active service in
the armed forces of this State or the United States for Operation
Enduring Freedom or Operation Iraqi Freedom. Such transitional services
were to be provided when no Department of Defense coverage for such
services was available or such member was not eligible for such
services through the Department of Defense or until an approved
application is received from the Federal Department of Veterans Affairs
and coverage is available to such member and such member's dependents.
As you well know, VA is very limited to providing care to any
``dependent''. The Vet Centers have traditionally been the only program
that includes dependents in their scope of practice. After some
experience with this program, Governor Rell has proposed that the
eligibility criteria for this program be expanded to include veterans
of Active Duty service and their families.
Funding for this program ($1.4M) came from a portion of the sales
realized when the State sold a decommissioned psychiatric hospital.
Once the funding was available, planning began to implement a program
that would be responsive to the needs of returning military and their
families. From the beginning, this initiative was a collaborative
effort between Connecticut's Departments of Mental Health and Addiction
Services (DMHAS), Veteran Affairs (CTVA), National Guard (CTNG)
Department of Families and Children (DCF) and the Family Readiness
Group. Building on the experience DMHAS had gained in assisting
families in the aftermath of 9/11, the concept of working with mental
health professionals in the community was ideally suited for the broad
context of the legislation and the geographical distribution of
potential clients.
Also taking from previous ``lessons learned'', the scope of the
program was created not only to include military members, their spouses
and children but immediate family members (parents, siblings) and
significant others were also eligible for care. With the assistance of
the State and Federal Departments of Veteran Affairs and the Adjutant
General, 16 hours of training in Military 101, dynamics of deployments
and post traumatic stress dirorder including panel discussions by OIF/
OEF veterans and their families was provided to 225 volunteer mental
health professionals licensed in Connecticut. Only clinicians,
completing the training were eligible to participate in the program.
The Military Support Program (MSP) was designed to streamline the
process of access to care with an emphasis on confidential services
throughout the state. The goal of delivering quality, appropriate,
timely and convenient services was further enhanced by a 24/7 manned
toll free center, three fulltime veteran outreach workers and State
reimbursement for clinical services when there was no other funding
available.
Typically, anyone eligible for the program can call the 24/7
number. In this day and age, it is important that a real person answers
the call. If the nature of the call does not involve a mental health
issue, the caller is directed to an individual at the appropriate
agency. For example, a veteran's benefit question would be directed to
the Connecticut Department of Veterans Affairs. Should the nature of
the call be a request for help with a problem best handled by a mental
health professional, the caller is given the names of three clinicians
in their immediate geographical area, who have completed the training
and are registered with DMHAS. The caller is free to choose which
clinician they will see. The strength of using clinicians in the
community comes from their availability of provide care after hours and
on weekends and obligation to assist in scheduled sessions and/or
crisis situations.
We believe that this is a model that can easily be adapted for any
State especially rural communities.
Another very attractive aspect of this approach is the fact that
families including the military member can have the opportunity to work
out their issues together.
Due to the limitations of VA Healthcare, families are often
excluded from the therapeutic process which can be counterproductive in
the long run. Family therapy is less threatening to a military member
who may not seek treatment because of the stigma associated with mental
health problems. A 2005 study of Iraq Veterans assigned to the Maine
National Guard indicated that 30% of those in the study indicated a
likelihood of participating in ``confidential services in the
community''. Responses to the question of who they would be most likely
to participate in support groups included ``with other veterans (32%),
couples' communication skills training (28%) and couples/marital
counseling (26%). (Wheeler, 2005) lends credence to the concepts we
have implemented.
In the 8 months the Connecticut Military Support Program has been
in operation, we have received over 316 calls and made 181 referrals. A
particularly important aspect of this program is the fact that callers
to the toll free number are contacted approximately 10-14 days after
the referral to determine if the client encountered any difficulties in
the process.
Connecticut has been caring for veterans since 1863. From that time
to this, each generation of Americans, who have shouldered the
responsibility of serving in our Armed Forces, has influenced the
development of the collective service systems provided by Federal,
State and Local governments. Just as the business of conducting war and
defending the Nation has changed dramatically, America and this
Committee need to rethink the delivery system and the care we extend to
those who have borne the battle. The old adage that ``if the military
wanted you to have a spouse they would have issued you one'' has been
outstripped by the number of married military members we rely on to
protect freedoms. In this day and age, the expectation of caring for
our military must include tending to the health of their families.
Prepared Statement of Stacy Bannerman, M.S., Fife, WA, Author,
When the War Came Home: The Inside Story of Reservists and the Families
They Leave Behind
During the few hours it takes for this historic hearing to
conclude, another veteran will commit suicide. Most likely it will be a
veteran of the Guard or Reserves, ``who have fought in Iraq and
Afghanistan [and] make up more than half of veterans who committed
suicide after returning home from those wars.'' (The Associated Press,
February, 2008) There will be at least seven family members left to
deal with the adjustment, loss, anger, and grief. Because their loved
one was a citizen soldier, they will do so alone. They will be forced
to live with the pain of their preventable loss for the rest of their
lives, without the formal and informal mental health services and
support available to active duty military families. Just as they did
during all phases of their loved ones' deployment.
I am the author of ``When the War Came Home: The Inside Story of
Reservists and the Families They Leave Behind.'' (Continuum Publishing,
2006) I am currently separated from my husband, a National Guard
soldier who served one year in Iraq in 2004-05. Just as we are
beginning to find our way back together, we are starting the countdown
for a possible second deployment. Two of my cousins by marriage have
also served in Iraq, one with the MN Guard, a deployment that lasted 22
months, longer than any other ground combat unit. My other cousin,
active duty, was killed in action.
My family members have spent more time fighting one war--the war in
Iraq--than my grandfather and uncles did in WWII and Korea, combined.
When the home front costs and burdens fall repeatedly on the same
shoulders, the anticipatory grief and trauma--secondary,
intergenerational and betrayal--is exponential and increasingly acute.
Nowhere is that more obvious than in Guard and Reserve households.
Our loved ones perform the same duties as regular active troops
when they are in theatre, but they do it with abbreviated training and,
all-too-often, insufficient protection and aging equipment. It was a
National Guardsman who asked then-Secretary of Defense Donald Rumsfeld
what he and the Army were doing ``to address shortages and antiquated
equipment'' National Guard soldiers heading to Iraq were struggling
with.
Guard families experience the same stressors as active duty
families before, during, and after deployment, although we do not have
anywhere near the same level of support, nor do our loved ones when
they come home. Many Guard members and their families report being
shunned by the active duty mental health system. Army National Guard
Specialist and Iraq War veteran Brandon Jones said that when he and his
wife sought post-deployment counseling, they were ``made to feel we
were taking up a resource meant for active duty soldiers from the
base.'' One Guardsman's wife was told that ``active duty families were
given preference'' when seeking services for herself and her daughters
while her husband was in Iraq.
The nearly three million immediate family members directly impacted
by Guard/Reserve deployments struggle with issues that active duty
families do not. The Guard is a unique branch of the Armed Services
that straddles the civilian and military sectors, serves both the
community and the country. The Guard has never before been deployed in
such numbers for so long. Most never expected to go to war. During
Vietnam, some people actually joined the Guard in order to dodge the
draft and avoid combat. Today's National Guard and Reservists are
serving with honor and bravery, each and every time they're called. But
when the Governor of Puerto Rico called for a U.S. withdrawal from Iraq
at the annual National Guard conference, more than 4,000 National
Guardsmen gave him a standing ovation. (``Troops cheer call for Iraq
withdrawal.'' The Associated Press, August 26, 2007)
These factors are crucial to understanding the mental health
impacts of the war in Iraq on the families of Guard/Reserve veterans,
and tailoring programs and services to support them.
Several weeks after my husband got the call he was mobilized. There
was very little time to transition from a civilian lifestyle and
employment to full-time active duty. The Guard didn't have regular
family group meetings, and I couldn't go next door to talk to another
wife who was going through the same things I was, or who had already
been there, done that. Most Guard/Reservists live miles away from a
base or Armory, many are in rural communities. We are isolated and
alone.
At least 20% of us experience a significant drop in household
income when our loved one is mobilized. This financial pressure is an
added stressor. The majority of citizen soldiers work for small
businesses or are self-employed. Some have lost their jobs or
livelihoods as a direct result of deployment. The possibility of a
second or third tour makes it difficult to secure another one. Guard
members have reported being put on probation or having their hours cut
within a few days of being put on alert status for deployment. Some of
us have to re-locate. Some of us go to food shelves. Where we once had
shared parenting responsibilities, the spouse left behind is now the
sole caregiver, without the benefit of an on-base child care center.
During deployment, we withdraw and do the best we can to survive.
Anxious, depressed, and alone, we may attempt to cope by drinking more,
eating less, taking Xanax or Prozac to make it through. We close the
curtains so we can't see the black sedan with government plates pulling
into our drive. We cautiously circle the block when we come home, our
personal perimeter check to make sure there are no Casualty
Notification Officers around. Every time the phone rings, our hearts
skip a beat. Our kids may act out or withdraw, get into fights, detach
or deteriorate, socially, emotionally, and academically. There are no
organic mental health services for the children of National Guard and
Reservists, even though they are more likely to be married with
children than active duty troops.
There are a growing number of military families with what
psychologists are beginning to recognize as Secondary Traumatic Stress
Disorder. Secondary Trauma may occur when a person has an indirect
exposure to risk or trauma, resulting in many of the same symptoms as a
full-blown diagnosis of PTSD. These symptoms can include depression,
suicidal thoughts and feelings, substance abuse, feelings of alienation
and isolation, feelings of mistrust and betrayal, anger and
irritability, or severe impairment in daily functioning. (``Walking On
Eggshells.'' Mary Tendall and Jan Fishler, Vietnow Magazine.)
One woman wrote, ``My husband is a Reservist and, foolishly or not,
we did not expect him to be activated and sent to Iraq. During my
husband's deployment I had anxiety, depression, loss of appetite,
difficulty sleeping, and hair loss from the stress. I had to cut back
on my work hours because I couldn't concentrate.''
When our soldiers come home, they are given a perfunctory set of
questions about their mental health status, and then they are given
back to us. Fifty percent of Guard/Reservists who have served in Iraq
suffer post-combat mental health issues, and the government has known
for decades that Reservists are at significantly higher risk.
Numerous studies conducted in the 1980's and '90's on the impact of
combat deployments in citizen soldiers found that ``Being a reservist,
having low enlisted rank, and belonging to a support unit increased the
risk for psychiatric breakdown. [And] Loss of unit support [post-
deployment] was considered a potential major factor for PTSD . . . In a
study of National Guard reservists . . . nearly all subjects reported
one or more PTSD-specific symptoms 1 and 6 months after returning from
the Persian Gulf area.'' (Possibilities for Unexplained Chronic
Illnesses Among Reserve Units Deployed in Operation Desert Shield/
Desert Storm. Southern Medical Journal, December 1996.)
The VA has done nothing about it. I question the practice of
commissioning reports and conducting studies if you're not going to
apply what you've learned. Perhaps rather than forking out another $5-
10 million for another study to define a problem that somehow never
fully gets defined, much less treated, you could use that same amount
of money to fund community-based centers providing our military
families and veterans three years of the free services that they are
begging for--individual, high touch, weekend and evening, experiential,
off-post--but aren't currently available.
Perhaps in addition to soliciting the fee-for-service advice of
people with Ph.D.'s in Psychology, you could commission the people with
Doctorates in Deployment, the military families and veterans who have
lived with it, worked with it and walked through it. They know what's
needed, what helps, and what the emerging issues are. I knew the
suicide rates of citizen soldiers who served in Iraq were going to be
off the charts when I started hearing from their family members more
than two years ago.
Although it stands to reason that the branch of service with the
highest rates of PTSD would be the same one with the highest rates of
suicide, it seems that the Department of Veterans Affairs had to do a
formal analysis in order to determine that citizen soldiers are more
likely to kill themselves as war veterans. A Military Citizens Advisory
Panel could likely have saved lives, dollars and years of pain.
``How Do You Mourn for Someone Who Isn't Dead?''
After our loved ones return from deployments that have all the
precursors for post-combat mental health issues, (civilian casualties,
longer than six months, significant combat exposure, enlisted rank,
citizen soldier, loss of unit support post-combat, etc.) we're given a
pamphlet and told to ``give it time.'' While we're reading and waiting,
we're losing our veterans, our marriages, and our families. One former
spouse said:
This war cost me my family. When my husband returned from
Iraq it quickly became apparent he was suffering from PTSD. He
became increasingly verbally and mentally abusive to not only
my daughter and I, but many of his subordinates at work who
either quit or he had fired. He refused to admit he had a
problem, and since the military does no mental status follow-up
[for Reservists] he hasn't received any treatment for his
condition. As a consequence, my family is destroyed. My son
isn't being raised by his dad and my daughter lost the only
father she knew. I know a divorce isn't as bad as losing my
husband to death, but I can honestly say the man I married died
in Iraq.
We are also given the option of five free sessions with a civilian
provider. Here's what one Guard wife wrote about that:
When my husband returned from Iraq, we were offered five free
``helping'' sessions--they were careful to stress that it was
not counseling or therapy--after which, we were on our own. In
our first session, my husband talked about the nightmares, the
sounds that would trigger a flashback or a rush of fear. Our
``helper'' chose to focus that particular session on . . . our
financial situation. She was a civilian, and was thoroughly
unfamiliar with any of the issues facing military families,
much less returning vets.
And so, my husband entered private therapy, at a cost of
$85.00 a week which we often didn't have. I was no longer a
part of this process. The impact of his deployments on our
family was no longer addressed. We were simply supposed to
continue on as if nothing had changed. But we had been changed.
Rob came back hardened, angry. I was angry myself, bitter and
resentful. We both experienced PTSD.
Any reminder of his deployment, such as hearing about a group
deploying or returning from Iraq, would send me into sobbing
panic attacks. I experience what I called ``home-front
flashbacks'', sudden overwhelming feelings of isolation, fear,
depression, helplessness, triggered by commercials, news
stories, or a particular song on the radio. What use were these
``helping sessions'' when our ``helper'' had no concept of what
life was like for a military family?
This is what life is like for another military family living with a
combat veteran:
Back in May, Kyle suffered a PTSD disassociative state of
mind [and] held me at knife point [and] wouldn't let me leave;
he had me and our family sitting on the floor and was speaking
to us in Arabic. This ordeal lasted about an hour and a half.
He calmed down with the help of a Vietnam veteran friend [on]
the phone . . . I took the kids next door and . . . the police
showed up, woke my husband and arrested him.
The veteran's unresolved traumatic re-enactment resulting in
domestic violence--which is at least three to five times more prevalent
in households with combat veterans--is the nucleus of intergenerational
trauma, which the children and grandchildren of these veterans will
live with for the rest of their lives. There are countless military
family members suffering in silence all across America. The wife of one
profoundly injured Marine with polytrauma asked, ``How do you mourn for
someone who isn't dead?'' The physical, financial, emotional and
psychological challenges faced by these caregivers are immense, and
they have little--if any--support from the system. (``How the U.S. is
Failing its War Veterans.'' Don Ephron and Sarah Childress, Newsweek,
March 5, 2007.)
The greatest grief is borne by the Gold Star families, and often
the parents and siblings have little, if any, support. If the parents
are divorced, one inevitably gets pushed aside. This was the case for a
grieving mother who contacted me, desperate for help for herself and
her surviving sons, she told me, ``I will spend the rest of my life in
a mild state of depression.'' Another Gold Star mom wrote:
My son, Spec Jeremy W. McHalffey served in the Army National
Guard and was killed in Iraq, January 4, 2005. Jeremy's older
brother Michael will never get over losing his brother. Jeremy
owned a home in Little Rock, Arkansas and I planned to retire
there in 5 years to live near both my sons. I don't want to
retire to a grave site. We plan a family vacation to the shore
each year. We have spent 3 years without Jeremy and it never
gets any better.
But, ``the military health system lacks the fiscal resources and
the fully trained personnel to fulfill its mission to support
psychological health'' of the troops and their families, according to a
Department of Defense mental health task force report released in June
of 2007.
When I went to the VA, I spoke with a program officer, who said,
``It's the wife's responsibility to set the tone for the whole
household.'' A veteran's advocate asked me, ``Why don't you take care
of him?'' The VA's mental health professionals preach to the wives
about resilience, but they aren't the ones being woken up at three in
the morning because their husband has shot the dog, or is holding a gun
to your head, or a knife at your throat.
Expecting the wife or family member to treat the veteran violates
the professional standard prohibiting family members from treating
their own; places the burden of care on the family; creates a highly
unfair and unethical expectation that we are trained mental health
providers; discounts our reality; excuses the VA from fulfilling its
responsibility to our veterans; and places an immoral burden upon the
family member, who is likely already suffering undue mental health and
financial consequences as the result of having their loved one
deployed.
The legacy of guilt and self-blame this creates is profound.
Virtually every family member I have talked to who lost their veteran
due to suicide or divorce has said, ``I thought if I loved him enough,
I could fix him.'' That the VA and the military continues to lay this
on the wives and family members, in practice, if not in policy, is a
gross moral and ethical violation and an abdication of responsibility.
It Is a Covenant, and It Has Been Betrayed.
After being denied care, having their symptoms dismissed, or put on
waiting lists of up to half a year, dozens of Guard/Reserve veterans
have committed suicide, including Jonathan Schulze, Jeffrey Lucey,
Chris Dana, Tim Bowman, and Joshua Omvig. Given the documented failure
(CBS News, November 2007) of the Veteran's Administration to track and
disclose veteran's suicide rates in a timely and forthright manner, and
the fact that they don't monitor Guard and Reserve, it is extremely
likely that the actual number is in the hundreds, if not a thousand or
more.
When the VA repeatedly proves to us that we cannot trust them to
take care of our loved ones, we feel betrayed. The 60% of military
family members of a veteran who has served in Iraq or Afghanistan and
say that the war in Iraq was not worth the cost feel betrayed. (Los
Angeles Times/Bloomberg poll, December, 2007) When our loved ones are
committing suicide after they are refused treatment by the VA, we feel
betrayed. When the Army's mouthpiece, Colonel Elspeth Ritchie, says,
``People don't tend to suicide as a direct result of combat . . .
failed personal relationships are the primary cause,'' then goes on to
further blame the military families by stating, ``Families are getting
tired. Therefore, they're more irritable, sometimes they don't take
care of each other the way they should, are not as nurturing as they
should be.'' WE FEEL BETRAYED.
There is no dictionary large enough to describe what you feel when
you learn that your loved one has fought, died, been wounded, is on the
ground or on alert to return to fight in a war that was launched on 935
lies. (The Center for Public Integrity, and the fund for Independence
in Journalism.)
According to the wife of an Ohio National Guardsman:
My husband served with his National Guard Unit on Victory
Base during 2004. [He] was deployed six months after our
wedding. . . . Neither of us believed that this war was just. .
. . The rage and anger at the sacrifices being asked of
military families, coupled with the severe emotional strain of
worrying about my husband in Iraq pushed me to a breaking
point. We were able to receive a hardship discharge for him to
come home because [of] my severe depression and anxiety. . . .
The shadows of the war are omnipresent in our lives still. We
both seek therapy.
Mental health experts refer to this as betrayal trauma, which
occurs when ``the people or institutions we depend on for survival
violate us in some way. Betrayal, as a form of deception, is the
breaking or violation of a presumptive social contract (trust) that
produces moral and psychological conflict within a relationship amongst
individuals, between organizations or between individuals and
organizations.'' (Wikipedia)
When it is life and death and your loved one on the line, when your
husband, father, mother, brother, daughter or son is fighting for
country and Constitution, military service is no mere contract. It is a
covenant, and it has been betrayed.
The Guard and their families are keeping their promise to this
country. It's time for this country, and the VA, to keep its promises
to them. Please provide our veterans and families the mental healthcare
and services they deserve.
Closing Remarks:
One of the most critical elements in promoting the short- and long-
term wellness of the combat veteran is the military family. Yet, Guard
and Reserve families are generally left to fend for themselves during
and after deployments. In order for the VA to genuinely care for
America's veterans, it must attend to the needs of the families who are
left behind during combat deployments, enduring the stress, trauma,
violence and grief of war, struggle with marriage and family cohesion
and reintegration, and serve as the first line of support for the
soldier during deployment and for the veteran upon his/her return.
However, within the Veterans Administration, treatment benefits are
tied to the veteran. Military spouses cannot access services at the VA
until their soldier has acknowledged his/her trauma, registered with
the appropriate agency, and provided paperwork/given permission for the
spouse to receive assistance or attend a support group, which may or
may not be available at that time.
