[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


                     U.S. GOVERNMENT PRINTING OFFICE
41-373 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001

                     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 
review. Group Dynamics: Theory, Research and Practice, 7(1), 3-12.
    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 
Psychotherapy Association
    Chemtob, C.M., Novaco, R.W., Hamada, R.S. & Gross, D.M. (1997). 
Cognitive Behavioral treatment for severe anger in post traumatic 
stress dirorder. Journal of Consulting and Clinical Psychology, 65, 
184-189.
    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.
    Makler, S., Sigal, M., Gelkopf, M., Kochba, B., & Horeb, E. (1990). 
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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.''
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.

                                 
