[Senate Hearing 110-187]
[From the U.S. Government Printing Office]


                                                        S. Hrg. 110-187
 
FIELD HEARING ON ADDRESSING MENTAL HEALTH CARE NEEDS OF VETERANS IN THE 
                          STATE OF WASHINGTON 

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 17, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director




















                            C O N T E N T S

                              ----------                              

                            August 17, 2007
                                SENATOR

                                                                   Page
Murray, Hon. Patty, U.S. Senator from Washington.................     1
    Response to written questions submitted to Department of 
      Veterans 
      Affairs....................................................     6

                               WITNESSES

Nylen, Kathy D., Department Service Officer, Department of 
  Washington, The American Legion................................     7
    Prepared statement...........................................     9
Jones, Brandon D., Member, Washington Army National Guard........    11
    Prepared statement...........................................    13
 Seger, Lieutenant Colonel Carol, State Family Programs Director, 
  Washington Army National Guard.................................    14
    Prepared statement...........................................    15
Franklin, Sergeant Stephen, Member, Washington Army National 
  Guard..........................................................    16
    Prepared statement...........................................    17
Purcell, Sergeant Daniel, Member, Washington Army National Guard.    18
    Prepared statement...........................................    19
Fry, Ron, Deputy Commander, Blue Mountain Veteran Coalition......    21
    Prepared statement...........................................    23
Zeiss, Antonette, Ph.D., Deputy Chief Consultant, Office of 
  Mental Health Services, Department of Veterans Affairs.........    29
    Prepared statement...........................................    31
Rubens, Diana, Director, Western Area, Veterans Benefits 
  Administration, Department of Veterans Affairs.................    32
    Prepared statement...........................................    34
Lewis, Dennis M., FACHE, Network Director, VISN 20, Department of 
  Veterans Affairs...............................................    39
    Prepared statement...........................................    41
Lowenberg, Major General Timothy J., Adjutant General, State of 
  Washington.....................................................    42
    Prepared statement...........................................    43
Baxter, Brigadier General Sheila, Commander, Madigan Army Medical 
  Center, Fort Lewis, Washington.................................    46
    Prepared statement...........................................    48
Lee, John, Director, Washington State Department of Veterans 
  Affairs........................................................    50
McFall, Miles, Ph.D., Director, PTSD Treatment Programs, VA Puget 
  Sound Health Care System.......................................    56
    Prepared statement...........................................    58
Gahm, Colonel Gregory A., Chief, Department of Psychology, 
  Madigan Army Medical Center, Fort Lewis, Washington............    59
    Prepared statement...........................................    60
Ramsey, Robert R., LICSW, Team Leader, Tacoma, Washington Vet 
  Center, Readjustment Counseling Service, Veterans Health 
  Administration, Department of Veterans Affairs.................    63
    Prepared statement...........................................    64
Barrick, G. Anthony, Ph.D., Licensed Mental Health Counselor, 
  Seattle, Washington............................................    65
    Prepared statement...........................................    67


FIELD HEARING ON ADDRESSING MENTAL HEALTH CARE NEEDS OF VETERANS IN THE 
                          STATE OF WASHINGTON

                              ----------                              


                        FRIDAY, AUGUST 17, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:45 a.m., in 
Bates Technical College-South Campus, Tacoma, Washington, Hon. 
Patty Murray, Member of the Committee, presiding.