The majority of the affected families/loved ones (parents,
children, siblings, significant others, etc.) are beyond the scope and
scale of mental healthcare and services provided by the military, the
Veterans Administration, and Vet Centers. Military ONE Source allows
for a maximum of six visits, and Guard/Reserve families, extended
family members, siblings and unmarried partners and significant others
of the soldier's family often do not have private insurance, cannot
afford the co-pay or out-of-pocket expense, and are unable to find an
adequate mental health provider. Few accept TRI-CARE (military medical
plan); fewer still have the experience, training and awareness to
address the particular needs of the military community during a time of
war. Such inadequacies put the health, well-being and future of
military family members and their veterans at risk.
Gaps in Mental Health Services for Families of Guard/Reserve Veterans:
1. Mental health resources available for military family members
are typically designated for active duty dependents.
2. Counseling/support is tied to the veteran, who may or may not
be seeking services AND may or may not be willing to provide permission
required in order for spouse to obtain care.
3. General disregard for veteran impact on family, reintegration
issues, and effect of combat-trauma on family members during and after
deployment.
4. DoD/VA subcontractors are often civilian providers with no
previous experience with military families or therapeutic skill in
counseling individuals struggling with the psychological stressors and
strains of all phases of combat deployments.
5. No programs available for parents, extended family members, or
gender-friendly events for male spouses/ partners of female Reservists.
6. No weekend or night sessions, when Guard/families are
typically available.
7. Lack of ad hoc or informal support opportunities.
8. No exposure to wives/parents/military family members/veterans
who have lived through combat deployments.
9. Virtually no services available in rural areas.
10. No regular phased follow-up i.e. 6, 12, 18, 24 months post-
deployment.
11. Attempting to apply active duty models to citizen soldiers
fails to recognize and address challenges and issues unique to families
of citizen soldiers.
RECOMMENDATIONS (Annotated--Proposals Available Upon Request)
The Military Citizens Advisory Panel (MCAP):
Real support for citizen soldier veterans and their loved ones
cannot be achieved without the perspectives of those who are directly
affected by combat deployments. It is critical that the expertise and
experience of military citizens, i.e. family members from all branches
of services, retired active duty and reserve, combat and non-combat
veterans, etc., who are able to speak about the realities of being a
veteran, the effects of combat deployments, and the battles that begin
when the war comes home, is brought into the policy, program and
oversight processes of the Veterans Affairs Committee. Because they are
the people they represent, the panel members' primary concern is for
service men and women, their families and communities, and the veterans
of the Armed Forces. They know first--and most accurately--what is
occurring with our veterans, the shortfalls in care and services,
emerging issues, suggestions for improvement.
Peer-to-Peer Support Groups: Peer counseling prior to/during/after
deployment by wives of combat veterans/military families/parents/combat
veterans.
Implement Adopt-A-Family Program: Involve community members in
taking a Guard/Reserve family under its wing throughout all phases of
combat deployment.
Conduct Home Visits: Many Guard/Reserve families lack
transportation or cannot easily travel to Guard Armories, and
approximately 40% of veterans live in rural areas.
Fund Community-Based Weekend Retreats/Experiential Programs & Non-
Clinical Services, including:
Veteran Mentoring/Peer Counseling
Family Group Counseling
Off post readjustment/reintegration counseling for
families of wounded warriors
Grief Counseling for Gold Star families
Developmentally appropriate play therapy for children
Respite & Bereavement Support: Taking care of the
caregivers
Outdoor/Experiential Programs
Develop & Implement Family Systems Theory Programs/Services
By definition, a family system functions because it is a unit, and
every family member plays a critical, if not unique, role in the
system. As such, it is not possible that one member of the system can
change without causing a ripple effect of change throughout the family
system. (Source Unknown) ``The entire family suffers when a Veteran's
mental health needs are not acknowledged and resolved; it can strain
even the strongest of marriages . . . the longer the problem is not
treated, the complicated the treatment becomes due to complications
that arise from the lack of treatment. As a result, our families suffer
through crisis on a daily basis.'' (LTC Carol Seger, WAARNG State
Family Programs Director, August 20, 2007)
FAST FACTS: National Guard & Reserve Veterans and Their Families
A. Since the onset of military operations in Iraq and Afghanistan,
more than 400,000 members of the National Guard and Reserve have served
in the Middle East (counting each deployment as unique), and more than
600,000 have been mobilized since 2001. (Office of the Under Secretary
of Defense, September 2007).
B. Assuming that each of those troops has seven immediate
relatives--such as parents/step-parents, spouses/partners/significant
others, siblings and children--the wars have closely affected more than
2,800,000 Guard/Reserve family members. (Formula adapted from ``War's
Invisible Wounds.'' Zak Stambor, APA Monitor on Psychology, Vol. 37,
No. 1, January 2006).
C. Almost 50 percent of the Guard and Reserve who have served in
Iraq are experiencing combat-related mental health problems, as are 38
percent of Soldiers, and 31 percent of Marines. (``An Achievable
Vision: Report of the Department of Defense Task Force on Mental
Health'' June 2007, Defense Health Board, Falls Church, VA, p. 6).
D. ``National Guard and Reserve troops who have fought in Iraq and
Afghanistan make up more than half of veterans who committed suicide
after returning home from those wars.'' (The Associated Press, February
2008).
E. ``No U.S. forces have ever been compelled to stay in sustained
combat conditions for as long as the Army units have in Iraq. In World
War II, soldiers were considered combat-exhausted after about 180 days
in the line.'' (Lieutenant General William E. Odom, (Ret.) 05 July
2007).
Key Issues: Impacts of Combat Deployments on Military Families.
The Journal of the American Medical Association (JAMA)
released a study looking at families of enlisted Army troops with
verified reports of child maltreatment. The report revealed that among
female civilian spouses, the rate of maltreatment during deployment was
more than three times greater; the rate of child neglect was almost
four times greater; and the rate of physical abuse was nearly twice as
great. (``Child Maltreatment in Enlisted Soldiers' Families During
Combat-Related Deployments'' Deborah A. Gibbs, MSPH; Sandra L. Martin,
PhD; Lawrence L. Kupper, PhD; Ruby E. Johnson, MS. JAMA 2007; 298:528-
535; Vol. 298 No. 5, August 1, 2007).
School counselors, teachers, therapists and military
family members report that a growing number of military kids are
exhibiting social, emotional, and behavioral problems during and after
deployments. These problems are intensified if their soldier returns
with a physical or psychological wound. (``Communication is Key for
Children of Deploying Parents'' Bilyana Atova, Army News Service,
August 15, 2007)
Divorce and separation rates among returning Iraq war
veterans are fast approaching double the rate of peacetime divorces.
(``Deployments Stress Marriages.'' Christine Metz, Lawrence Journal-
World & News, October 8, 2007). The wife and child(ren) of the veteran
suffer significant impacts of separation/divorce, including a major
drop in household income, stress and expense of re-location, loss of
friends, loss of sense of identity/connection to military, etc., in
addition to the usual stressors associated with the dissolution of a
marriage and the break-up of a family.
According to the Miles Foundation (hometown.aol.com/
milesfdn), domestic abuse in military households is already five times
greater than the rate of civilian domestic abuse, and the numbers do
not take into account assaults that occurred off-base, or involving
domestic partnerships/common law spouses, etc. It has been shown
repeatedly that violence in the home and on military bases and
installations increases during wartime, and spikes in the first year
post-deployment, as evidenced in the spate of spousal murders at Ft.
Bragg in the first months of redeployment from Afghanistan.
Preliminary research, self-reports and anecdotal
information suggest that upward of 30% of military family members are
exhibiting war-related ``Secondary Trauma,'' which shares some of the
same symptoms as a full-blown diagnosis of post traumatic stress
dirorder, including emotional withdrawal, increased anxiety, depression
and poor anger management.
With an unprecedented wound-to-kill ratio of nearly 16 to
1 and the prevalence of Traumatic Brain Injury (TBI) parents
(particularly mothers), spouses, grandparents and siblings are becoming
the primary caregiver of their grievously injured veteran and have
scant support or services.
Prepared Statement of Peter Leousis, Principal Investigator,
Citizen Soldier Support Program National Demonstration, and,
Deputy Director, H.W. Odum Institute for Research in Social Science,
University of North Carolina at Chapel Hill
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to speak to you this morning about the mental health needs
of families of veterans.
Specifically, I want to address the question before the
Subcommittee about ``the need for the U.S. Department of Veterans
Affairs to provide mental health treatment for family members of
veterans within VA medical facilities.'' More broadly, I want to
describe the approach our North Carolina initiative is taking to
address the mental health needs of Operation Enduring Freedom and
Operation Iraqi Freedom veterans and their families.
My name is Peter Leousis and I am the principal investigator for
the Citizen Soldier Support Program National Demonstration. The Citizen
Soldier Support Program was funded by the Congress to develop model
approaches to mobilize and engage community support for members of the
National Guard and Reserve and their families. I am currently Deputy
Director of the Odum Institute for Research in Social Science at UNC
Chapel Hill. Before that, I was Assistant Secretary for Human Services
for seven years under former North Carolina Governor Jim Hunt.
I want to thank the North Carolina Congressional delegation and the
University of North Carolina's Board of Governors for their support of
this work and for their efforts to provide federal funding. I want to
emphasize that while we have been laying the groundwork for our mental
health initiative for more than a year, many elements of the program
are just getting underway. We will have a much clearer assessment of
the program in four to six months.
The focus of the Citizen Solider Support Program is on the Reserve
Component of the military, which includes the National Guard and
Reserves. Whether these service men and women are in the Army National
Guard or the Marine Corps Reserve, the Army Reserve or the Air National
Guard they are widely dispersed throughout the nation. In North
Carolina, the majority of Reserve Component service members do not live
near a military installation. In fact, historically many of them have
not thought of themselves as military families. In most cases, the
formal and informal networks that provide support for families in the
Active Component are not available to them.
Rural Communities
Our efforts focus on rural communities and communities that do not
have easy access to VA medical facilities and Vet Centers. In North
Carolina, for example, there are no Vet Centers west of Charlotte
despite the large numbers of Citizen Soldiers and veterans living in
that part of the state.
Figure 1--Reserve Component by County: March 31, 2007
[GRAPHIC] [TIFF OMITTED] T1373A.001
Figure 1 shows the geographic distribution of more than 22,000
Reserve Component service members across North Carolina on March 31,
2007. This does not include more than 8,000 service members in the
Individual Ready Reserve.
Although some counties clearly have concentrations of Citizen
Soldiers, they and their families live in all counties of the state and
significant numbers of them live in rural counties in the eastern and
western regions of the state.
Figure 2--VA Medical Centers, Vet Centers, and Reserve Component: March
31, 2007
[GRAPHIC] [TIFF OMITTED] T1373A.002
The circles on Figure 2 are centered on VA medical centers and Vet
Centers located in North Carolina. The radius of each circle is 20
miles, or approximately 30 minutes driving time. As shown on this map,
most Citizen Soldiers do not live near a VA Medical Center or Vet
Center.
Figure 3--Licensed Clinical Social Workers and Reserve Component:
March 31, 2007
[GRAPHIC] [TIFF OMITTED] T1373A.003
The dots in Figure 3 show the number of licensed clinical social
workers in North Carolina. The largest urban counties of Mecklenburg,
Wake, Durham, Forsyth, and Guilford have the largest numbers of
licensed clinical social workers. But virtually every county has
several. These licensed mental health providers and others like them
are target groups of the Citizen Soldier Support Program. We focus on
building the mental health infrastructure outside urban areas and at
locations far removed from VA Medical Centers and Vet Centers through
training developed in collaboration with partners who are experts on
post traumatic stress dirorder (PTSD) and combat-related mental health
issues.
The Mental Health Needs of Families
The Subcommittee has asked about the mental health needs of
families of OEF and OIF veterans. We know that the majority of Reserve
Component families are resilient. They are able to cope with the
demands and challenges of repeated deployments with few lasting
effects. But there is mounting evidence that service in OEF and OIF
comes at a price for families. We know, for example, that the incidence
of child maltreatment in families with deployed parents rises
significantly. (Am J Epidemiol 2007; 165:1199-1206).
Post-deployment reintegration of veterans can be as challenging for
families as for soldiers and Marines themselves. For example, the
report of a joint working group composed of the Department of Veterans
Affairs Office of Research and Development, the National Institute of
Mental Health, and the United States Army Medical Research and Materiel
Command concluded that:
[T]he burden of illness, including the cost of PTSD and other
trauma responses, spans beyond symptoms to impairment, altered
functioning, and disability, and crosses family, occupational,
and social realms. This applies not only to those who have
served in the military and suffer from deployment-related
problems, but also to their spouses, partners, and children
(``Mapping the Landscape of Deployment Related Adjustment and
Mental Disorders: A Meeting Summary of a Working Group to
Inform Research,'' working paper 2006; p. 9).
There is evidence that exposure to combat has an even greater
effect on Reserve Component service members. According to the
``Longitudinal Assessment of Mental Health Problems Among Active and
Reserve Component Soldiers Returning from the Iraq War'' (Journal of
American Medical Association; 11/14/2007), ``clinicians identified
20.3% of active duty and 42.4% of reserve component soldiers as
requiring mental health treatment.''
Over 360,000 ``citizen soldiers'' have served in Afghanistan and
Iraq so far. More than 10,000 are from North Carolina alone. They do
not return to military installations where the community ``gets it''
and appropriate services are available, but rather to their hometowns
and communities that might not even be aware of their service and
sacrifice.
We know that PTSD has a secondary effect on spouses and partners
and that the repeated deployments typical of OEF and OIF are having
lasting effects on service members and their families. The report of
the Mental Health Advisory Team IV published in the December 2007 issue
of Traumatology notes that:
Not surprisingly, deployment length and multiple deployments
to Iraq were related to soldier mental health and well-being,
with soldiers deployed longer than 6 months and soldiers on
their second deployment to Iraq being more likely to screen
positive for a mental health problem than soldiers who were
deployed less than six months or on their first deployment
(``The Intensity of Combat and Behavioral Health Status,''
Traumatology 2007; 13; 6).
Clearly, the mental health needs of returning veterans, including
but not limited to PTSD, have an impact on their entire family, not
just themselves. The issue is not whether the families of returning
veterans may face serious mental health challenges, but how best to
make sure they get the mental health services they need when and where
they need them.
When returning veterans and their families have reasonable access
to VA medical facilities, mental health treatment should be made
available to the entire family, not just the veteran, when it is
clinically appropriate. We define reasonable access as living within a
30-minute drive of a mental health treatment provider.
The CSSP Approach
The Citizen Solider Support Program's efforts are guided by three
fundamental principles. First, the program seeks to complement and
strengthen the work of others and avoid duplicating similar efforts. To
that end we have developed a partnership with Dr. Harold Kudler, M.D.,
VA Mid-Atlantic Healthcare Network, VISN 6. Dr. Kudler and his
colleague, Dr. Kristy Straits-Troster, PhD, have been key collaborators
and advisors to CSSP.
The steering committee that guided the development of our mental
health initiative is listed at the end of my remarks. It includes
experts with firsthand knowledge of the needs of returning veterans and
their families and key stakeholders in the military and North
Carolina's public and private mental health community.
A second guiding principle is that fundamental, lasting change can
best be accomplished by taking a ``systems'' approach. Accordingly, our
efforts are focused on leveraging existing mental health training and
delivery systems and mechanisms to reach mental health providers and to
enhance delivery of mental health services throughout our state.
A third guiding principle is that there is no silver bullet.
Relying on one approach will not work. We have to move forward on many
different fronts at the same time. Thus, our mission to ensure that
Citizen Soldiers and their families have access to mental health
services encompasses five goals:
1. Provide evidence-based, best practice behavioral health
training and products for healthcare professionals who render services
to Citizen Soldiers and other veterans and their families. This
includes primary care physicians and mental health providers.
Our goal is to train 1,000 health and mental healthcare
providers annually until we achieve a 70% to 80% market penetration
rate. Currently this training is offered face-to-face to providers
through the North Carolina Area Health Education Centers (AHEC) system.
There are nine AHECs in North Carolina, and we offered our first full-
day training session to 98 mental health professionals in January 2008.
We will also make training available online to licensed providers.
Ultimately, we plan to replicate this effort in the 40-plus states that
have training systems similar to North Carolina's AHECs.
2. Provide specialized health and mental health services to
returning Citizen Soldiers and other veterans and their families using
the model of Integrated Care at family health clinics in Haywood, Clay
and Jackson Counties, three rural underserved counties in Western North
Carolina.
The stigma of seeking mental health treatment is alive and well.
Our experience is that offering treatment through family health clinics
will reduce the likelihood that service members concerned about their
career (and their families) will not seek care. Additionally, evidence
suggests that mental health treatment should be provided through a
``multidisciplinary approach centered in primary care.'' A goal of this
demonstration is to make the mental health component self-sustaining
within three years through TRICARE, third-party payers, and Medicaid.
3. Expand TRICARE participation by primary healthcare and mental
health service providers and pharmacies to all 100 North Carolina
counties.
At each of our trainings a half hour is devoted to educating
providers about TRICARE and dispelling some of the myths about it. Care
must be accessible and affordable for returning veterans and their
families. We recognize that we must identify ``funding streams'' to
help veterans and families pay for needed services wherever they are
available.
4. Address the critical shortage of psychiatric clinicians
available to meet the needs of Citizen Soldiers and other veterans and
their families in the 50 medically underserved counties in North
Carolina.
Rural healthcare disparities exist throughout the nation, and
North Carolina is no exception. One of our goals is to secure long-term
funding for a stipend and loan forgiveness program for psychiatric
nurse practitioners who in return would agree to practice in
underserved rural communities for a set number of years.
5. Provide online access to information about mental health
issues. Information for ``Military and families'' is available through
the NC Health Info Web site (http://www.nchealthinfo.org/) and for
family practice physicians and mental health professionals through the
NC AHEC Digital Library.
These resources exist today through our collaborative work with
the Health Sciences Library at the University of North Carolina at
Chapel Hill. We invite Members of the Subcommittee and your staff to
explore these Web sites. With very little tweaking, the content
information contained in these Web pages could be made available to
other states. Information about locally available services could be
replaced with information specific to other communities.
Consumer information for military families is located at:
http://www.
nchealthinfo.org/health_topics/people/military/
MilitaryFamilies.cfm
Information on military mental health for mental health
professionals is located at: http://library.ncahec.net/
scMain.cfm?scid=53
Our objective is to implement these goals and strategies in North
Carolina, evaluate and improve them, and then help other states
replicate those that are successful. We will continue to work with
stakeholders such as the VA and private mental health providers,
especially those in underserved rural communities, to improve and
expand mental health services to Citizen Soldiers and other veterans
and their families.
Thank you for the opportunity to speak this morning before the
Subcommittee on Health, and thank you for all you are doing to improve
health and mental health services for our veterans and their families.
Behavioral Health Steering Committee
Citizen Soldier Support Program
Denisse Marion-Landais Ambler, MD North Carolina Neuropsychiatry,
PA, and adjunct assistant professor, Department of Psychiatry, UNC
School of Medicine
COL James A. Cohn, North Carolina National Guard
Rev. Dennis Goodwin, District Superintendent, The United Methodist
Church; CH (COL) 30th Brigade Combat Team (ARNG Ret.) Chair
Brigadier General Dan Hickman (ARNG Ret.) Executive Vice President,
Cape Fear Community College
COL Danny Ray Hill, Officer in Charge, Tactical Operations Center,
Foreign Army Training Command 108th Division (Institutional Training)
USAR
Harold Kudler, MD, VA Mid-Atlantic Healthcare Network, VISN 6
Michael Lancaster, MD, Chief of Clinical Policy for the NC Division
of Mental Health/Developmental Disability/Substance Abuse, NC
Department of Health and Human Resources
Peter Leousis, Deputy Director Odum Institute for Research in
Social Sciences and CSSP Principal Investigator
Major General Gerald A. (Rudy) Rudisill, Jr. (ARNG Ret.); Deputy
Secretary, NC Crime Control and Public Safety
Karen Stallings, RN, NC AHEC Associate Director, Program
Activities, UNC Chapel Hill
Flo Stein, M.P.H., Chief, Community Policy Management, NC Division
of Mental Health/Developmental Disability/Substance Abuse, NC
Department of Health and Human Resources
John Tote, Executive Director, Mental Health Association in North
Carolina
Prepared Statement of Charles Figley, Ph.D., LMFT, Fulbright Fellow and
Professor, College of Social Work, Director, Traumatology Institute and
Psychosocial Stress Research and Development Program,
Florida State University, Tallahassee, FL,
on behalf of American Association for Marriage and Family Therapy
Dear Mr. Chairman and other members of the Subcommittee:
On behalf of the American Association for Marriage and Family
Therapy (AAMFT), I would like to thank you for shedding light on the
need for the Department of Veterans Affairs (VA) to expand VA mental
health services to include family members of veterans in addition to
the veterans themselves. We are honored to participate in this
important dialog. By holding today's hearing; ``Mental Health Treatment
for Families: Supporting Those Who Support Our Veterans,'' access to
family oriented mental health services will finally be formally
addressed, so we can begin to help heal the clandestine wounds
increasingly affecting those closest to returning service members.
As background, the AAMFT is a national non-profit professional
association representing the interests of the over 52,000 Marriage and
Family Therapists (MFTs) across the United States since its inception
in 1942. Family Therapists are the ONLY mental health professionals
required to receive training in family therapy & family systems. Not
only are MFTs licensed in 48 states plus the District of Columbia, but
each licensed or certified MFT must meet strict professional
requirements including a minimum of a master's degree ( 30 percent with
Doctorate degrees) in marriage and family therapy or an equivalent
degree with substantial coursework in MFT. In addition, all MFTs must
complete at least two years of a post-graduate clinical supervised
internship.
At the end of 2006, the President signed into law a sweeping
veterans' bill that finally added Marriage and Family Therapists (MFTs)
as eligible providers of mental health services under the Veterans
Administration (VA), Public Law 109-461. As one of the five core mental
health professions (designated by the Heath Resources and Services
Administration), Family Therapists are trained to treat disorders
commonly faced by veterans, including clinical depression, post
traumatic stress dirorder (PTSD), and schizophrenia, among others.
Despite our on-going collaboration with leadership at the VHA and the
law having been in effect for well over a year, the 52,000 U.S. Family
Therapists are still awaiting implementation of our services into the
VA system so we can begin to aid our Nation's veterans, as we have
served active-duty military for over 30 years. Family Therapists have
been eligible to provide medically necessary mental health services to
active military personnel and their families under the CHAMPUS/TRICARE
program for decades, as well as through the Department of Defense.
Additionally, Family Therapist interns serve veterans in VA facilities,
but presently cannot continue this care as licensed MFTs since our VA
implementation is incomplete.
The impact of mental illness on our veterans and their families is
striking. Recognition of the need to expand VA mental health services
to include families is growing as the impact of mental health disorders
among veterans from OIF-OEF manifest, following their mustering out of
military positions. A 2004 study by Hoge, Castro, Messer, McGurk,
Cotting, and Koffman, demonstrated the significant mental health
consequences from the wars in Afghanistan and Iraq. In ``Combat duty in
Iraq and Afghanistan, mental health problems, and barriers to care,''
from the New England Journal of Medicine, the estimated risk for PTSD
from service in the Iraq War was listed at 18%, while the risk for PTSD
from the Afghanistan mission was 11%. According to Sherman, Sautter,
Jackson, Lyons, Han, in ``Domestic Violence in Veterans with post
traumatic stress dirorder Who Seek Couples Therapy,'' Journal of
Marital and Family Therapy, October 2006, ``domestic violence rates
among veterans with post traumatic stress dirorder (PTSD) are higher
than those of the general population. Individuals who have been
diagnosed with PTSD who seek couples therapy with their partners
constitute an understudied population.''
Service member deployment length is intrinsically related to higher
rates of mental health problems and marital problems. Within the U.S.
military report, ``the Mental Health Advisory Team IV,'' (MHAT IV)
released on November 17, 2006 there have been at least 72 confirmed
soldier suicides in Iraq since the beginning of OIF. As with previous
MHAT reports, this study also found suicide rates were 28% higher
compared with average army rates for those not deployed (16.1 vs. 11.6
soldier suicides per year per 100,000, respectively). For soldiers,
deployment length and family separations were the top noncombat
(deployment) issues. Marital concerns were higher than in previous
surveys among Operation Iraqi Freedom troops, and like other concerns,
they were related to deployment length. Those in Iraq more than 6
months were 1.5 to 1.6 times more likely to be assessed as having
mental health problems. In addition, troops in Iraq for more than 6
months were more likely to have marital concerns (31% vs. 19%), report
problems with infidelity (17% vs. 10%), and were almost twice as likely
to be planning a marital separation/divorce (22% vs. 14%).
In post-deployment reassessment data completed in July 2005, Army
researchers found that 21% of soldiers returning from combat areas were
misusing alcohol a year after their return home; just 13% were found to
misuse alcohol prior to deployment. Soldiers with anger and aggression
problems increased from 11% to 22%, and the divorce rate rose from 9%
to 15%. Those planning to divorce their spouse rose from 9% to 15%
after time spent in the combat zone. With the rise in the psychological
needs of our veterans, it is critical that they have access to the most
appropriate providers, including Family Therapists at Vet Centers as
well as at other VA facilities.
This urgency for access to qualified mental health practitioners
within the VA is clear: ``one of the most troubling problems facing the
VA today is the near crippling effects of severe staffing shortages in
nearly every conceivable staff category,'' reports the Eastern
Paralyzed Veterans Association (EPVA). More specifically, monthly VA
staffing surveys provided to the EPVA by the Veteran's Administration
indicate significant shortages of mental health professionals (see
position paper ``Veterans Healthcare,'' October 2002).
This leads to an obvious problem hampering veteran access to mental
health services--a shortage of qualified mental health providers in
rural communities. One sure way of addressing the staffing problem is
through increasing access to mental health services provided by
practitioners who are widely present in rural communities; Family
Therapists. AAMFT data shows that 31.2% of rural counties have at least
one Family Therapist, demonstrating our strong MFT representation in
rural America. Improving access is crucial, particularly since the
National Rural Health Association reports that the average distance for
rural veterans to get VA care is 63 miles. This is unacceptable travel
time for those who have already traveled the world on our behalf in
pursuit of U.S. safety and security. Our service members deserve more
than this to help make a seamless transition out of active duty and
into veteran status.
The use of mental health services provided by MFTs toward this
seamless transition is more than just a geographically logical fit. A
meta-analysis of applicable research found that the use of family
psychotherapy has been shown to significantly improve the lives of
individuals experiencing clinical depression by addressing the
cognitive, behavioral and interpersonal aspects of this debilitating
disorder within a systemic context (Beach, S., M.D. Marital and Family
Therapy for Depression: Empirically Supported Treatments and
Implications for Clinical Decision Making, 2002). Don R. Catherall,
Ph.D., in ``Family Treatment When a Member Has PTSD'' from NCP Clinical
Quarterly, indicates that ``unlike many forms of individual therapy,
families rarely remain in treatment if they can not see its immediate
relevance to the concerns which brought them to seek help. Though we
may view a family's problems as a result of traumatization, we will not
be permitted to successfully probe the trauma unless the family can be
helped to see how the presenting problem(s) is linked to the
traumatization. When the family therapist can demonstrate such a link,
he or she then has a mandate to pursue the traumatized material . . .''
Additionally, according to Ralph Ibson of Mental Health America, ``VA
healthcare, and particularly mental healthcare, would often be more
effective if barriers to family involvement were eliminated.''
I feel that what has set these most recent wars apart from the
Vietnam War is the enduring appreciation and respect for the men and
women in uniform who, despite their personal misgivings, answer the
call to serve their country in war. We as a Nation and as mental health
professionals owe them and their families the very best help possible
for as long as it is needed. On behalf of the AAMFT and myself, I trust
that this special hearing coupled with our continued collaborations on
the expansion of VA mental health services, contributes to that goal.
Prepared Statement of Ralph Ibson, Vice President for Government
Affairs,
Mental Health America
Mr. Chairman and Members of the Subcommittee:
Mr. Chairman, Mental Health America commends you for scheduling
this hearing, and for your and this Committee's ongoing concern about
the mental health of our veterans.
Mental Health America (MHA) is the country's oldest and largest
nonprofit organization addressing all aspects of mental health and
mental illness. In partnership with our network of 320 state and local
Mental Health Association affiliates nationwide, MHA works to improve
policies, understanding, and services for individuals with mental
illness and substance abuse disorders, as well as for all Americans.
Established in 1909, the organization changed its name in 2006 from the
National Mental Health Association to Mental Health America in order to
communicate how fundamental mental health is to overall health and
well-being. MHA is a founding member of the Campaign for Mental Health
Reform, a partnership of 17 organizations which seek to improve mental
healthcare in America, for veterans and non-veterans alike.
This morning's hearing raises far-reaching questions relating to
the toll of military engagement and the responsibility of our country
and its institutions to those who bear the costs of war.
This country has a long, honorable tradition of keeping faith with
those who have served in uniform. We can be proud of the comprehensive
system of veterans' benefits Congress has established and of its
creation of a cabinet-level department that administers those benefit
programs. Congress has, of course, long supported the operation of a
nationwide healthcare system in the Department of Veterans Affairs
dedicated to providing needed care, rehabilitation and readjustment
services. That system focuses on the veteran, and, in accordance with
law, gives priority and the fullest array of benefits to those with
service-incurred health conditions. How should that system respond to
war-related mental health needs experienced by families of returning
veterans?
Unique Impact of Operations Iraqi Freedom and Enduring Freedom (OIF/
OEF) on Families
More than 1 million American troops have served in the Global War
on Terrorism. Their service has been unique in several respects.
Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) have relied to
a greater extent than ever before on the ``citizen-soldiers'' of the
National Guard and Reserve forces. These operations have called on our
forces to an unprecedented degree to undertake both extended and
multiple deployments. Service members in previous wars were typically
young and without families. In contrast, some 58 percent of those in
our armed forces are married, and nearly 2 million children have been
affected by deployments since September 2001. Increasingly we are
coming to realize that the strains this war has placed on our armed
forces overall mirror in many respects the strains it has placed on
individual combatants and on their families.
While there is widespread recognition of the extent of post
traumatic stress dirorder (PTSD) and other war-related mental health
problems among those who served in Iraq and Afghanistan, much less
attention has been given to the strain these military operations have
had on the mental health of service-members' families. We are only
beginning to appreciate fully the implications of those problems on
veterans' readjustment and mental health.
As many have observed, military deployment, particularly for
National Guardsmen and Reservists, can be enormously stressful on
families who may have had little time to prepare, and lack military and
community support systems. This war has involved unique stresses on
service families related to combat exposure, length of deployments, and
the high incidence of casualties. These stresses have been compounded
in a war marked by repeated deployments (and short turnarounds before
redeployment) and in which high percentages of service members have
experienced traumatic events. Hoge et al (2004), reporting on a survey
of 894 soldiers who served in Iraq, found that 95% had observed dead
bodies or remains, 93% had been shot at, 89% had been attacked or
ambushed, 65% observed injured or dead Americans, and 48% had killed an
enemy combatant. Families experience measurable distress associated
with service members planning to redeploy as soon as 12 months after
returning from a fifteen-month deployment and from the constant sense
of danger associated with graphic media coverage of daily battles and
casualty reports. (Flake, et al., ``The Effects of Deployment on
Military Children'', 2007).
The strain that war places on families and marriages does not
necessarily end with the veteran's homecoming. The post-deployment
period following a joyous homecoming can also be a time of difficult
readjustment. As one writer put it, ``in many instances, a traumatized
soldier is greeting a traumatized family, and neither is `recognizing'
the other'' (Hutchinson and Banks-Williams, 2006, p. 67). Clinicians
have described adjustment reactions among OIF/OEF veterans that include
feeling anxious, having difficulty connecting to others, experiencing
sleep problems, strains in intimate relationships, as well as problems
with impulse control and aggressive behavior. (Bowling, U.B., &
Sherman, M.D. (in press). ``Welcoming them home: Supporting soldiers
and their families with the tasks of reintegration.'' Professional
Psychology: Research and Practice.) These understandable reactions
complicate the process of reintegrating an individual back into family
life.
Family reintegration may be still more difficult in instances where
veterans are grappling with PTSD or other mental health conditions. In
the case of a veteran with PTSD, for example, that disorder has been
associated with severe, pervasive negative effects on marital
adjustment, general family functioning, and the mental health of
partners, with high rates of separation and divorce and interpersonal
violence. PTSD can also have a profound impact on veterans' children.
Indeed there is cause for real concern regarding the war's impact on
these children. Data from a recent study indicate that one in three
families with a deployed service member identified a school age child
as ``at high risk'' for psychosocial difficulties (Flake, 2007). While
there has not been much research on the effects of war on military
children, the literature does show that parental wellness is the single
most predictive factor of child wellness.
Clearly, the family has a profoundly important role to play in
veterans' readjustment, especially in the case of veterans who have
sustained injuries or deep psychological wounds. As VA's Special
Committee on post traumatic stress dirorder (a statutorily created
panel of clinicians which reports annually to VA and to Congress) has
advised, ``the strength of a war fighter's perceived social support
system is one of the strongest predictors of whether he/she will or
will not develop PTSD.'' But family members who are scarred by the
trauma of long separations and multiple and extended tours of duty, and
in some cases by their own experience with depression or anxiety, may
not have the capacity to provide that needed support.
In assessing the wide range of post-deployment mental health issues
confronting veterans and their families, VA's Special Committee on PTSD
advised in a February 2006 report that ``VA needs to proceed with a
broad understanding of post deployment mental health issues. These
include Major Depression, Alcohol Abuse (often beginning as an effort
to sleep), Narcotic Addiction (often beginning with pain medication for
combat injuries), Generalized Anxiety Disorder, job loss, family
dissolution, homelessness, violence toward self and others, and
incarceration.'' The Committee advised that ``rather than set up an
endless maze of specialty programs, each geared to a separate diagnosis
and facility, VA needs to create a progressive system of engagement and
care that meets veterans and their families where they live. . . . The
emphasis should be on wellness rather than pathology; on training
rather than treatment. The bottom line is prevention and, when
necessary, recovery.'' Importantly, the Special Committee also advised
that ``Because virtually all returning veterans and their families face
readjustment problems, it makes sense to provide universal
interventions that include education and support for veterans and their
families coupled with screening and triage for the minority of veterans
and families who will need further intervention.'' [Emphasis added.]
Strengthening family relationships can be crucial to a veteran's
mental health. But despite recognition in the VA regarding the mental
health needs of returning veterans' families and the importance of
engaging family members in the veteran's readjustment and treatment,
current law and practice limit VA's assistance to, and work with,
family members.
Roles for the Department of Veterans Affairs
VA is an integrated healthcare system which offers a relatively
full continuum of care and services for eligible veterans. But whether
or not VA staff provide counseling or other support to members of the
immediate family of a veteran returning from war appears to vary by
facility. A veteran with PTSD, for example, could receive services for
that condition at a VA medical center, an outpatient clinic, or at one
of VA's ``Vet Centers'' that are operated independently of VA medical
centers and clinics. Family therapy is often a component of the
readjustment counseling provided at Vet Centers. But veterans who live
far from a Vet Center and who rely instead on a VA medical center or
clinic often encounter a system that focuses on the veteran-patient
(rather than on the veteran as part of a family unit) and generally
does not provide counseling and related services to family members.
(And yet there are a number of VA medical centers that for years have
provided family consultation and education and longer term family
psycho-education, employing a program developed by VA clinicians. See
Operation Enduring Families, www.ouhsc.edu/safeprogram; Sherman, M.D.
(2003)). The S.A.F.E. Program: A family psycho-educational curriculum
developed in a VA Medical Center. Professional Psychology: Research and
Practice, 34(1), 42-48.)) Such variability in a national healthcare
system is perplexing. It is difficult to conceive of a sound
programmatic rationale for engaging family support at one particular
set of facilities (Vet Centers) and not at VA medical centers and
clinics, particularly when each of these facility models provides
services to OIF/OEF veterans with PTSD, for example. VA healthcare, and
particularly mental healthcare, would certainly be more effective if
barriers to family engagement were eliminated.
Current law appears to cause difficulty. In the case of a veteran
being treated for a service-connected condition, current law states
that ``the Secretary shall provide such consultation, professional
counseling, training, and mental health services as are necessary in
connection with that treatment.'' (38 U.S. Code section 1782(a)) But
with respect to any other veteran, VA may provide such services to
family members but only where the services had been initiated during a
period of hospitalization and continuation is essential to hospital
discharge. (38 U.S. Code section 1782(b).) Under that provision, VA
might conclude that family services could not be provided where it is
treating an OIF/OEF veteran who has not been adjudicated service-
connected and is not hospitalized. But while current law provides broad
authority to furnish needed mental health services to family members of
veterans who are service connected, we are not aware that any VA
facilities are providing (or contracting for provision of) mental
health services (other than consultation, education and psycho-
education) to family members. Yet current law surely contemplates that
VA would provide, or arrange to provide, mental health services to a
spouse whose anxiety or depression, for example, compromised the
readjustment or treatment of a veteran who is service-connected for
PTSD.
Certainly, there is potentially great benefit to a veteran under VA
treatment for a mental health problem from having VA also counsel or
provide needed mental health treatment to a spouse. We see no
compelling reason to foreclose VA from making such services available
to family members of OIF/OEF veterans. To the contrary, the family has
a unique role to play in providing support, and it is entirely
consistent with VA's mission to help family members carry out that
role. However the law now makes a distinction, relating to provision of
family services, between a veteran being treated for a service-
connected and a nonservice-connected condition. But it is noteworthy
that VA is authorized to provide medical care and services (subject to
a 5-year time limit in the case of veterans) to OIF/OEF veterans who
are not otherwise eligible for VA care. This special eligibility
effectively treats the veteran who served in a combat theater on what
amounts to a presumptive service-connected basis. Given that the law
effectively considers health problems experienced by combat veterans as
though they are service-connected for treatment purposes, there appears
no obvious rationale for treating an OIF/OEF veteran's mental health
problem differently for purposes of counseling family members. In fact,
the language in current law, linking provision of family services to
the goal of hospital discharge appears to be a relic of a long-
abandoned provision of a prior eligibility law. Congress should have no
hesitation about amending current law to enable family members of OIF/
OEF veterans to get counseling and services that would enable them to
better support the veteran in his/her treatment.
VA clinicians have pioneered and developed impressive programs that
provide family members early intervention and support and aim to
prevent long term problems (See Operation Enduring Families). We would
hope to see such programs far more widely implemented across the
system. But as you recognized, Mr. Chairman, in developing the Veterans
Healthcare Improvement Act of 2007, H.R. 2874 (which the House passed
last July), many of our veterans--especially in the National Guard and
Reserves--live in areas remote from VA facilities and must be provided
reasonable access to needed services as well. Importantly, HR 2874
makes provision for partnering with community mental health centers and
similar providers where VA cannot reasonably provide that care in its
own facilities.
Congress has already established a basic principle that should
guide provision of family mental health services for OIF/OEF veterans.
As reflected in section 1782(a) of title 38, VA should provide
counseling and mental health services to immediate family members when
those services are necessary to support the veteran's treatment. Just
as long-distance travel may make it necessary for VA facilities to
develop sharing agreements or to contract with community partners to
provide veterans needed treatment, VA should look beyond its four walls
in those instances where it lacks adequate staffing or facilities to
provide counseling and related services to family members.
Mr. Chairman, given the importance of outreach and early
intervention to ameliorate the potential for more serious and chronic
mental health problems among OIF/OEF veterans, we urge Congress to
foster the broadest possible efforts to provide counseling, support and
services to meet the war-related mental health needs of veterans'
families.
Ultimately, however, one might ask a broader question: can and
should the Department of Veterans Affairs pursue a broader role than it
has to date in meeting the mental health needs of returning veterans,
and by extension those of their families? Systemwide, VA has not
mounted an effort to engage family members, a particularly striking
lapse in the case of OIF/OEF veterans who are service-connected for
PTSD or other mental health problems. In our view, the Department has
also been timid and unimaginative in looking beyond its own facilities
even to meet OIF/OEF veterans' needs, and has been appropriately
criticized for a largely passive stance in failing to reach out
aggressively to the approximately 500 thousand OIF/OEF veterans and
their families--a population at significant risk of readjustment and
mental health problems--who are not under VA care for any condition.
Despite the limited reach of its facilities in rural America, VA has
only minimally pursued opportunities for partnerships with community
providers of mental health services, resulting in widespread
disparities in access to mental health services. And it has failed to
heed the advice of its expert advisory body, the Special Committee on
PTSD which urged the Department to mount a program of education and
support for all returning veterans and their families. It may be that
such an undertaking is beyond the scope of the Department's capacities,
but--despite widespread and profound national concern regarding the
mental health issues facing many OIF/OEF veterans and their families--
VA has clearly neither budgeted for such an initiative nor, to our
knowledge, reached out to other potential partners (to include its
sister agency, the Substance Abuse and Mental Health Services
Administration) to assist in such an initiative.
Mr. Chairman, we would welcome the opportunity to work with the
Committee to further develop these issues in support of our troops, and
I would be pleased at this time to answer any questions you might have.
Prepared Statement of Suzanne B. Phillips, Psy.D., ABPP, CGP,
Psychologist-Psychoanalyst, Group Therapist, Northport, NY;
Adjunct Professor of Clinical Psychology, C.W. Post Campus,
Brookville, NY, Post-doctoral Faculty, Derner Institute,
Postdoctoral Program in Group Psychotherapy and Psychoanalysis,
Adelphi University, Garden City, NY, on behalf of American Group
Psychotherapy Association, Inc.
I am here today on behalf of the American Group Psychotherapy
Association (AGPA) to address the needs of veterans and their families.
In the aftermath of 9/11, AGPA responded to the needs of a traumatized
population with an extensive number of group programs including those
for bereaved spouses, families, traumatized children, adolescents,
schools, communities, survivors, service delivery workers and uniformed
service personnel. Groups and trainings were conducted in person,
online and via the telephone. In all, AGPA conducted over 600 groups in
group programs providing services to over 5,000 people and trained over
1,500 clinicians in group interventions. What I propose is that many of
these programs have particular relevance to the needs of veterans,
their families and those who work with them. As will be discussed,
group intervention has been shown to be therapeutically effective,
cost-effective and most importantly attends to the restoration of trust
and connection needed in the recovery from trauma (Burlingame,
Fuhriman, & Mosier (2003)).
I. Rationale for Collaboration of the American Group Psychotherapy
Association with The Veterans Administration In Meeting Mental
Health Needs
With more than 3,000 soldiers killed and more than 25,000 wounded
in Iraq and Afghanistan, the mental health needs of those who have
served are considerable (Hoge, Castro, Messer, McGurk, Cotting, &
Koffman, 2004; Hoge, Auchterlonie, & Milliken, 2006). The numbers of
servicemen and women who will eventually seek help for post traumatic
stress dirorder and mental health symptoms, will far outstrip the
Department of Veterans Affairs' professional resources and scope of
services. The American Group Psychotherapy Association (AGPA) is
particularly suited to support the DVA's efforts in terms of expertise
with trauma, group expertise and 9/11 lessons learned as reflected in
programs described and formally published in Group Interventions for
Treatment of Psychological Trauma (Buchele & Spitz, 2004) and Public
Mental Health Service Delivery Protocols: Group Interventions For
Disaster Preparedness And Response (Klein & Phillips, 2008). Drawing
upon such experience AGPA, a national organization for over 60 years
with over 3,000 professional members, can serve as a resource for
consultation, training and/or direct service to address the mental
heath needs of veterans, their families and the clinicians and DVA
personnel who work with them.
Rationale for the Use of Groups with Veterans
The relevance of a group based military initiative that could
incorporate various theoretical models, time phases, sub-groups, and
readjustment issues and needs can be supported from many perspectives.
Historically, each major military conflict has spurred the development
and utilization of group methods to meet the sudden and greatly
increased demand for psychiatric services coupled with the limited
availability of qualified clinicians. The vast numbers of military
casualties suffering from what were previously labeled ``wartime
neuroses'' or ``battle fatigue'' syndromes were treated in groups
following World War II, both in the U.S. and in Britain. The
``Northfield Experiment'' (Northfield Hospital) in England involved the
application of group methods in a hospital setting. These efforts in
turn spurred the development of ``therapeutic communities'' in the U.S.
for providing treatment. Small groups were used for group therapy and
large groups were used to create a therapeutic milieu and to examine
the role and value of capitalizing on and using group dynamics in the
treatment process.
With the Vietnam conflict, we saw the development of ``rap
groups.'' The use of a variety of groups for dealing with trauma began
to grow. More recently, group therapy has been labeled the treatment of
choice for combat trauma since World War II: ``The favored use of group
as a modality is not a matter of economy, but of effectiveness
(Kingsley, 2007, p. 65).''
Theoretically, several reasons underscore the effectiveness of
groups in treating combat disorders. To begin with, traumatic events
isolate and disconnect. They assault a sense of self, safety and the
systems of attachment and meaning to others. Herman (1997) notes that
``Traumatized people feel utterly abandoned, utterly alone, cast out of
the human and divine systems of care and protection that sustain life''
(Herman, 1997, p. 52). Central to the recovery of any trauma victim,
and particularly to the returning veteran, is the need to recover a
sense of trust and connection with self and others. Adding to this,
groups for the military can utilize the ``band of brothers'' mentality
that is central to the cohesion and resilience of military personnel.
Underlying all group interventions is the development of trust and the
communalization of trauma within a cohesive group. Based upon his
extensive work with Vietnam vets, Jonathan Shay (2002) underscores the
importance of group work as a necessary component to all treatment.
According to Shay, people recover in community and although a vet may
need individual treatment, group is seen as a crucial step in the
``reconnection'' needed for recovery. A group offers substantive
validation from an audience that knows and can bear witness--an
audience that can help with the destruction of social trust that often
prevails when someone has survived the chaos of war.
Economically and expeditiously, groups can successfully address the
needs of many simultaneously. Group modalities have been effectively
used with veterans to address specific symptoms as well as the needs of
specific sub-groups within the military populations. PTSD, anger
management, stress management, combat nightmares, etc. have all been
successfully treated using groups (Bolton, Lambert, Wolf, Raja, Varra
and Fisher, 2004; Chemtob, Novaco, Hamada & Gross, 1997; Allen & Bloom,
1994; Brockway, 2005). In addition, group interventions have been used
effectively with sub-groups of African American vets with PTSD and
veterans suffering from war and childhood trauma (Goodman & Weiss,
1998; Jones, Brazel Peskind Morelli & Raskind, 2000). Underscoring the
viability of group intervention post--deployment, Makler, Sigal,
Gelkopf, and Horeb (1990) reported in their work with Israeli soldiers
that group therapy was particularly valuable in dealing with the rage,
guilt, shame, dehumanization, abandonment and betrayal attendant to
combat PTSD. Foy, Glynn, Schnurr, Jankowski, Wattenberg, Weiss, Marmar
& Gusman (2004), who reviewed group treatments with a variety of trauma
populations (sexual assault victims, male combat veterans, multiple
trauma survivors, etc.) with multiple symptom clusters found positive
outcomes in 13 out of 14 published studies.
This body of evidence has led many healthcare providers and
professional organizations to endorse the value of group interventions
for the treatment of PTSD, including the International Society for
Traumatic Stress Studies (ISTSS) (Foa, Keane, & Friedman, 2004).
Similarly, the Iraq War Clinician Guide recommends group models as one
of the viable interventions for addressing PTSD, grief and bereavement,
anger management, and substance abuse, etc. (Schnurr & Cozza, 2004).
Given the number of military personnel and their families seeking
healthcare, and the shortage and overload on military personnel
(American Psychological Association Presidential Task Force on Military
Deployment Services for Youth, Families and Service Members, 2007), the
use of evidence-based group models addresses the economics of mental
health response and the importance of early and timely intervention.
This modality allows for the provision of care for a large number of
individuals while decreasing the demands on clinicians' time. The
opportunity to reach and respond to more servicemen and women and their
families in a timely way with group models that facilitate screening
for higher levels of care, normalization of symptoms, transition and
family re-adjustment as well as treatment for grief, depression, PTSD
or delayed PTSD is likely to reduce the severity and overall duration
of suffering for those returning from war.
Operation Enduring Freedom and Operation Iraqi Freedom have seen
the deployment of more women into active service with combat exposure
than any prior war. The unique needs of this group may be well served
by a modality that offers a venue for dealing with issues of isolation,
distrust, and sexual trauma as well as for affirming resilience and
supporting transition to civilian life. Also at risk are reservists and
guardsmen who, unlike career military, do not have the military
infrastructure to support post-deployment and home-coming issues.
Months or even years after a war or mission, PTSD symptoms may present
or be masked as anger, isolation, family problems, or substance abuse
(Kates, 2001; Meyers, 2003; Schnurr & Cozza, 2004; Shay, 2002). While
Readiness Programs have worked to serve these families, the delay in
combat PTSD underscores the value of different types of group programs
to address personal, marriage and workplace post-deployment needs.
One of the most compelling rationales for using group modalities in
meeting the mental health needs of military is that group experience by
normalization and communization of traumatic symptoms reduces the
barriers to care. Even as symptoms appear, barriers persist to seeking
help in the military. Stigma, fear of being judged, the view of the
self as helpless and weak, and the risk to military careers, make
attending to emotional needs difficult, if not impossible (Hoge, et
al., 2004). The group modality capitalizes on reinstating the integrity
of the ``band of brothers.'' Servicemen and women are not alone in
their reactions or their grief. Whereas there is a natural trauma
bonding that occurs even for civilians who have shared a life--
threatening event, this is even more pronounced with uniformed service
personnel who expect to rely on each other as they face dangerous
situations.
Overall, group interventions have the potential to provide a
structure, reduce shame and helplessness, foster symptom management,
validate traumatic experience, permit ventilation and grief, rebuild
safety and trust, decrease isolation, render meaning and support the
reconnection to self, family, belief systems and society.
Rationale for Use of Programs for Marriages and Families of Veterans
The collateral damage from war is too often the destruction of the
marriages and families of veterans--38% of the marriages of Vietnam
veterans dissolved within 6 months of their return from Southeast Asia.
We are already aware of the difficult homecomings of our veterans from
OIF and OEF. Homecoming is a complicated process. It is difficult to
reverse battlemind mentality. The hypervigilance, mission focus, non-
negotiation, targeted aggression, necessary numbing and use of a weapon
necessary for survival in war does not translate into mutuality and
intimacy in marriages. Similarly the split off grief for loss of
buddies or shame and self-blame for being injured translates into
anxiety, depression and PTSD. Veterans serve bravely and then bring the
war home in the physical wounds and post traumatic stress dirorder
symptoms they bear. Over 29,000 of our veterans have been wounded and
25% of those seen at the DVA have mental health diagnoses. Their
marriages and families are both at great risk and are the greatest
resources they have--Research tells us that the lack of social support
and subsequent life events are variables that put veterans at great
risk for PTSD. Conversely, the strength of close social ties like
marriages and families are the most potent antidotes to the despair and
isolation of Combat stress.
II. Programs and Expertise of the American Group Psychotherapy
Association With Established Effectiveness and Suitability to
the Needs of Veterans, Families and Staff Servicing Them
The American Group Psychotherapy Association has expertise in group
based mental health responses. AGPA provides evidence-based and
supported interventions within pre-existing systems in order to deliver
services efficiently, effectively and insure that the effort can be
sustained into the future. We strive to build expertise and strengthen
infrastructure simultaneous with direct service delivery.
The Association also uses a ``train the trainers'' format whereby
national experts teach others to carry out the work. There are over 30
local and regional affiliates of AGPA positioned to work in their
communities with assistance from a national network of experts. We have
been delivering these programs nationally and internationally in
response to a variety of traumatic events including the events of 9/11,
hurricanes and tsunami, and school violence. Training and service
programs have been delivered in person, online and via the telephone.
An overview of our programs and the populations serviced follows; these
can be tailored to the specific needs of each community, including
military personnel and their families.
For Service Providers/Caregivers: Helpers have an enormous need for
consultation and support in the face of the demands of trauma work.
Military and veteran administration settings are frequently
understaffed with large client populations. The following are program
elements that can be stand-alone or integrated based upon need.
Didactic and experiential group intervention training in
working with trauma, bereavement, the medically ill and more: basic
group dynamics, the elements of responses to trauma, whether for
chronic issues or responding to catastrophic events, as well as in-
depth training in evidence-based group programs.
Support groups and consultation for mental health
professionals and clergy: a key element is the provision of a forum in
which to process their experiences and connect with colleagues.
Groups for other personnel providing trauma-related
services (management, administrators, etc.): a more psycho-educational
orientation for non-clinicians to support the cooperative goals of a
setting requiring multiple areas to cooperate for overall patient care.
Educational programs focusing on self-care: Provides
clinicians, clergy and other helpers with self-care tools to assist
them in their work going forward, increasing their resiliency.
For Active Duty members and their Families: The following programs
have been developed specifically for this community, and can be
modified even further to attend to the differences between service
branches which are specialized populations with unique cultures and
needs for themselves and for their families.
On-site support services at service headquarters:
provides an opportunity to receive care and support in a familiar and
easily accessed setting, such as the military base, VA hospital or
local agency.
``Family Days'' for armed service workers and their
spouses and children: A program model successfully initiated with the
Fire Department of New York Counseling Services Unit (FDNY-CSU), which
provides support and connections for families of those in the service
and for families of deceased service personnel.
Couples programs to provide relationship support: The
Couple Connection Program was initiated in partnership with The FDNY-
CSU; this program is designed to provide support and increase familial
resiliency by strengthening relationships. Couple Connection Program
for Retirees addresses marriage and family issues in the aftermath of
forced retirement due to injury.
Telephone and online consultation with experts in working
with trauma in groups: For those situations and locales when an in-
person visit is not practical or timely (such as for homebound veterans
or those in remote locations). An ongoing group with one's peers can be
an important support providing ongoing connections with peers and an
experienced clinician.
For Children and Adolescents: Children and adolescents are best
helped with programs designed to recognize their differing needs
according to their age and developmental stage, which can be impacted
by the chronic stressors of having a parent(s) on active duty and/or
the loss of a parent.
School-based groups for affected children (with possible
co-leadership with school staff): Provides direct services to children
and is designed to aid the healing and increase the resiliency of
children using the school system (a familiar, naturally occurring
setting with minimal disruption and stigmatization).
School-based training and support for teachers and
guidance counselors: Providing adult caretakers with the tools to
provide the services insures continuation of the program and increases
the community's resiliency.
Groups for affected families (including parents): An
intervention model that provides the family structure with support and
a forum in which to develop coping skills, augment personal resiliency
and strengthen supportive resources. This program works in cooperation
with military institutions, faith based service groups, public service
agencies and schools in order to utilize existing and familiar
community structures. The Going On After Loss (GOALS) program is an
example of this and has potential to be adapted as Going On After War.
Consultation and educational programs for caregivers
(parents, teachers, daycare/after-school workers and others): Another
avenue of providing adult caretakers with skills and tools to attend to
the needs of children.
Program Format Options:
Single Session Public Education Groups--This often
involves a speaker offering information about a selected topic (e.g.
trauma and its impact, the effects of trauma on children and
adolescents, etc.) followed by small group discussion; this format is
highly effective in coping with the stigma attached to mental health
issues as it normalizes responses and feelings.
Time-Limited Groups--A specified number of group
sessions, usually from 10-15, during which membership may be closed, or
open when a ``drop in'' format is used. The goals of these programs are
usually to help work through a specific challenge, avoid relapse and/or
bolster coping and resiliency skills.
Extended Services Groups--Groups extending beyond 15
sessions for those who need more work to recover. Members usually stay
until they have accomplished their goals and are ready to move on.
System Consultation--This usually involves a needs
assessment followed by an intervention tailored to the particular needs
of the organization in question, in conjunction with recommendations on
infrastructure changes to continue to support the program and the
staff/community needs.
Online and Telephone-Based Groups--Trainings and support
groups for both caregivers and the general population are delivered
online and via telephone. These are effective options for the homebound
and those in remote and/or rural locales with minimal or no access to
services.
Printed Materials Available:
Training Curricula
Group Interventions for Treatment of Psychological
Trauma_Ten (10) training modules for mental health professionals who
work with different populations and phases of trauma work. The modules
address: group interventions for adults, children and adolescents;
evidence-based programs for adults, children and adolescents; the later
stage (coping with the aftermath of traumatic events);
countertransference, unique aspects of group work, masked trauma
reactions, and bereavement. PowerPoint's that can be used for training
accompany each module.
Public Mental Health Service Delivery Protocols: Group
Interventions For Disaster Preparedness And Response_A set of
population-specific best practice interventions for use in delivering
mental health services following disasters including Uniformed Service
Personnel (also applicable to the Armed Services), children and
families, school communities, adolescents, survivors, witnesses and
family members, helpers and service delivery workers, organizations and
systems, local community outreach programs, and the role of the
philanthropic community. These protocols, which are group-based and
focus on lessons learned from actual service delivery practices, have
been collaboratively developed with organizations and professionals who
have responded to past disasters, nationally and internationally.
Summaries of the Public Mental Health Service Delivery Protocols are as
follows:
Children and Families Dealing with a Traumatic Event--Maureen Underwood
M.S.W., CGP
Consistent with a strength-based or resilience paradigm, this
protocol uses a family group intervention that acknowledges families'
pain, fear and loss and then identifies and emphasizes strengths and
effective coping. The protocol presented has applicability for use by
faith-based agencies, school districts, disaster mental health agencies
and communities. Drawing upon a pilot program utilized after 9/11 with
families that have lost a father, it is a detailed guideline of a
program that involves a series of community-based psycho-educational
support groups. It includes parallel parent-child interventions
carefully planned in terms of timing, structure, content and group
activities to address trauma and the grief process while restoring and
expanding family stability, communication, coping skills and hope. It
includes suggestions for initial and continuing outreach, criteria for
screening, referrals for additional services, leadership qualifications
and guidelines, and evaluation and research.
Caring for a Traumatized School Community--Toby Chuah Feinson, Ph.D.,
CGP
This module draws upon a school protocol that served as a response
to the traumatized school communities seeking help in the aftermath of
9/11. It delineates a multi-level template that can be adapted to the
needs of diverse school communities. The school protocol presented is
two pronged in that it addresses both the direct and secondary
traumatization in school caregivers as well as the direct
traumatization in children. Described with detail, it involves
training, supporting and supervising school personnel to lead
children's groups, and co-lead children's groups with a trained
facilitator. It is designed to equip school staff with the tools,
skills, guidance, strategies and on-going support to strengthen their
own inner resiliency while expanding their group leadership skills for
taking positive action in the face of children's needs. It offers
guidelines for identification, parent appraisal and permission,
screening for eligibility, selection and pre-group preparation, group
contract and parameters, and developmentally appropriate tasks for
strengthening resiliency, developing emotional insulation and using the
peer group as an agent of change and healing.
Group Treatment with Traumatized Adolescents--Seth Aronson, Psy.D.,
CGP, FAGPA
Group treatment is a particularly appropriate modality for
addressing the impact of trauma on adolescents given that both research
and empirical experience reveal the adolescent peer group to play a
crucial role in development of identity, self-esteem, social-
interpersonal maturation and separation from family of origin. Drawing
upon theory, and clinical material from adolescents groups, this
protocol illuminates the impact of trauma on the developmental tasks of
adolescence, delineating and discussing the steps and issues in setting
up an adolescent trauma group. Issues addressed include proximity of
the traumatic event to the group, match of needs to type of group, the
screening interview, selection and balancing of group members, use of a
group contract, roles and guidelines for leaders, and stages and phases
of group development.
Responding to the Needs of Uniformed Service Personnel--Suzanne B.
Phillips, Psy.D., ABPP, CGP and Nina Thomas, Ph.D., CGP
A comprehensive guide for working with uniformed personnel, it
underscores the importance of understanding the culture, resilience,
command structure, sense of mission, attitude toward injury, perception
of mental health intervention etc. of firefighters, police, emergency
medical services and military. This protocol highlights the pre-
existing group mentality, the ``Band of Brothers,'' as a rationale for
utilizing group response and intervention with uniformed personnel and
emphasizes the goal of ``added value'' and restoring functioning
without pathologizing. Drawing upon theory, research, consultation and
experiences with members of each of the services after 9/11 and with
respect to prior disasters and deployments, it offers responses,
interventions, programs and resources to be utilized across the
timeline of disaster and war.
Lessons Learned in Group Strategies for Survivors, Witnesses and Family
Members--Richard Beck, M.S.W., CGP, FAGPA, Estelle Rauch
M.S.W., CGP, Uri Bergmann, Ph.D., Alexander Broden, M.D., CGP,
Bonnie Buchele, Ph.D., ABPP, CGP, DFAGPA, and Yael Danieli,
Ph.D.
Vignettes of actual 9/11 group interventions are combined with
theoretical expertise in this protocol, which is intended to expand the
skills of previously trained mental health workers. The authors
delineate high risk factors, the impact of trauma on neurochemistry and
the impact of disaster when there has been previous trauma. The
protocol both describes and exemplifies the characteristics of trauma
groups for survivors, witnesses and family members as well as the types
of trauma support groups that can be used across the spectrum of
disaster recovery (short term grief groups, single session groups,
corporate groups etc). Guidelines for groups as well as the role of the
leader are offered.
Support for Disaster Response Helpers and Service Delivery Workers--
Michael Andronico, Ph.D., CGP, FAGPA, Trish Cleary, M.S. CCMHC,
LCPC-MFT, CGP, FAGPA, Felicia Einhorn, LCSW, CGP, Madelyn
Miller, LCSW, ACSW, CGP, Emanuel Shapiro, Ph.D., CGP, FAGPA,
Henry Spitz, M.D., CGP, DFAGPA and Kathleen Ulman, Ph.D., CGP,
FAGPA
This protocol underscores the attention and informed care deserved
by service providers who are affected directly and indirectly and
through shared experience with survivors. Group is recommended as an
intervention that affords a context for sharing challenges,
understanding experiences, sustaining identity, addressing self-care
and supporting a sense of hope often compromised by all that providers
must contain in the face of disaster. The protocol is a comprehensive
guideline for providing group interventions for mental health service
providers and other support workers. Reflecting theoretical
understanding and clinical experience it addresses everything from
suggested time frames to the specifics of group content. It also
includes an extensive set of appendices addressing vicarious
traumatization measures, evaluation tools and group climate measures.
Crisis Intervention at the Organizational Level--Priscilla Kauff,
Ph.D., CGP, DFAGPA and Jeffrey Kleinberg, Ph.D., CGP, FAGPA
This protocol provides a group-centered response to trauma with an
organization as the client. It aims at returning an organization to its
original pre-trauma structure and level of productivity. Recommending
the use of ``clinician consultants,'' highly skilled group therapists
with appropriate theoretical understanding of individuals, groups and
systems, it stresses the needs of the organization as well as the
individual must be addressed if the intervention is to be effective.
Using experience and theoretical perspective, this protocol offers
guidelines for the process of engagement with an organization, needs
assessment, developing a working alliance, establishing a contract with
management that accounts for issues of staff participation, and
clarification of the advantages of a group format. The actual
components of an intervention are detailed (e.g. design, composition,
use of outreach leaders, content of material, decisions re mixing
employees and supervisors) and address services to management,
evaluation, long term relationship with the organization and helping
the helpers.
Local Community Outreach Programs in Response to Disaster--Diane
Feirman, CAE and Randi Cohen, M.S.W., M.A., CGP
This protocol delineates a community outreach model as an effective
means of identifying, establishing and delivering group mental health
interventions in the aftermath of disaster. The protocol is divided
into two sections. The first section offers practical strategies for
implementing an outreach model, i.e. identifying a Community Based
Organization (CBO) as central to the effort, clarifying the role of the
CBO, pairing with other agencies, identifying community needs and
resources etc. The second section describes the actual clinical aspects
of the model. It includes descriptions of the role of a clinical
liaison in initiating and developing outreach possibilities, the
consideration of community outreach across the time frame of disaster
and the possible group interventions used in an outreach model.
The Role of the Philanthropic Community in Disaster Response--Robert
Klein, Ph.D., ABPP, CGP, DLFAGPA and Harold Bernard, Ph.D.,
ABPP, CGP, DFAGPA
This is an integrated set of recommendations for members of the
philanthropic community, with recommendations drawn from the experience
of major contributors to the relief and recovery work following 9/11.
Resonating with the sentiments of Gotbaum, former CEO of the 9/11 fund
that ``the greatest challenge in helping the victims of 9/11 was not
getting the resources--it was working together,'' this protocol fills a
valuable need by recommending specific pre- and post-disaster steps for
philanthropic response, e.g. pre-disaster plans between government and
philanthropic entities. It includes issues for philanthropies'
consideration, such as understanding donors' intent, tailoring efforts
to remain consistent to their mission, accessing communication networks
between and among philanthropies and government agencies and providing
clarity regarding the purpose and criteria for extending financial aid
in the aftermath of disaster and transparency with regard to follow-up
and evaluation.
Public Education Information:
Group Works: What Everyone Should Know About Trauma_a
short brochure geared to the general population which describes what
groups are and how they work, and which contains an insert with
information about responses to traumatic events. Electronic and hard
copy are available, in both English and Spanish.
Clinician Research Tools
CORE Battery-Revised_An assessment toolkit for promoting
optimal group selection, process and outcome.
III. Prior Collaboration between AGPA and Service Providers
When you have the privilege of doing trauma work, when someone
trusts you with their pain, by necessity you enter hazardous terrain.
Aware of the impact on caregivers after 9/11, AGPA provided group
training and curriculum guides to agencies and organizations to prevent
and reduce secondary PTSD and Vicarious Traumatization in clinicians,
spiritual caregivers, First Responders and other service providers.
AGPA has continued to collaborate with agencies and institutions to
provide Care to the Caregivers in initiatives set up in response to
Hurricanes Katrina & Rita, and with First Responder Groups (police,
fire and EMT) in the aftermath of critical incidents and disasters. For
example, a program is planned in April 2008 for Military, First
Responders and clinicians in the aftermath of the California Fires.
IV. Present Collaboration between AGPA and the Department of Veterans
Affairs
Program initiatives for clinicians and staff working with veterans
are presently in process with Houston and San Antonio DVA Departments:
In Houston, Texas, plans are in place for a Basic Group Therapy
Training Course for psychiatric nurses. This will be a 4-month, 24-hour
course specifically designed to build the group therapy skills of DVA
nursing staff assigned to programs in Mental Health Services at Michael
E. DeBakey VA Medical Center, Houston, Texas. Special emphasis is
placed on the unique issues that DVA group therapists face in serving
Veterans and their families in this healthcare facility. The San
Antonio DVA Department is working with a plan to do a needs assessment
of Mental Health Personnel for workshops provided by AGPA. There is
particular interest in trauma group training for ancillary staff (e.g.
dental hygienists and occupational and physical therapists) with a
recognition that in a system all aspects of support for veterans serve
as resources to enhance their recovery. When staff are trained and
understand PTSD, their risk of secondary PTSD is lowered and their
potential to offer ``added value'' to veterans and families is
enhanced.
V. Personal Feedback from Recipients of Programs of the American Group
Psychotherapy Association
Staff Support Group Member:
The facilitators have done an excellent job in providing
counseling to many if not all of the staff members in our
division. Personally, I must admit that at first I was not too
crazy about going to the Wellness Group. I was skeptical and
didn't feel comfortable talking about my issues and
frustrations at the work place. But S. and G. (the therapists)
won me over. Since I have been attending the meetings I have
felt much more relaxed and I look forward to attending every
Thursday meeting. These meetings have helped me both
professionally and personally and I see the difference every
day.
Family Group Member:
My daughter, 7, and I often had the most meaningful
conversations after group. They clearly stemmed from group
topics. I know she is internalizing your messages, when I hear
the following kind of response. I recently told her about 2
boys, ages 8 and 10, whose father died unexpectedly at the age
of 37. I asked her what advice she would give them since she
had been through the same situation. She very naturally replied
that she would say, ``Sometimes life is unfair, but you are
strong and you can get through it. Some days will be bad but
you can still have fun and be happy.
First Responders:
This weekend was wonderful. My husband & I have erected walls
around us & this was a giant step toward knocking them down. It
won't be easy but thank you for giving us tools that we can
use.
Thank you for this opportunity! My husband and I definitely
grew from our experiences here. Couples counseling is extremely
important when dealing with the recent trauma we've
experienced. We all need to support our family unit!
VI. Summary
The last and most difficult stage in the recovery from PTSD is
reconnection to self and others. I ask you to consider that the group
programs and lessons learned by the American Group Psychotherapy
Association in the aftermath of 9/11 hold potential as significant
options for expanding the services to veterans and their families. By
directly including spouses and children in programs, we not only reduce
the impact of PTSD on them, we enhance the recovery of our servicemen
and women. As their families and marriages are their greatest assets,
we make possible the emotional connections that finally bring them
home.
References
American Psychological Association Presidential Task Force on
Military Deployment Services for Youth, Families and Service Members
(2007) The Psychological Needs of U.S. Military Service Members and
Their Families: A Preliminary Report.
Burlingame, G.M., Fuhriman, A.F. & Mosier, J. (2003). The
differentiated effectiveness of group psychotherapy: A meta-analytic
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Bolton, E., Lambert, J., Wolf, E., Raja, S., Varra, A., & Fisher,
L. (2004) Evaluation of a cognitive-behavioral group treatment program
for veterans with post traumatic stress dirorder. Psychological
Services, Vol., No. 2, 140-146.
Brockway, S. (2005) Group treatment of combat nightmares in post
traumatic stress dirorder. Journal of Contemporary Psychotherapy, Vol.
17, No. 4, December 1987. 270-284.
Buchele, B. & H. Spitz (Eds.) (2004), Group Interventions for
Treatment of Psychological Trauma. New York: American Group
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Chemtob, C.M., Novaco, R.W., Hamada, R.S. & Gross, D.M. (1997).
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Foy, D.W., Glynn, S. Schnurr, P., Jankowski, M., Wattenberg, M.,
Weiss, D., Marmar, C., & Gusman, F. (2000) Group Therapy in E.B. Foa,
T.M. Keane, & M.J. Friedman (eds.), Effective treatments for PTSD (pp.
155-175). New York: Guilford Press.
Goodman, M. & Weiss, D. (1998). Double trauma: A group therapy
approach for Vietnam veterans suffering from war and childhood trauma.
International Journal of Group Psychotherapy, 48, (1), 39-53.
Galovski, T. & Lyond, J. (2004). Psychological sequelae of combat
violence: A review of the impact of PTSD on the veterans' family and
possible interventions. Aggression and Violent Behavior, 9, 477-501.
Herman, J. (1997) Trauma and recovery. New York: Basic Books.
Hoge, C. MD, Auchterlonie, J., Milliken C., Mental health problems,
use of mental health services and attrition from military service after
returning from deployment to Iraq and Afghanistan, JAMA. 2006;
295:1023-1032.
Hoge, C., Auchterlonie, J., Milliken, C. (2006) Mental health
problems, use of mental health services and attrition from military
service after returning from deployment to Iraq and Afghanistan, JAMA.
2006;295:1023-1032.
Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D., &
Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health
problems, and barriers to care. The New England Journal of Medicine,
351, 13-22.
Jones, L., Brazel, D., Perkind, E., Morelli, T., & Raskind, M.
(2000). Group therapy program for African-American veterans with post
traumatic stress dirorder. Psychiatric Services, 51(9), 1177-1179.
Kates, A.R. (2001). Copshock: Surviving posttraumatic stress
dirorder (PTSD). Tuscan: Hillbrook Street Press.
Kingsley, G. (2007) Contemporary Group Treatment of Combat-Related
post traumatic stress dirorder. Journal of the American Academy of
Psychoanalysis and Dynamic Psychiatry, 35(1), 51-69.
Klein, R. and S.B. Phillips (Eds.), (2008) Public Mental Health
Service Delivery Protocols: Group Interventions for Disaster
Preparedness and Response. New York: American Group Psychotherapy
Association.
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Combat-related, chronic post traumatic stress dirorder: Implications
for group-therapy intervention. American Journal of Psychotherapy, Vol.
XLIV (3), 381-395.
Meyers, S.L. (2003, June 21). Battlefield aid for soldiers'
battered psyches. The New York Times, pp. A1, A8.
Schnurr, P., & Cozza, S. (Eds.). (2004). Iraq war clinician guide.
(Second Edition). Washington, D.C.: Department of Veterans Affairs,
National Center for PTSD.
Shay, J. (2002). Odysseus in America: Combat trauma and the trials
of homecoming. New York, New York: Scribner.
Prepared Statement of Scott N. Sundsvold, Assistant Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
The American Legion appreciates this opportunity to share its views
on mental health treatment for families of veterans. Mr. Chairman, in
order to ensure this nation's veterans receive a complete continuum of
care, families of those injured must receive the most appropriate
treatment to understand, accommodate, and transition with the veteran.
When military personnel are deployed, the families are the most
tangible source of trust and disclosure. They are affected by the
letters, emails and phone calls from those deployed. Although they
aren't the actual personnel deployed, their love and care of those who
are in the way of danger may indeed cause permanent stress related
issues. When their loved one returns from deployment, there is yet
another possible stressor, the transition from military duty to
civilian life.
Department of Defense and Seamless Transition
According to a 2005 Department of Defense (DoD) Survey of Health-
Related Behaviors among Military Personnel (DSHRB), 74 percent of
active duty personnel cope with stress by talking with a friend or
family member. Spouses and family members are often the first to
recognize when service-members require assistance.
The National Defense Authorization Act for Fiscal Year (FY) 2006
directed the Secretary of Defense to establish a Task Force to examine
issues relating to mental health and the Armed Forces and create a
report containing an assessment of, and recommendations for improving,
the effectiveness of mental health services provided to members of the
Armed Forces.
The report's introduction spoke on this nation's involvement in the
Global War on Terrorism (GWOT) and the unforeseen demand on military
members and their families. It was also stressed that DoD must expand
its capabilities to support the psychological health of its service
members and their families.
According to the Task Force, data from the Post-Deployment Health
Re-Assessment indicate that 38 percent of Soldiers and 31 percent of
Marines report psychological symptoms. Among members of the National
Guard, the figure rises to 49 percent; that includes Air Force, Army,
and Navy. It further reported psychological concerns were significantly
higher among those with repeated deployments.
There were also psychological concerns among family members of
deployed and returning Operation Iraqi Freedom and Operation Enduring
Freedom (OIF/OEF) veterans, in addition to the hundreds of thousands of
children being affected by the deployment of a parent. The vision of
this group of professionals was to also ensure service-members and
their families receive a full continuum of excellent care in both
peacetime and wartime, but particularly when service members have been
injured or wounded in the course of duty.
In June 2007, The Defense Health Board Task Force on Mental Health
released the report titled, ``An Attainable Vision''. This report
derived from the Task Force's visits throughout the military community
at 38 installations worldwide. According to the Task Force, the
Military Health System lacked the fiscal resources and personnel to
fulfill its mission to support psychological health.
Mr. Chairman, these findings also imply that if the treatment was
insufficient during the military member's term of service, the
veteran's issues don't vanish upon entry into the civilian community
and they often affect the family as well.
However, the Task Force did make several recommendations to improve
care for service members and their families, to include, ensuring a
full continuum of excellent care for service members and their
families, underlined by, continuity of care, which is often disrupted
during transitions among providers, as well as filling gaps in the
continuum of care for psychological health and addressing which
services are offered, where services are offered, and who receives
services, especially since the entire family are military health care
beneficiaries.
The findings and recommendations reported by the Task Force suggest
an elevation of family involvement in mental health treatment. When
transitioning from military to civilian life, veterans and their
families' full continuum of care should not be stifled by excluding
this proven effective treatment.
Department of Veterans Affairs
Currently, the VA does not have the authority to include veterans'
family members in treatment for mental health concerns. The American
Legion is in agreement with the statement by Secretary of Defense,
Robert M. Gates, who stated, ``care for our wounded must be our highest
priority.'' This statement includes those affected both mentally and
physically.
According to the Task Force report, the cost of mental illnesses
extends beyond discharge from military service. Of the 686,306 OIF/OEF
veterans separated from active duty service between 2002 and 2006 who
were eligible for VA care, 229,015 or 33 percent accessed care at a VA
healthcare facility. Of those 229,015 veterans who accessed care since
2002, approximately 83,889 received a diagnosis of or were evaluated
for a mental disorder, including post traumatic stress dirorder, non-
dependent abuse of drugs, and depressive disorder. With the enactment
of Public Law 110-181, OIF/OEF veterans' access to free VA healthcare
has been extended from 2 years to 5 years. Therefore, additional
potential mental health patients can be expected.
There was also a recognized need for extensive family involvement
in the long-term process of rehabilitation and community reintegration,
to include close involvement of families in the recovery process, as
well as greater responsiveness in the treatment of family members'
needs.
Vet Centers as an Example
The VA's Vet Centers, created in 1979, were designed to provide
services exclusively for veterans who served in theaters of conflict or
experienced trauma within the military.
In 2007, The American Legion conducted site visits to various Vet
Centers throughout this nation, to include Puerto Rico.
During these visits, it was reported that successful services
provided ranged from marriage/couple's counseling to reunion
debriefings. However, no mental health services for family members were
provided. Also offered was family therapy for veterans suffering from
mental illnesses, ensuring that the veteran's immediate support network
is prepared to care for and cope with the veteran's mental health
issues, but no mental health support for the veteran's immediate family
members.
The success of services provided within VA and their satellite
facilities as they relate to veterans and their families should be
extended, to include mental health treatment for family members to
fully ensure a complete and successful transition into the community.
Conclusion
The DoD and VA have initiated steps to integrate programs for
treating service-members who suffer from mental illnesses. To ensure
treatment is consistent, the VA's Office of Seamless Transition
assigned case managers at major Military Treatment Facilities to
identify and assist service-members whose care will be extended to the
VA. Currently, a memorandum of agreement (MOA) between DoD and VA
provides referrals to VA Medical facilities for health care and
rehabilitation for those who have sustained spinal cord injury (SCI),
Traumatic Brain Injury (TBI), and blindness.
Mr. Chairman, to ignore the need for mental health support for
family members invalidates the meaning of ``full continuum of care.''
The American Legion urges Congress to appropriate sufficient funds for
VA to ensure comprehensive mental health services are available to
veterans and their family members.
Mr. Chairman and Members of the Committee, The American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you to improve the lives of America's veterans
and their families. Thank you.
Prepared Statement of Joy J. Ilem, Assistant National Legislative
Director,
Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this hearing to consider care and support programs by the
Department of Veterans Affairs (VA) for personal caregivers of severely
disabled veterans, with a special focus on examining the need to
provide mental health treatment for family members of veterans dealing
with serious physical injuries and/or post-deployment readjustment
issues. We are pleased to appear before the Subcommittee today to
discuss this timely and important topic.
Mr. Chairman, as an organization of 1.3 million service-disabled
veterans, DAV has a growing concern about the effects of wartime
exposures we are seeing in the newest generation of disabled veterans
of the wars in Iraq and Afghanistan. Reflecting the current challenges
in military service, specifically, frequent multiple deployments for
many service members, and the stress-related mental health conditions
resulting from wartime experiences and inadequate rest between
deployments, we believe these disabled veterans and their families have
some new and unique needs that Congress should address to enable VA to
begin meeting them.
Many severely wounded and disabled veterans require continuous and
intensive family caregiver support that may last from a few months to
many years, to a lifetime depending on individual circumstances. In
most of these cases, a spouse, parent or other family member, or
significant other assumes the role of primary caregiver, often leaving
behind jobs, college or other personal goals and responsibilities. The
impact of service-related polytraumatic injuries and mental health
problems exact a severe toll not only on the veteran but on military
and veteran family members as well. Currently VA has limited authority
to provide caregiver assistance, counseling and related services but
lacks a comprehensive and cohesive program to ensure these families
receive adequate support. The one exception is VA's spinal cord injury
program, which we believe could serve as an excellent model for
polytraumatic injured veterans and their families.
In that exceptional program, family members of spinal cord injured
veterans are properly educated and trained to deal with symptoms of,
and how to live with someone who has experienced this type of
devastating injury. This type of program could easily be adapted to
veterans who have polytrauma including Traumatic Brain Injury (TBI),
post traumatic stress dirorder (PTSD,) depression and/or anxiety
disorders, substance-use disorders, and other post-deployment mental
health problems. If left untreated, these conditions can destroy
marriages and ultimately separate families, and even result in
homelessness and criminal convictions. When such breakdowns occur,
these disabled veterans have the potential to become more dependent on
VA and other public agencies to provide substitute services, with
higher costs and more social consequences for them and society as a
whole. Likewise, during this transitional period caregivers themselves
are at risk for stress-related mental health disorders and adverse
physical health effects. For this reason, we support and recommend that
Congress authorize, and VA should be required and funded to provide, a
full range of psychological and social support services as an earned
benefit to family caregivers of severely injured and ill veterans. At a
minimum, this benefit should include relationship and marriage
counseling, family counseling, technical training and related
assistance for the families coping with the stress and continuous
psychological burden of caring for a severely injured or permanently
disabled veteran. VA should provide such services at every medical
center and substantial community-based outpatient clinic. When
warranted by circumstances, these services should be made available
through other means, including the use of telemental health technology
and the Internet. When necessary because of scarcity or rural access
challenges, VA's local adaptations should include consideration of the
use of competent, trained community providers on a fee or contract
basis to address the needs of these families.
We note that in December 2007, VA announced that it would dedicate
$4.7 million to help caregivers through a variety of caregiver
assistance pilot programs at VA medical centers across the country.
These programs are intended to help expand and improve healthcare
education and provide needed training and resources for caregivers who
assist disabled and aging veterans in their homes. VA reported the key
services provided to caregivers are: transportation, respite care, case
management and service coordination, assistance with personal care
related to activities of daily living, social and emotional support,
and home safety evaluations. VA also notes that caregivers are taught
skills such as time management techniques, medication management,
communication skills with the medical staff and the veteran, and ways
to take better care of themselves. We are pleased that VA has initiated
these important programs and we look forward to a report on their
effectiveness and consumer satisfaction rates. We recommend that VA
expeditiously develop a long-term comprehensive program based on the
best-practices garnered from these pilot programs. We are encouraged
that many of the projects use technology, including computers, Web-
based training, video conferencing and teleconferencing to support the
needs of caregivers who often cannot leave their homes to participate
in support activities.
Gaps in services and the issue of more fully addressing the needs
of caregivers has also been discussed in the President's Commission on
Care for America's Returning Wounded Warriors (Dole/Shalala) and the
Veterans Disability Benefits Commission (VDBC). Recommendations from
these Commissions include: extending TRICARE coverage for respite and
aid and attendance benefits for seriously injured service members;
extending the Family Medical Leave Act coverage to family members of a
veteran who has a combat-related injury; the need for additional
caregiver training and counseling for family members of seriously
injured veterans; extension of the Civilian Health and Medical Program
of the Department of Veterans Affairs or CHAMPVA program and creation
of a ``caregiver allowance'' for caregivers of severely injured
disabled veterans.
The main direct health benefit that accrues to family members of
seriously disabled veterans is through CHAMPVA. This program provides
health insurance coverage for immediate dependent family members of
veterans with disabilities that are permanent and total in nature, and
survivors of veterans who die from service-connected disabilities,
provided they are not eligible for health benefits under the Department
of Defense (DoD) TRICARE program. Within CHAMPVA the so-called in-house
treatment initiative or ``CITI'' program allows family members to use
VA medical centers for their care on a voluntary basis, but we
understand this program has been nearly phased out in most areas due to
lack of available capacity. Other than CHAMPVA, care for immediate
family members is limited to care or treatment that furthers treatment
goals for veterans under VA care, and bereavement counseling for
dependent survivors of a servicemember who dies on active duty. Travel
and transportation benefits are restricted to dependents who are
CHAMPVA beneficiaries, and to immediate family members receiving
counseling, treatment or education on behalf of a veteran who has a
service-connected disability. As noted in the VDBC recommendations,
expansion of the CHAMPVA program could benefit primary caregivers of
veterans with lower rated service-connected conditions such as mild to
moderate TBI but who need constant supervision of a caregiver to help
with personal care, daily living skills, attending medical and
rehabilitation appointments and emotional and advocacy support.
As direct caregivers, immediate family members of severely injured
or ill veterans of Operations Iraqi and Enduring Freedom (OIF/OEF) face
daunting challenges while serving in this unique role. They must cope
simultaneously with the complex physical, emotional and mental health
issues of the severely wounded or ill veteran, plus deal with the
complexities of the systems of care that these veterans must rely on.
At the same time, they struggle with disruption of family life,
interruptions of personal and professional goals, employment, and
dissolution of other ``normal'' support systems that existed
beforehand--all because of the changed circumstances resulting from the
veteran's injuries and illnesses. We discussed these challenges in the
Family and Caregiver Support Issues Affecting Severely Injured Veterans
section of the Independent Budget for FY 2009 and refer the
Subcommittee to that section for more detail.
Beyond the need for mental health services for family caregivers we
agree that as early as practicable every family of a severely injured
or ill veteran from OIF/OEF should be assigned a trained, knowledgeable
and professional advocate. The advocate's essential function should
coordinate military, VA and other federal programs that provide
services, benefits and family support services, including inpatient,
specialty and primary care, mental healthcare and counseling for
veterans and, where needed, family caregivers--rehabilitation,
transition and community reintegration assistance, home care, respite
care, vocational services, financial services, and child care services.
The advocate should be assigned to support each severely disabled
veteran for as long as services are required for the family. We note
VA's appointment of 100 ``patient advocate'' positions and recent
announcement of the appointment of 10 ``recovery coordinators,'' and
appreciate this development and urge additional personnel be assigned
to such duties for recently separated disabled veterans as necessary.
However, unless a restructured more flexible system of benefits for
caregivers is authorized by Congress, we are concerned that these
advocates and recovery coordinators may not focus on family-support
issues to the extent warranted by their situations.
DAV believes that a strong case management system should be
designed to promote a smooth and transparent handoff of severely
injured and ill veterans and their family caregivers between DoD and VA
facilities. This case management system should be held accountable to
ensure uninterrupted support as these veterans return home, when and
where family caregivers become their critical link to VA services.
With the wars in Iraq and Afghanistan the demographics, family
dynamics and cultural expectations of disabled veterans and their
families have changed--and so too should the VA benefits and services
package. A severely injured veteran's spouse is likely to be young,
have dependent children, and reside in a rural area where access to
support services of any kind can be limited. An increasing number of
the severely injured are from Reserve components. Their families likely
have never lived on military bases and do not have access to the
numerous and often vibrant social support services and networks
connected with military life, such as the DoD Family Advocacy Program.
That program, available only to active duty personnel, pays for
counseling for military service members, for services such as
counseling for school truancy of their children, provides a variety of
counseling and care services for emotional and behavioral problems
within families, and is a source of emotional support to families at
home during service members' long deployments overseas. Many parents
and siblings are included in pre- and post-deployment counseling and
reintegration programs by the military services advocacy centers.
However, no equivalent VA program exists for veterans, even severely
service-disabled veterans. While the circumstances of a military family
during deployments are dissimilar to that of families of severely
disabled veterans, the changed conditions in these families warrant a
new program with similar aims: to care for and comfort these families,
and provide relevant and specialized support and counseling services
when they need them.
As indicated earlier in this testimony, spouses must often give up
their own employment (or withdraw from school in many cases) to care
for, attend, and advocate for the seriously injured or ill veteran.
This can have a direct impact on their long-term earnings capacity for
retirement and other benefits. Caregivers also often fall victim to
bureaucratic mishaps in the shifting responsibility for conflicting
government pay and compensation systems (military pay, military
disability pay, military retirement pay, VA disability compensation and
Social Security Disability benefits) that they must rely upon for
subsistence in absence of other personal income or savings.
Additionally, for many younger, unmarried disabled veterans their
primary caregivers remain their parents, who have limited eligibility
for military assistance, often are on limited incomes themselves, and
have very limited eligibility for VA benefits or services of any kind.
They, too, face the same dilemmas as spouses of severely injured or
disabled veterans, and we believe Congress should also address the
needs of parents who have returned to the basic caregiver role for
their severely injured or ill children.
Immediate family caregivers (including parents in many cases) must
cope with tremendous personal stress. Unfortunately, the government
support systems they may need are limited or restricted, often
informal, and are clearly inadequate for the long term. Within the
military itself, TRICARE mental health benefits are reported to be
inadequate. In VA, the spouse of an enrolled veteran is eligible for
limited VA mental health services and counseling but only as a so-
called ``collateral'' of the veteran. Outside the VA's readjustment
counseling services program or VET Centers--such services are
infrequent across the VA healthcare system. We understand that one
place mental health services are being provided for family members are
at VA polytrauma centers. VA clinicians indicate that they are
providing a significant amount of training, instruction and counseling
to spouses and parents of severely wounded or ill veterans who are
already attending to these veterans during their hospitalizations.
However, local VA officials are concerned about the absence of legal
authority to provide these services to family members, and that scarce
resources that are needed elsewhere are being diverted to these needs,
without recognition in VA's internal resource allocation system. Thus,
medical centers devoting resources to family caregiver support are
penalizing themselves in doing so, but they clearly have recognized the
urgency of this need and are trying to meet it, despite these concerns.
We believe Congress must provide clear permanent authority in the law
so that these services can be provided throughout the system when
needed.
The most seriously injured or ill veterans and their families
embark on a very long and often difficult journey together. Without
question--these family caregivers are the unsung heroes. We recognize
that family support is critical to a veteran's successful
rehabilitation; therefore, these families need training and support so
they do not become overwhelmed with responsibilities in caring for
these extraordinary veterans. We believe our recommendation has equal
applicability to families faced with extreme physical challenges as
well as those who are challenged by mental illness following wartime
service. To this end, VA should establish a specialized respite pilot
program that includes a dual track initiative for severely disabled
veterans and family members. The goal would be to furnish training for
family members in the skills necessary to facilitate optimal recovery,
particularly for younger, severely injured or ill veterans. Recognizing
the tremendous disruption to their lives, the pilot program should
focus on helping the veteran and other family members restart their
lives (the true definition of ``rehabilitation'') after surviving
devastating injuries or life-changing illnesses. The track for the
veteran should focus on rehabilitation and coping skills while an
integral part of this program should include family counseling and
family peer groups so they can share solutions for the set of common
problems they face.
Today, VA's system for providing needed rest or respite care for an
immediate family caregiver, generally is governed by local VA nursing
home care unit (NHCU) and adult day healthcare (ADHC) policies. We
mention this program because we believe that respite care is a
necessary mental health benefit for caregivers. Understandably, these
programs are targeted to older veterans with chronic illnesses, because
the elderly veteran population has been a primary enrollee in VA
healthcare. Nevertheless, many veterans who have survived horrific
injuries in Iraq and Afghanistan, or bear the long-term mental scars of
that combat experience, are still in the early parts of their lives.
Thus, VA's NHCU and ADHC programs usually do not include a
rehabilitative component and therefore remain unattractive to many OIF/
OEF veterans' families. These programs need to be adapted or
supplemented with new approaches or model of care to become more
acceptable and attractive to this latest generation of disabled war
veterans and their families. Caregivers have indicated that they must
feel comfortable when they are leaving the veteran during the respite
period and want to be assured their loved one is receiving quality
care. We note that one of the VA caregiver pilot programs mentioned
above offers 24-hour in-home respite care to temporarily relieve
caregivers up to 14 days a year. This kind of service--offered in the
home--may be an optimal setting for many severely disabled veterans.
We believe VA should establish a new national program to make
periodic and age-appropriate respite services available to all severely
injured or disabled veterans who need it. This program should be
designed to meet the needs of younger, severely injured or ill
veterans, as contrasted with the generally older veteran population now
served by VA programs. Where appropriate VA services cannot be made
available directly because of geographic barriers, VHA should develop
contractual relations with appropriate, qualified private or other
public facilities to provide respite services tailored to this
population's needs. We appreciate the new authority Congress provided
for VA to furnish age-appropriate nursing home programs for younger
veterans, in section 1707 of the National Defense Authorization Act for
Fiscal Year 2008. Nevertheless, we believe that family caregivers need
more assurance that VA will also be available to help them actively
care for, and will provide appropriate respite periods, as they take on
this lifetime challenge of care-giving responsibility.
Based on this testimony and given the nature of these issues, and
the unique situation that confronts our newest generation of severely
disabled war veterans, DAV believes Congress and the Administration
need to address a number of observed deficits, at least those discussed
above, to make a family caregiver's support role more manageable over
the long term. This is in the best interests of these families, whose
absence as personal caregivers and attendants for these seriously
disabled veterans would mean even higher costs to the government to
assume total responsibility for their care, and would lower the quality
of life for the very veterans for whom VA was established to care for.
To summarize, we urge the Subcommittee to develop legislation or
oversight that would accomplish the following goals:
Provide a full range of psychological and social support
services as a benefit to family caregivers of veterans with severe
service-connected injuries or illnesses including relationship and
marriage counseling, family counseling, and related assistance to the
family coping with the inevitable stress and often discouragement
attendant to caring for the severely disabled veteran.
Appoint accountable advocates and case managers to each
severely injured or ill veteran's family, empowered to assist with
medical benefits and family support services, including vocational
services, financial services, and child care services.
Publish clear policies requiring every VA nursing home
and Adult Day Healthcare Program to provide appropriate facilities and
programs for respite care for severely injured or ill veterans.
Facilities should be restructured to be age-appropriate, with strong
rehabilitation goals suited to the needs of a younger veteran
population, rather than expect younger veterans to blend with the older
generation typically resident in VA NHCUs and ADHC programs.
As we have indicated in prior Independent Budgets and in testimony
before this Subcommittee, we believe that VA must continue to adapt its
services to the particular needs of this new generation of disabled
veterans, and not simply require these veterans to accept what services
are currently available. Likewise, such services should also be
improved and available for previous generations of veterans with
similar disabilities. In this matter of family assistance, VA will also
need to make a cultural change from a system that focuses only on the
needs of a veteran patient to one that embraces the challenges of
family caregiving.
Mr. Chairman, this concludes my testimony on behalf of DAV. We hope
you will consider our recommendations and develop legislation to deal
with family caregiver issues for severely disabled veterans. I will be
pleased to address any questions you or other Members of the
Subcommittee may wish to ask.
Prepared Statement of Fred Cowell, Senior Health Analyst,
Paralyzed Veterans of America
Mr. Chairman, and members of the Subcommittee, the Paralyzed
Veterans of America (PVA) appreciates this opportunity to present its
views and recommendations concerning how the U.S. Department of
Veterans Affairs (VA) can best assist veterans with mental illness by
providing counseling and education services to their families.
Mr. Chairman, evidence is growing that the prevalence of mental
illness is high in veterans who served in Iraq and Afghanistan. Combat
exposure coupled with long and frequent deployments are associated with
an increased risk for post traumatic stress dirorder (PTSD) and other
forms of mental illness. VA reports that Operation Iraqi Freedom and
Operation Enduring Freedom (OIF/OEF) veterans have sought care for a
wide array of possible co-morbid medical and psychological conditions,
including adjustment disorder, anxiety, depression, PTSD, and the
effects of substance abuse. VA reported that of the 299,585 separated
OIF/OEF veterans who have sought VA healthcare since fiscal year 2002,
a total of 120,049 unique patients had received a diagnosis of a
possible mental health disorder. Almost 60,000 enrolled OIF/OEF
veterans had a probable diagnosis of PTSD, almost 40,000 OIF/OEF
veterans have been diagnosed with depression, and more that 48,000
reported nondependent abuse of drugs.\1\
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\1\ Department of Veterans Affairs, VHA Office of Public Health and
Environmental Hazards. ``Analysis of VA Healthcare Utilization Among
U.S. Global War on Terrorism (GWOT) Veterans: Operation Enduring
Freedom, Operation Iraqi Freedom,'' January 2008.
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The impact of a veteran's mental illness is far reaching and
obviously has serious consequences for the individual veteran being
affected. However, less obvious are the serious consequences, stemming
from a veteran's mental illness, that confront his/her spouse, their
children and other family members. Families of veterans provide the
most basic support network for returning veterans. Spouses of veterans
are usually the first to identify readjustment issues, and they are
usually the best advocates for guiding the veteran into professional
care. However, to provide correct guidance on treatment these family
members must have a basic understanding of VA mental health resources
and how to access them. This understanding can only come from
comprehensive VA family counseling and education services.
Additionally, spouses and other family caregivers who provide love,
support and assistance to the veteran must also cope with tremendous
personal stress as well. Unfortunately, VA's Mental Illness family
support services are limited or restricted. PVA believes that Congress
should formally authorize, and VA should provide, a full range of
psychological and social support services as an earned benefit to
family caregivers of severely injured and ill veterans.
Family counseling support services that are needed by recently
returning OIF/OEF veterans are only available, on a limited basis in
VA, despite the increasing need for such services. For example, in the
most recent survey of soldiers and marines in Iraq, which included a
large number of reservists, 20 percent of soldiers and 13 percent of
marines indicated that they were planning a divorce, double the rate
found just two years ago.\2\ Additionally, in a recent anonymous survey
of Maine National Guard members, after repatriation from deployments,
36 percent acknowledged relationship problems with a spouse and/or
children.\3\ Despite this information few VA medical centers or VA
community-based outpatient clinics provide any marital and/or family
counseling.
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\2\ Office of the Surgeon Multinational Force--Iraq (OMNF-I) and
Office of the Surgeon General United States (OTSG), U.S. Army Medical
Command, Mental Health Advisory Team (MHAT-IV), Operations Iraqi
Freedom 05-05 Final Report, 17 November 2006.
\3\ Wheeler, E. Self-Reported Mental Health Status and Needs of
Iraq Veterans in the Maine Army National Guard. Community Counseling
Center, 2007 (unpublished).
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Mr. Chairman, VA's Vet Center program has a long history of
treating the mental health needs of America's veterans. Family
counseling is provided when possible and as needed for the adjustment
of the veteran. However, veteran's families represent the ``frontline''
of the support network for returning veterans. PVA believes, a
veteran's successful mental health treatment often depends on the
stability and understanding of his/her family unit. Therefore, PVA
believes that VA should expand its support services for veteran's
families. We support expansion of mental health services for veterans
and counseling/education services for families in all VA major care
facilities. However, in the near term, Vet Centers should increase
coordination with VA medical centers to accept referrals for family
counseling; increase distribution of outreach materials to family
members with tips on how to better manage the dislocation; improve
reintegration of combat veterans who are returning from deployment; and
provide information on identifying warning signs of suicidal ideation
so veterans and their families can seek help with readjustment issues.
PVA believes that an effective VA mental illness family counseling/
education program can improve treatment outcomes for veterans,
facilitate family communication, increase understanding of mental
illness, increase the use of effective problem solving and reduce
family tension.\4\ PVA agrees with VA's Family Mental-Health Learning
Program (FaMHeLP) when it says, ``Working with family members helps
both veterans and their families. Research has shown that family
members of veterans with mental illness are happier when they fully
understand the nature of the illness. Family members also want to learn
the best ways to help their loved ones. Family members are often in a
good position to help because they know the veteran better than anyone
else. Veterans do better in their daily lives at home and work when
they live with family members who understand their illness. These
veterans are also less likely to have a mental health crisis.''
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\4\ FaMHeLP, North Florida/South Georgia Veterans Health System
(NF/SGVHS) Psychology Service. For more information contact: Jennifer
W. Adkins, Ph.D., Psychology Service (352) 246-1420 or Sheryl A.
Conner, Ph.D. LCSW, Social Work Service (352) 246-1282.
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PVA strongly believes that VA must embrace new models of support
for the families of this generation of combat veterans. Family
counseling support services that are needed by recently returning OIF/
OEF veterans must be expanded. The spouse of a veteran with combat
related mental illness is likely to be young, have dependent children,
and reside in a rural area where access to support services of any kind
can be limited. It is additionally possible that other individuals who
play significant roles in the veteran's life such as, mom and dad, the
significant other, the best friend, a brother or sister or a paid
personal care attendant will also require access to these services.
Whether the caregiver resides in an urban or rural setting, VA mental
health services for veterans and services for veteran's family or
caregivers members must be readily available.
PVA also believes Congress should formally authorize, and VA should
provide, a full range of psychological and social support services as
an earned benefit to family members of severely injured and ill
veterans. At a minimum this benefit should include education on mental
illness, relationship and marriage counseling, family VA benefit
counseling, and related assistance for the family coping with the
stress and continuous psychological burden of caring for a severely
injured or mentally ill veteran.
As this Subcommittee moves forward with deliberations on how best
to provide services to the families of veterans with mental illness it
may be worth reviewing VA progress regarding section 214 of Public Law
109-461. Section 214 required VA to implement a pilot program to assess
and improve caregiver assistance services. Public Law 109-461 required
the VA Secretary to carry out the pilot over a 2-year period within 120
days following enactment of Public Law 109-461. Caregiver assistance
referred to VA services that would assist caregivers such as:
adult-day care
coordination of services needed by veterans, including
services for readjustment and rehabilitation
transportation services
caregiver support services, including education,
training, and certification of family members in caregiver activities
home care services
respite care
hospice services and other modalities of non-
institutional VA long-term care
This list of services is part of VA's basic benefit package and is
available to all enrolled veterans. PVA believes that the availability
of these long-term care benefits should be a part of any family
counseling/education program under consideration. Public Law 109-461
authorized $5,000,000 for each of fiscal years 2007 and 2008 to carry
out the pilot project. PVA has made inquiries to VA regarding the
status of the pilot project but has yet to receive a detailed briefing
of the projects progress.
Finally, Mr. Chairman, PVA has over 60 years of experience
understanding the complex needs of spouses, family members, friends and
personal care attendants that love and care for veterans with lifelong
medical conditions. Additionally, because some PVA members with spinal
cord injury also have a range of co-morbid mental illnesses, we know
that family counseling and condition specific education is fundamental
to the successful reintegration of the veteran into society. Our
experience has shown that when the veteran's family unit is left out of
the mental illness treatment plan veterans with spinal cord injury who
also have mental health conditions experience lifelong reoccurring
medical and social problems. However, when family counseling/education
services are provided by VA, veterans are more apt to become
independent and productive members of American society.
Mr. Chairman, I would like to thank you again for the opportunity
to address this important subject. This concludes my statement. I will
be happy to answer any questions that you may have.
Prepared Statement of Thomas J. Berger, Ph.D., Chairman,
National PTSD and Substance Abuse Committee,
Vietnam Veterans of America
Mr. Chairman, Ranking Member Buyer, and other distinguished members
of this Subcommittee, Vietnam Veterans of America (VVA) appreciates the
opportunity to present our views on the need for the Department of
Veterans Affairs (VA) to provide mental health assistance and treatment
within VA medical centers for family members of veterans. VVA thanks
you for your concern and leadership about the mental healthcare of our
veterans' families, and in seeking out the views of veterans' service
organizations on this very important, timely, and relevant issue.
As you are well aware, one of the recommendations of the Dole-
Shalala Commission was to ``significantly strengthen support for
families.'' This will not be an easy task, but VVA believes this
hearing can serve as the opening dialog on a very serious concern.
As more and more troops return home damaged emotionally and
mentally as well as physically, their families must contend not only
with the shock of seeing the physical desolation of their loved ones,
but come to grips with the new reality of their lives, which have
changed dramatically, and not for the better. Take for example a 35-
year-old soldier or Marine with two children who returns home with what
is diagnosed as Traumatic Brain Injury (TBI). His impairment affects
the future of the entire family. His, or her, spouse and children have
to deal with his/her inability to concentrate, the mood swings,
depression, anxiety, even the loss of employment. As you can imagine,
the economic and emotional instability of a family can be as terrifying
and as real as any difficulty focusing or simply waking and crying in
the middle of the night. In cases of severely brain-damaged casualties,
spouses, parents, and siblings may be forced to give up careers,
forsake wages, and reconstruct homes to care for their wounded
relatives rather than consign them to the anonymous care at a nursing
home or assisted living facility.
VVA believes that the mental health stresses of war may be even
greater for the families of those serving in the National Guard or
Reserves in that deployment of these individuals often results in
dramatic losses of income along with numerous legal and family
complications affecting the children. These can include domestic
violence and substance abuse. In addition, unlike family members of
active-duty military who often have an established support system
available to them on base, family members of Guard and Reserve troops
must often struggle to create their own systems of support.
There will be cries that the VA medical facilities (with the
notable exception of the VA VET CENTERS operated by the Readjustment
Counseling Service) are not authorized to provide mental health
treatment for the families of veterans. You will also hear that neither
the military nor the VA (including the Vet Centers) has the
organizational capacity or personnel resources to provide such. In
addition, you will hear that there are issues about the intensity and
drains of vitally needed family support that will be hard to sustain,
as well as significant issues regarding the complexity of other medical
and specialized needs that have to be addressed simultaneously with the
mental health needs. All of this was true last year. However in
calendar year 2007, thanks largely to the leadership of this Committee,
Chairman Spratt, and Chairman Obey as well as the Speaker of the House
more than $11 Billion was infused into the VA system, mostly for
healthcare. Unfortunately this is only a start, albeit a very good
start, toward restoring/building the organizational capacity needed to
properly take care of veterans of every generation who have earned the
right to healthcare by virtue of their service to country in uniform.
Frankly, much in the way of proper diagnosis of mental health in
the veteran does not transpire on the primary care teams because those
teams at many facilities are seeing too many veterans per clinician to
be able to do the kind of thorough job of which they are capable. We
need a funding level for the Veterans Health Administration that is
significantly above the Administration's request, by at least $3
Billion (and that is just for health care).
VVA believes that many of these logistical and organizational
challenges can be overcome through legislation that authorizes
partnerships between the VA and professional mental health
organizations (such as the National Council for Community Behavioral
Healthcare, which represents 1,400 community-based mental health
programs), as is already suggested in H.R. 2874, the Veterans'
Healthcare Improvement Act of 2007, and its companion bill S. 38, the
Veterans' Mental Health Outreach and Access Act of 2007. A model of
such a collaborative partnership involving the VA, the Maine National
Guard, and the Community Counseling Center, a local behavioral
healthcare provider, has been in operation since 2006 in Portland,
Maine, and has achieved positive results. The example of what is
happening in Connecticut is another model of the type of creative
partnerships and very effective and useful work that can be done when
VA does not insist on having total bureaucratic control over all of the
activities and care delivery in which they may play some role.
Vet Centers
Certainly, the experience at the Vet Centers, where families of
veterans are in fact part of the therapeutic milieu, illustrates the
importance and efficacy of providing counseling for family members.
This can and ought to be extended, considering the current reality of
too many of our troops returning to our shores discombobulated
mentally, and too many family members frustrated and seemingly impotent
about what to do to help them. Last year there was $20 million added to
the VA budget for additional Vet Center staff in the Emergency War
Supplemental Appropriation that was never spent to hire an additional
250 fulltime qualified clinicians in the existing Vet Centers, as
directed in that legislation. Since the Readjustment Counseling Service
did not receive the $20 million from OMB and the business office at VA
Central office in time to hire any staff, what they did with the money
was to purchase vehicles to do much more rural outreach, and do some
long overdue computer enhancements.
VVA understands that the 100 non-clinician peer counselors that
work for the Vet Centers have been converted to permanent positions,
and that the Vet Centers have finally hired an additional 62 clinicians
for existing centers since last summer. However, that is not nearly
enough when you are talking about more than 200 service delivery
points. If the Vet Centers are going to be able to utilize those
vehicles to do much needed rural outreach and satellite sessions for a
day per week at remote sites without taking away from the veterans
currently being served by an overworked staff, then they need to hire
additional personnel in the Readjustment Counseling Service. Why has
the VA continued to refuse to hire adequate staff in the Vet Center
system to meet the continually growing demand?
VVA is frankly puzzled as well as frustrated by this inaction on
the part of the most senor leadership of the Veterans Health
Administration (VHA), as the Vet Centers are our forward aid stations
in regard to suicide prevention, PTSD, and readjustment counseling
needs of combat veterans of every generation, but particularly those
returning home today from Iraq and Afghanistan.
The Vet Centers are also the most studied of any VA program, and
have consistently proved to be the most cost efficient, cost effective
medical program operated by VA. They by and large do great work, AND
they can serve the families as well. However, they can't do it unless
VA will use some of the ``new'' additional funds to expand the size of
the clinical staff of the Vet Centers.
Joint Hearings
It may be time to do a joint hearing with the authorizing and/or
the appropriations Committees that oversee the Federal dollars that go
to local community mental health programs, in order to see if there can
be incentive funds made available for those centers to better serve the
families of those returnees (as well as the families of those families
while the service member is deployed).
Frankly, these citizens are in need now, and there are significant
Federal dollars that flow through the Governors to these local
communities. Because these problems are due to Federal service of the
service member, it is only right that the funds from Health and Human
Services (HHS) be increased specifically for this purpose. VVA stresses
that these should be ``fenced'' funds that can only be used for this
specific purpose of acquiring proper PTSD clinicians and family
counselors, and training/re-training of existing staff of community
mental health centers. VA must be mandated to fully cooperate and to
provide training where possible to community leaders/clinicians.
This distinguished panel can make a difference by promoting the
process of healing--of veteran and family member in a way that has
never been done before if there is cooperation across the jurisdictions
of the Congress.
I thank you for affording VVA the opportunity to present our views,
and thank you for what you are doing to assist veterans and their
families. I will be pleased to answer any questions you may have.
Prepared Statement of Todd Bowers, Director of Government Affairs,
Iraq and Afghanistan Veterans of America
Mr. Chairman, ranking member and distinguished members of the
committee, on behalf of Iraq and Afghanistan Veterans of America, and
our thousands of members nationwide, I thank you for the opportunity to
testify today regarding the mental health needs of military families. I
would like to point out that my testimony today does not reflect the
views of the United States Marine Corps. I am here testifying today in
my civilian capacity as the Director of Government Affairs for Iraq and
Afghanistan Veterans of America.
In my 10-year career as a Marine reservist, I have had the honor of
serving in Iraq twice. When I returned home from my tours, I realized
that combat deployments are hard on members of the Armed Services, but
they are even more difficult for military families.
My family was no different. During my second tour in Iraq, I was
wounded when a sniper's bullet impacted the scope on top of my rifle.
Fragments of the bullet are still lodged in my face today, a constant
reminder of how lucky I was on that hot October day in Fallujah. The
circumstances surrounding my injury were so fantastic that I knew my
parents would eventually hear about the incident. My command, and
myself, felt it was important that I contact my family via satellite
phone to inform them of what had happened. While this was the correct
decision, I knew the impact on my loved ones would be tremendous. Over
the phone I told my mother, ``You can hear my voice. I'm alright.''
But the incident that physically wounded me wounded my mother much
worse. She had a difficult time understanding what had happened. In her
own words: ``I never knew why someone would want to shoot my Todd.''
While I was completing my tour in Iraq, my mother needed help at home.
My family lives far from the reserve center that I deployed from, and
was not involved with any formal family counseling groups. Her only
contact with fellow military families was via email or phone. As she
struggled to cope with the knowledge of my injury, my mother was more
than alone, she was lost. She sought assistance through the only means
she was aware of, the mental health counseling covered by her own
health coverage.
For the 1.6 million veterans of Iraq and Afghanistan, the stresses
of deployment hit home. As the Committee knows, rates of psychological
injuries among new veterans are high and rising. According to the VA
Special Committee on PTSD, at least 30 to 40% of Iraq veterans, or
about half a million people, will face a serious psychological injury,
including depression, anxiety, or PTSD. Data from the military's own
Mental Health Advisory Team shows that multiple tours and inadequate
time at home between deployments increase rates of combat stress by
50%. These deployments, the Mental Health Advisory Team has concluded,
also put families under tremendous strain; 27% of soldiers and Marines
in Iraq are reporting marital problems.
Marital Problems Among Soldiers in Iraq
[GRAPHIC] [TIFF OMITTED] T1373A.004
Over the course of the war, troops have reported growing concerns
about marital infidelity. Twenty-seven% of soldiers now admit they are
experiencing marital problems, and 20% of deployed soldiers say they
are currently planning a divorce.
Source: Mental Health Advisory Team IV Final Report.
It is not only marriages that are being tested; more than 155,000
children have parents currently deployed in support of the wars in Iraq
and Afghanistan, and 700,000 children have had a parent deployed at
some point during the conflicts, according the American Psychological
Association. According to the Pentagon, almost 19,000 children have had
a parent wounded, and 2,200 children have lost a parent in Afghanistan
or Iraq.
There are not yet conclusive numbers on divorce rates among Iraq
and Afghanistan veterans. But the signs of family strain resulting from
mental health injuries are clear. In a recent VA study of new veterans
referred to VA specialty care for a behavioral health evaluation, two-
thirds of married or cohabiting veterans reported some kind of family
or adjustment problem. Twenty-two percent of these veterans were
concerned that their children ``did not act warmly'' toward them or
``were afraid'' of them. Among those veterans with current or recently
separated partners, 56% reported conflicts involving ``shouting,
pushing or shoving.'' Moreover, a May 2007 study in the American
Journal of Epidemiology has suggested that deployments have also led to
a dramatic increase in the rates of child abuse in military families.
For all of these reasons, concrete action is necessary to ensure
that troops, veterans, and their families have access to mental
healthcare. In the media and in Congress, IAVA has been at the
forefront of efforts to improve military and veteran families' access
to treatment for psychological injuries.
This year, I am proud to announce that IAVA has partnered with the
Ad Council, the nonprofit organization responsible for some of
America's most effective and memorable public service campaigns,
including ``A Mind is a Terrible Thing to Waste,'' ``Only You Can
Prevent Forest Fires,'' and ``Friends Don't Let Friends Drive Drunk.''
This summer, the Ad Council and IAVA will launch a multi-year campaign
to destigmatize mental healthcare for servicemembers and their
families. The broadcast, print, web and outdoor ads will encourage
those who need it to seek mental healthcare and inform all Americans
that seeking help is a sign of strength rather than weakness. We are
very excited to partner with Ad Council to help get troops, veterans,
and their families the care they need and deserve.
Mental health and support for veterans' families are also key
components of IAVA's 2008 Legislative Agenda. One of IAVA's six
legislative priorities this year is new funding to combat the shortage
of mental health professionals. The VA must be authorized to bolster
its mental health workforce with adequate psychiatrists, psychologists
and social workers to meet the demands of returning Iraq and
Afghanistan veterans, including funding for Vet Centers to alleviate
staffing shortfalls. While IAVA applauds the VA initiative to hire new
Iraq and Afghanistan veterans as ``Outreach Coordinators,'' as of April
2007, VA numbers show that more than half of the 200-plus Vet Centers
need at least one more psychologist or therapist. IAVA also supports
the creation of new VA programs to provide family and marital
counseling for veterans receiving VA mental health treatment. For the
many military and veteran families who, unlike my family, are among the
47 million uninsured Americans, this may be their only access to the
mental healthcare that they need to cope with the effect of the wars on
their families.
I thank you for providing me the opportunity to testify before you
this afternoon. All the data and IAVA recommendations I have cited are
available in our Mental Health report and our Legislative Agenda. I
have brought copies of our Legislative Agenda, and our report on Mental
Health with me today for your convenience. It would be my pleasure to
answer any questions you may have for me at this time.
[The IAVA report entitled, ``Mental Health Injuries, the Invisible
Wounds of War,'' January 2008, will be retained in the Committee files.
The report can be downloaded from the IAVA Web site at: http://
www.iava.org/documents/Mental_
Health.pdf.]
Prepared Statement of Kristin Day, LCSW, Chief Consultant,
Care Management and Social Work Service, Office of Patient Care
Services,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and members of the Subcommittee. Thank
you for the opportunity to discuss mental health treatment for families
and the Department of Veterans Affairs' (VA's) efforts to support those
who support our veterans. I am accompanied by Dr. Ira Katz, Deputy
Chief, Patient Care Services Officer for Mental Health in the Veterans
Health Administration (VHA) and Dr. Alfonso Batres, Director of the
Readjustment Counseling Service. I would like to request my statement
be submitted for the record.
VA supports caregivers, including caregivers of wounded or ill
veterans, by providing assessment, counseling and training related to
the caregiver's ability to provide adequate care. Specifically, this
includes education about the veteran's illness or disability, either
mental or physical, and referral to community agencies for services VA
is unable to offer. We offer visits to assess the adequacy of the home
environment and the need for home equipment or modifications and can
offer the same for vehicles. VA can contract for adult day healthcare
up to eight hours per day, five days per week to allow family members
to leave home for work or leisure.
As more fully described below, VA provides limited services to
immediate family members, which includes: members of the immediate
family, the legal guardian of a veteran, or the individual in whose
household the veteran certifies an intent to live. The law provides in
general that the immediate family members of a veteran being treated
for a service-connected disability, may receive counseling, education,
and training services to the veteran's family in support of that
treatment. We diligently extend these services under those
circumstances. Likewise, if a veteran is receiving hospital care for a
non-service connected disability, VA is authorized to provide those
services, as are necessary in connection with that treatment, if the
services were initiated during the veteran's hospitalization and their
continuation on an outpatient basis is essential to permit the
discharge of the veteran from the hospital. Outside of our hospital
system, VA's Vet Centers also provide family counseling to family
members in furtherance of a post-combat veteran's successful
readjustment to civilian life.
A number of caregiver and family support groups also meet with
family members at our facilities to address caregiver burnout or
depression. In so doing they help address the individual counseling
needs of family members that fall beyond VA's limited caregiver
authority. Thankfully, many veterans remain independent in the
community because of neighbors, friends, and others who step in and
provide assistance when family members cannot.
VA supports the families of our veterans every day, but we must
continue to adjust not merely to clinical advances, but to demographic
ones as well. The aging of our veteran population also represents
unique challenges, and we are working with community-based resources to
respond to their needs.
Our Voluntary Service continues to provide needed support and
guidance. Generous donations to VA Voluntary Services by Veterans
Service Organizations, businesses, and other organizations allow VA to
assist families with temporary lodging, free or discounted meals,
transportation, and entertainment for veterans' family members, among
other such needs.
The Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) is a comprehensive health care program in
which VA shares the cost of covered health care services and supplies
with eligible beneficiaries. CHAMPVA provides coverage, provided the
dependents are not otherwise eligible for DoD TRICARE benefits, to the
spouse or widow(er) and to the children of a veteran who is rated
permanently and totally disabled due to a service-connected disability,
was rated permanently and totally disabled due to a service-connected
condition at the time of death, died of a service-connected disability,
or died on active duty. CHAMPVA provides broad health coverage and
includes a $50 annual deductible and 25% co-payment for services.
Turning to specific VHA program areas, family members of patients
in our Polytrauma System of Care are actively engaged by VA clinicians
and staff regarding treatment decisions, discharge planning, and
therapy sessions, as appropriate, so they can help their loved one
learn to be as independent as possible when he or she returns home. The
designated traumatic brain injury (TBI) and Polytrauma case manager
assigned to every veteran and active duty service members receiving
care in VA's Polytrauma System of Care coordinates support-efforts to
match the needs of each family.
Over the past few years, VA Mental Health Services includes
families in over 500,000 units of service. This includes involvement of
families in mental health evaluations, participation in treatment
planning, and collaboration in monitoring treatment outcomes. Families
can be seen when their involvement is included in a treatment plan
designed to benefit the veteran, as discussed above. One example is
family psycho-education, an intervention providing information to
families about the patient's illness and training on how to respond to
symptoms and problem behaviors. Although the intervention is with the
family, research strongly supports the benefits to the veteran.
In August 2007, VHA selected eight caregiver assistance pilot
programs across the Nation at total cost of approximately $5 million.
The goal of these pilots is to explore options for providing support
services for caregivers in areas where such services are needed and
where there are few other options available.
In addition, a new position in the VHA Care Management and Social
Work Service has been created to develop a more systemic approach to
serving caregivers. The position of Caregiver Support National Program
Manger has just been filled. This individual will spearhead an internal
interdisciplinary Advisory Group tasked with developing educational
tools and training modules to assist VA staff in supporting our
caregivers as they support our veterans.
In October 2007, VA partnered with the Department of Defense (DoD)
to establish the Joint VA DoD Federal Recovery Coordinator Program
(FRCP). VA hired an FRCP Director, a FRCP Supervisor and eight Federal
Recovery Coordinators (FRCs) in December 2007. The FRCs are currently
deployed to Water Reed and Brook Army Medical Centers as well as
National Navel Medical Center at Bethesda. Two additional FRCs are
currently being recruited and will be stationed at Brook Army Medical
Center and Balboa Naval Medical Center in San Diego. The FRCP is
intended to serve all seriously injured service members and veterans,
regardless of where they receive their care. The central tenet of this
program is close coordination of clinical and non-clinical care
management for severely injured service members and their families
across the lifetime continuum of care.
As briefly alluded to above, Vet Centers, administered by VA's
Readjustment Counseling Service, provide family counseling for
military-related problems that negatively affect the veteran's
readjustment to civilian life. Indeed, within the context of the Vet
Center service model, families are central to the combat veteran's
care. Family members are usually the first to realize the effects of
possible war-related problems, especially among National Guard and
Reserve members. Effective intervention through preventive family
education and counseling helps many returning veterans stabilize their
post-military family lives.
Veterans who served in a combat theater are eligible for
readjustment counseling, even if they have not enrolled for health care
benefits. Family services at our Vet Centers are not time limited and
are available as necessary for the veteran's readjustment throughout
the life of the veteran. Vet Centers have full latitude to
professionally include family members in the treatment process as long
as this is aimed at post-war readjustment for the veteran. Spousal
counseling groups are conducted at many Vet Centers to help spouses
cope more effectively with the veteran's war-related problems,
including PTSD, substance use, depression, anxiety disorders, grief,
anger management, social alienation, unemployment, or other conditions.
Professional family readjustment counseling at Vet Centers is
provided by licensed social workers, psychologists, and nurse
psychiatric clinical specialists with additional professional training
for marriage and family counseling. In locations where a Vet Center
does not have staff with expertise in family counseling, our teams
provide clinical assessments, preventive behavioral health education,
basic counseling, and referrals to local VA or other qualified family
counselors in the community. These Vet Centers are well-networked with
local human service providers.
In the event a service member dies while on active duty, Vet
Centers provide bereavement services to the surviving family members.
Between 2003 and the end of FY07, Vet Centers have assisted 1,713
family members and 1,136 families of fallen service members, 807 (71%)
of whom were in-theater casualties in Iraq or Afghanistan.
VHA works diligently to support veterans, their families and their
caregivers. Often without the support of these dedicated family and
friends many veterans would not be able to maintain their independence
or their preferred community-based lifestyle.
Thank you again for the opportunity to appear here today. My
colleagues and I would be happy to answer any questions you may have.
Statement of Barbara Cohoon, Deputy Director,
Government Relations, National Military Family Association, Inc.
Chairman Michaud and Distinguished Members of this Subcommittee,
the National Military Family Association (NMFA) would like to thank you
for the opportunity to present testimony today on the mental health
needs for families who support our veterans. We thank you for your
focus on the many elements necessary to ensure quality mental health
care for our wounded/ill/injured service members, veterans, and the
families who care for them as they transition for care between the
Department of Defense (DoD) and the Department of Veterans Affairs (VA)
health care systems.
NMFA will discuss on several issues of importance to wounded/ill/
injured service members, veterans, and their families in the following
subject areas:
1. Wounded Service Members Have Wounded Families
2. Who Are the Families of Wounded Service Members?
3. Caregivers
4. Mental Health
Wounded Service Members Have Wounded Families
Transitions can be especially problematic for wounded/ill/injured
service members, veterans, and their families. NMFA asserts that behind
every wounded service member and veteran is a wounded family. Spouses,
children, parents, and siblings of service members injured defending
our country experience many uncertainties. Fear of the unknown and what
lies ahead in future weeks, months, and even years, weighs heavily on
their minds. Other concerns include the wounded service member's return
and reunion with their family, financial stresses, and navigating the
transition process from active duty and the DoD health care system to
veteran and the VA health care system.
The two agencies' health care systems should alleviate, not
heighten these concerns, and provide for coordination of care that
starts when the family is notified the service member has been wounded
and ends with the DoD and VA working together to create a seamless
transition as the wounded service member transfers between the two
agencies' health care systems and eventually from active duty status to
veteran status.
NMFA congratulates Congress on the National Defense Authorization
Act for Fiscal Year 2008 (NDAA FY08), especially the Wounded Warrior
provision, in which many issues affecting this population were
addressed. We also appreciate the work DoD and the VA have done in
establishing the Senior Oversight Committee (SOC) to address the many
issues highlighted by the three Presidential Commissions. Many of the
Line of Action items addressed by the SOC will help ease the transition
for active duty service members and their families to life as a veteran
and civilian. However, more still needs to be done. Families are still
being lost in the shuffle between the two agencies. Many are moms,
dads, siblings who are unfamiliar with the military and its unique
culture. There is certainly more work to be done by DoD and the VA. We
urge Congress to establish an oversight Committee to monitor DoD and
VA's partnership initiatives, especially with the upcoming
Administration turnover and the disbandment of the SOC early this year.
Who Are the Families of Wounded Service Members?
In the past, the VA and the DoD have generally focused their
benefit packages for a service member's family on his/her spouse and
children. Now, however, it is not unusual to see the parents and
siblings of a single service member presented as part of the service
member's family unit. In the active duty, National Guard, and Reserves
almost 50 percent are single. Having a wounded service member is new
territory for family units. Whether the service member is married or
single, their families will be affected in some way by the injury. As
more single service members are wounded, more parents and siblings must
take on the role of helping their son, daughter, sibling through the
recovery process. Family members are an integral part of the health
care team. Their presence has been shown to improve their quality of
life and aid in a speedy recovery.
Spouses and parents of single service members are included by their
husband/wife or son/daughter's military command and their family
support and readiness groups during deployment for the Global War on
Terror. Moms and dads have been involved with their children from the
day they were born. Many helped bake cookies for fund raisers, shuffled
them to soccer and club sports, and helped them with their homework.
When that service member is wounded, their involvement in their loved
one's life does not change. Spouses and parent(s) take time away from
their jobs in order travel to the receiving MTF (Walter Reed Army
Medical Center or the National Naval Medical Center at Bethesda) and to
the follow-on VA Polytrauma Centers to be by their loved one. They
learn how to care for their loved one's wounds and navigate an often
unfamiliar and complicated health care system.
It is NMFA's belief the government, especially the DoD and VA, must
take a more inclusive view of military and veterans' families. Those
who have the responsibility to care for the wounded service member must
also consider the needs of the spouse, children, parents of single
service members and their siblings, and the caregivers. We appreciate
the inclusion in the NDAA FY08 Wounded Warrior provision for health
care services to be provided by the DoD and VA for family members as
deemed appropriate by each agencies' Secretary. According to the
Traumatic Brain Injury Task Force, family members are very involved
with taking care of their loved one. As their expectations for a
positive outcome ebb and flow throughout the rehabilitation and
recovery phases, many experience stress and frustration and become
emotionally drained. The VA has also called for recognition of the
impact on the veteran when the caregiver struggles because of their
limitations. NMFA recommends DoD and VA include mental health services
along with physical care when drafting the NDAA FY08's regulations.
NMFA recently held a focus group composed of wounded service
members and their families to learn more about issues affecting them.
They said following the injury, families find themselves having to
redefine their roles. They must learn how to parent and become a
spouse/lover with an injury. Each member needs to understand the unique
aspects the injury brings to the family unit. Parenting from a
wheelchair brings on a whole new challenge, especially when dealing
with teenagers. Reintegration programs become a key ingredient in the
family's success. NMFA believes we need to focus on treating the whole
family with programs offering skill based training for coping,
intervention, resiliency, and overcoming adversities. Parents need
opportunities to get together with other parents who are in similar
situations and share their experiences and successful coping methods.
DoD and VA need to provide family and individual counseling to address
these unique issues. Opportunities for the entire family and for the
couple to reconnect and bond as a family again, must also be provided.
The impact of the wounded/ill/injured on children is often
overlooked and underestimated. Military children experience a
metaphorical death of the parent they once knew and must make many
adjustments as their parent recovers. Many families relocate to be near
the treating Military Treatment Facility (MTF) or the VA Polytrauma
Center in order to make rehabilitation process more successful. As the
spouse focuses on the rehabilitation and recovery, older children take
on new roles. They may become the caregivers for other siblings, as
well as for the wounded parent. Many spouses send their children to
stay with neighbors or extended family members, as they tend to their
wounded/ill/injured spouse. Children get shuffled from place to place
until they can be reunited with their parents. Once reunited, they must
adapt to the parent's new injury and living with the ``new normal.''
Brooke Army Medical Center has recognized a need to support these
families and has allowed for the system to expand in terms of
guesthouses co-located within the hospital grounds. The on-base school
system is also sensitive to issues surrounding these children. A warm,
welcoming family support center located in Guest Housing serves as a
sanctuary for family members. Unfortunately, not all families enjoy
this type of support. The VA could benefit from looking at successful
programs like Brooke Army Medical Center's who have found a way to
embrace the family unit during this difficult time. NMFA is concerned
the impact of the injury is having on our most vulnerable population,
children of our military and veterans.
Caregivers
Caregivers need to be recognized for the important role they play
in the care of their loved one. Without them, wounded service members
and veterans' quality of life, such as physical, psycho-social, and
mental health, would be significantly compromised. They are viewed as
an invaluable resource to VA health care providers because they tend to
the veteran's needs on a regular basis. And, their daily involvement
saves VA health care dollars in the long run. According to the VA, ``
`informal' care givers are people such as a spouse or significant other
or partner, family member, neighbor or friend who generously give their
time and energy to provide whatever assistance is needed to the
veteran.'' The VA has made a strong effort in supporting veterans'
caregivers.
So far, we have discussed the initial recovery and rehabilitation
and the need for mental and health care services for family members.
But, there is also the long-term care that must be addressed.
Caregivers of the severely wounded, ill, and injured service members
who are now veterans, such as those with severe traumatic brain injury
(TBI), have a long road ahead of them. In order to perform their job
well, they must be given the skills to be successful. This will require
the VA to train them through a standardized, certified program, and
appropriately compensated for the care they provide. The VA currently
has eight caregiver assistance pilot programs to expand and improve
health care education and provide needed training and resources for
caregivers who assist disabled and aging veterans in their homes. These
pilot programs are important, but there is a strong need for 24-hour
in-home respite care, 24-hour supervision, emotional support for
caregivers living in rural areas, and coping skills to manage both the
veteran's and caregiver's stress. These pilot programs, if found
successful, should be implemented by the VA as soon as possible and
fully funded by Congress. However, one program missing is the need for
adequate child care. Veterans can be single parents or the caregiver
may have non-school aged children of their own. Each needs the
availability of child care in order to attend their medical
appointments, especially mental health appointments. NMFA encourages
the VA to create a drop-in child care for medical appointments on their
premises or partner with other organizations to provide this valuable
service.
NMFA has heard from caregivers the difficult decisions they have to
make over their loved one's bedside following the injury. Many don't
know how to proceed because they don't know what their loved one's
wishes were. The time for this discussion needs to take place prior to
deployment and potential injury, not after the injury had occurred. We
support the recent released Traumatic Brain Injury Task Force
recommendation for DoD to require each deploying service member to
execute a Medical Power of Attorney and a Living Will. We encourage
this Subcommittee to talk to their Congressional Armed Service
Committee counterparts in requesting DoD to address this issue because
the severely wounded, ill, and injured along with their caregivers will
eventually be part of the VA system.
NMFA strongly suggests research on veterans' families, especially
children of wounded/ill/injured OIF/OEF veterans; standardized
training, certification, and compensation for caregivers; individual
and family counseling and support programs; a reintegration program
that provides an environment rich for families to reconnect; and an
oversight Committee to monitor DoD's and VA's continued progress toward
seamless transition.
Mental Health
As the war continues, families' needs for a full spectrum of mental
health services--from preventative care and stress reduction
techniques, to individual or family counseling, to medical mental
health services--continue to grow. The military offers a variety of
mental health services, both preventative and treatment, across many
helping agencies and programs. However, as service members and families
experience numerous lengthy and dangerous deployments, NMFA believes
the need for confidential, preventative mental health services will
continue to rise. It is important to note if DoD has not been effective
in the prevention and treatment of mental health issues, the residual
will spill over into the VA health care system. The need for mental
health services will remain high for some time even after military
operations scale down and service members and their families'
transition to veteran status. The VA must be ready. They must partner
with DoD in order to address mental health issues early on in the
process and provide transitional mental health programs. They must
maintain robust rehabilitation and reintegration programs for veterans
and their families that will require VA's attention over the long-term.
The Army's Mental Health Advisory Team (MHAT) IV report links the
need to address family issues as a means for reducing stress on
deployed service members. The team found the top non-combat stressors
were deployment length and family separation. They noted that Soldiers
serving a repeat deployment reported higher acute stress than those on
their first deployment and the level of combat was the key ingredient
for their mental health status upon return. The previous MHAT report
acknowledged deployment length was causing higher rates of marital
problems. Given all the focus on mental health prevention, the study
found current suicide prevention training was not designed for a
combat/deployed environment. Recent reports on the increased number of
suicides in the Army also focused on tour lengths and relationship
problems. These reports demonstrate the amount of stress being placed
on our troops and their families and the level of stress they will
bring with them as they become veterans. Is the VA ready? Do they have
adequate mental health providers, programs, outreach, and funding?
Better yet, where will the veteran's spouse and children go for help?
Who will care for them now that they are no longer part of the DoD
health care system? Many will be left alone to care for their loved
one's invisible wounds left behind from frequent and long combat
deployments.
DoD's Task Force on Mental Health stated timely access to the
proper mental health provider remains one of the greatest barriers to
quality mental health services for service members and their families.
Access for mental health care, once they are wounded/ill/injured,
further compounds the problem. Families want to be able to access care
with a mental health provider who understands or is sympathetic to the
issues they face. The VA has ready available services. The Vet Centers
are an available resource for veterans' families providing adjustment,
vocational, and family and marriage counseling. Vet Centers are located
throughout the United States and in geographically dispersed areas,
which provide a wonderful resource for our most challenged veterans and
their families, the National Guard and Reserves. These Centers are
often felt to remove the stigma attributed by other institutions.
However, they are not mandated to care for veteran or wounded/ill/
injured military families. The VA health care facilities and the
community based outpatient clinics (CBOCs) have a ready supply of
mental health providers, yet regulations restrict their ability to
provide mental health care to veteran's caregivers unless they meet
strict standards. Although NMFA supports the Independent Budget
Veterans Service Organizations (IBVSOs) recommendations to expand
family counseling in all VA major care facilities; increase
distribution of outreach materials to family members; improve
reintegration of combat veterans who are returning from a deployment;
and provide information on identifying warning signs of suicidal
thoughts so veterans and their families can seek help with readjustment
issues. NMFA believes this is just a starting point for mental health
services the VA should offer families of severely wounded service
members and veterans. NMFA recommends Congress require Vet Centers and
the VA to develop a holistic approach to veteran care by including
their families, as deemed appropriate by the Secretary of Veterans
Affairs, in providing mental health counseling and programs.
Thousands of service member parents have been away from their
families and placed into harm's way for long periods of time. Military
children, the treasure of many military families, have shouldered the
burden of sacrifice with great pride and resiliency. We must not forget
this vulnerable population as the service member transitions from
active duty to veteran status. Many programs, both governmental and
private, have been created with the goal of providing support and
coping skills to our military children during this great time of need.
Unfortunately, many support programs are based on vague and out of date
information. You ask, why should the Veterans' Affairs Committee be
interested in military children?
Given the concern with the war's impact on children, NMFA has
partnered with RAND Corporation to research the impact of war on
military children with a report due in April 2008. In addition, NMFA
held its first ever Youth Initiatives Summit for Military Children,
``Military Children in a Time of War'' last October. All panelists
agreed the current military environment is having an effect on military
children. Multiple deployments are creating layers of stressors, which
families are experiencing at different stages. Teens especially carry a
burden of care they are reluctant to share with the non-deployed parent
in order to not ``rock the boat.'' They are often encumbered by the
feeling of trying to keep the family going, along with anger over
changes in their schedules, increased responsibility, and fear for
their deployed parent. Children of the National Guard and Reserve face
unique challenges since there are no military installations for them to
utilize. They find themselves ``suddenly military'' without resources
to support them. School systems are generally unaware of this change in
focus within these family units and are ill prepared to look out for
potential problems caused by these deployments or when an injury
occurs. Also vulnerable are children who have disabilities that are
further complicated by deployment and subsequent injury. Their families
find stress can be overwhelming, but are afraid of reaching out for
assistance for fear of retribution on the service member. They often
choose not to seek care for themselves or their families.
NMFA encourages the VA to partner with DoD and have them reach out
to those private and nongovernmental organizations who are experts in
their field on children and adolescents to identify and incorporate
best practices in the prevention and treatment of mental health issues
affecting our military children. At some point, these children will
become children of our Nation's veterans. We must remember to focus on
preventative care upstream, while still in the active duty phase, in
order to have a solid family unit as they head into the veteran's phase
of their lives.
NMFA is especially concerned with the scarcity of services
available to the families as they leave the military following the end
of their activation or enlistment. They may be eligible for a variety
of health insurance programs, such as TRICARE Reserve Select, TRICARE,
or VA. Many will choose to locate in rural areas where there may be no
mental health providers available. We ask you to address the distance
issues families face in linking with mental health resources and
obtaining appropriate care. Isolated veterans and their families do not
have the benefit of the safety net of services and programs provided by
MTFs, VA facilities, CBOCs, and Vet Centers. NMFA recommends the use of
alternative treatment methods, such as telemental health; modifying
licensing requirements in order to remove geographical practice
barriers that prevent mental health providers from participating in
telemental health services outside of a VA facility; and, as the VA
incorporates Project Hero, to educate civilian network mental health
providers about our military culture.
The VA must educate their health care and mental health
professionals, along with veterans' families of the effects of mild
traumatic brain injury (TBI) in order to help accurately diagnose and
treat the veteran's condition. Veterans' families are on the ``sharp
end of the spear'' and are more likely to pick up on changes
contributed to either condition and relay this information to VA
providers. VA mental and health care providers must be able to deal
with polytrauma--post traumatic stress dirorder (PTSD) in combination
with multiple physical injuries. NMFA appreciates Congress establishing
a Center of Excellence for TBI and PTSD. Now with the new Center, it is
very important DoD and VA partner in researching TBI and PTSD. Also,
the VA needs to educate their civilian health care providers on how to
identify signs and symptoms of mild TBI and PTSD.
Because the VA has as part of its charge ``to care for the widow
and the orphan,'' NMFA was concerned about reports that many Vet
Centers may not have the qualified counseling services they needed to
provide promised counseling to survivors, especially to children. DoD
and the VA must work together to ensure surviving spouses and their
children can receive the mental health services they need, through all
of VA's venues. New legislative language governing the TRICARE
behavioral health benefit may also be needed to allow TRICARE coverage
of bereavement or grief counseling. While some widows and surviving
children suffer from depression or some other medical condition for a
time after their loss, many others simply need counseling to help in
managing their grief and help them to focus on the future. Many have
been frustrated when they have asked their TRICARE contractor or
provider for ``grief counseling'' only to be told TRICARE does not
cover ``grief counseling.'' Available counselors at military hospitals
can sometimes provide this service and certain providers have found a
way within the reimbursement rules to provide needed care, but many
families who cannot access military hospitals are often left without
care because they do not know what to ask for or their provider does
not know how to help them obtain covered services. Targeted grief
counseling when the survivor first identifies the need for help could
prevent more serious issues from developing later. The goal is the
right care at the right time for optimum treatment effect. The VA and
DoD need to better coordinate their mental health services for
survivors and their children.
NMFA has heard the main reason for the VA not providing health care
and mental health care services is because they cannot be reimbursed
for care rendered to a family member. However, the VA is a qualified
TRICARE provider. This allows the VA to bill for services rendered in
their facilities to a TRICARE beneficiary. There may be a way to bill
other health insurance companies, as well. No one is advocating for
care to be given for free when there is a method of collection.
However, payment should not be the driving force on whether or not to
provide health care or mental health services within the VA system. The
VA just needs to look at the possibility for other payment options. The
NDAA FY08 authorized an active-duty TRICARE benefit for severely
wounded/ill/injured service members once they are medically retired,
but their family members were not mentioned in the bill's language. A
method of payment to the VA for services rendered without financially
impacting the family would be to include the medically retired service
member's spouse and children. NMFA recommends an active duty benefit
for 3 years for the family members of those who are medically retired.
This will help with out-of-pocket medical expenses that can arise
during this stressful transition time and provide continuity of care
for spouses, especially for those families with special needs children
who lose coverage once they are no longer considered active duty
dependents.
NMFA asks you to continue to put pressure on DoD and VA to step up
the recruitment and training of mental and health care providers to
assist service members, veterans, and their families. Congress needs to
address the long-term continued access to mental health services for
this population.
NMFA would like to thank you again for the opportunity to present
testimony today on the mental health needs for families who support our
veterans. Military families support the Nation's military missions. The
least their country can do is make sure wounded service members,
veterans, and their families have consistent access to high quality
health care in the DoD and VA health care systems. Wounded service
members and veterans have wounded families. DoD and VA must support the
caregiver by providing standardized training, access to mental health
services, and assistance in navigating the health care systems. The
system should provide coordination of care and DoD and VA working
together to create a seamless transition. We ask this Subcommittee to
assist in meeting that responsibility.
Statement of Hon. John T. Salazar,
a Representative in Congress from the State of Colorado
Good Morning Chairman Michaud, Ranking Member Miller and
distinguished members of this Subcommittee.
I am proud that we are meeting today to discuss the need for mental
health services for veteran's families.
I thank the members of this subcommittee for gathering to discuss
an issue that gives due credit to the families who support our veterans
every day.
It is critical that we review these issues immediately to keep pace
with the demands our military puts on the families of our service
members and veterans.
Our nation's responsibility to our veterans and troops must change
as the needs of our military change.
Our veterans serve our country honorably and their families are a
vital support system while they serve and when they return home.
This issue should be examined fully to ensure that those who served
our Nation receive the benefits they have earned.
I look forward to evaluating the current system of mental health
services that we have in place and I thank the members of this
committee for giving us the opportunity to discuss issues that benefit
our veteran's families.