            OPENING STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Good morning to all of you. I would like to 
officially call this hearing of the Senate Veterans' Affairs 
Committee to order. First of all, I want to thank Bates 
Technical College for hosting this event today. I really want 
to thank them and all their staff for helping us set up and 
putting this together today, and I really appreciate all they 
have done. I want to welcome all of you who are here today and 
I want to thank you for coming. As everyone here knows, the 
topic of this Committee hearing today is veteran's mental 
health care. As the senior member of the Senate Veteran's 
Affairs Committee, I am holding this hearing here in Washington 
State to better understand how the invisible wounds of war have 
impacted those who have born the burden of battle and how this 
has and will impact their families and their communities. I 
want to acknowledge the staff and doctors at the VA who are 
some of the most caring and compassionate I have ever met. I 
agree with many of the veterans who believe that the care at 
the VA is excellent, and I'm here today not to give the VA a 
black eye or to bash them, but to look at ways that we can do 
things better. Sometimes we do things just because they've 
always been done a certain way, but if we could do better by 
our vets, we should.
    I'm here to listen today and to ask questions so that I can 
take the stories and information I hear back to Washington, DC, 
with me and advocate for the resources that can make our VA 
system do better. Our understanding of mental illness has come 
a long way since the famous incident in 1943 when General 
George Patton slapped a soldier being treated at a hospital in 
Italy for exhaustion. PTSD, or Post Traumatic Stress Disorder, 
has had a variety of names throughout the years, after the 
Civil War it was called soldier's heart; after the First World 
War it was called shell shock; after the Second World War it 
was called battle fatigue, and after the Vietnam War it was 
called post-Vietnam syndrome.
    Although PTSD as it is called today has changed names over 
the years, the horrors of wars have remained the same. Our 
understanding of the impact of that warfare has had on the 
minds of warriors has evolved over the years. But one thing we 
do know for sure is that the mental wounds that our men and 
women in uniform suffer can run just as deep and can be just as 
devastating as the physical injuries that are sustained on the 
battlefield. The wars in Iraq and Afghanistan are no exception. 
As the Iraq War enters its fifth year, it is clear that the 
fighting overseas has taken a tremendous toll on the lives of 
our troops who have served this Nation so honorably, as well as 
their families who've born the sacrifice in so many different 
ways.
    When it comes to identifying and treating all of the 
returning veterans with mental health problems, we are facing 
serious challenges. According to the VA, one third of all 
returning Iraq veterans who have enrolled in the VA have sought 
treatment for a mental health problem. That is an astounding 
statistic, but it is also probably too low. We know that many 
servicemembers and veterans do not seek care because of the 
stigma surrounding treatment or because of fear that a mental 
health diagnosis will negatively impact their military career. 
And far fewer will speak out about their own experiences in a 
forum like this as I've found out when I began searching for 
servicemembers and veterans to testify about their personal 
mental health illness.
    My staff spoke to a number of veterans with compelling and 
heartbreaking stories to share, but who for many reasons did 
not feel comfortable testifying publically. Some veterans were 
concerned that sharing their struggle would negatively impact 
their jobs, others thought it would impact their military 
career or the perception of their fellow troops, while others 
did not feel comfortable sharing their struggles because they 
had not told their family or their friends. I so appreciate the 
bravery and willingness of the veterans and the family members 
on our first panel who have come today to share their stories 
with all of us. Their testimony and openness in answering 
questions will allow all of us to better understand the hidden 
costs of war. They are here speaking out for a lot of people 
who couldn't be here today or couldn't feel that they could do 
this, and their testimony is going to have a far-reaching 
impact and effect on the policies of our country and the lives 
of all who serve.
    We know that as troops are deployed overseas for the third, 
fourth and some now even fifth tour of duty, the likelihood of 
PTSD and other mental health care conditions increases. We also 
know that the Iraq War has created unique challenges for the 
military and the VA to provide care for all the veterans 
needing health care treatment, whether they're 20 years old and 
just back from Iraq, or a Vietnam veteran who is experiencing 
PTSD for the first time. But we've known about many of these 
problems for a long time and, unfortunately, the National VA 
has too often failed to act. Last year the GAO issued a report 
indicating that the VA did not spend all the mental health 
money it was provided by Congress. The bureaucracy and poor 
communication from the VA central office likely resulted in 
mental health funds being used for other health care purposes. 
In the spring of 2006, a senior VA official said that waiting 
lists at VA facilities across the country rendered mental 
health care and substance abuse treatment virtually 
inaccessible. And just this past February the American 
Psychological Association released a report that found many 
servicemembers and their families are not receiving mental 
health care because of the limited availability of such care 
and the barriers to accessing it.
    Our National Guard and Reserve members have been 
particularly hard hit. These citizen soldiers who leave their 
families and jobs at home to serve our Nation overseas often 
live in areas far away from VA medical centers making it 
difficult for them to receive care once they do return home.
    I hear from Guardsmen, Reservists and their families all 
the time who've encountered problems accessing care at the VA, 
and that has to change. We are also now hearing that Vet 
Centers, an integral part of the VA's mental health care 
network don't have enough staff to meet the growing number of 
veterans who are accessing our clinics. According to a recent 
USA Today article, the number of returning veterans from Iraq 
and Afghanistan has more than doubled since 2004, but the 
staffing levels at our Vet Centers have increased by less than 
10 percent. It is clear that the VA is still not on a war-time 
footing to deal with this problem. It's also clear that the 
Administration and the top VA has failed to make the mental 
health treatment needs of our veterans into account as a part 
of the cost of this war, and sadly that has cost them and our 
families dearly.
    Fortunately, there is some help on the way. This year, the 
Senate passed a budget that provides the VA with $43.1 billion 
for this fiscal year. That is $3.6 billion more than the 
President's budget and 99 percent of what the Independent 
Budget, which is an independent analysis of these budgetary 
needs put together by four major veterans service organizations 
called for. In addition, Congress sent to the President an 
emergency supplemental bill that provides $1.8 billion in 
directed funding for veteran's health care, including $100 
million in funds directed to veteran's mental health care 
programs. The President did not request any funding for 
veterans in his supplemental, but we fought in Washington, DC, 
to make sure we had it, because caring for our troops when they 
return home is a cost of war.
    This funding will help the VA to better meet the needs of 
the estimated one third of returning Iraq and Afghanistan 
veterans who have sought care at the VA for mental health 
problems. In addition, recently the Senate passed the Dignified 
Treatment of Wounded Warriors Act which will help meet the 
needs of our troops and our veterans as they transition from 
the battlefield to the VA and everywhere in between. That bill 
will require the Department of Defense and the VA to work 
together to develop a comprehensive plan to prevent, treat and 
diagnose TBI and PTSD. It also directs the two agencies to 
develop and implement a joint electronic health record so that 
critical medical records are not lost as our wounded troops 
move from the battlefield doctors to medical hold and on to the 
VA. It will also require the military to use VA standards for 
rating disabilities only allowing deviation from VA standards 
when it will result in a higher disability rating for our 
servicemembers, and it will require the military to adopt the 
VA presumption that a disease or injury is service-connected 
when our heroes who are healthy prior to service have spent six 
months or more on active duty.
    With our troops fighting overseas, with their tours being 
extended, it's up to all of us to make sure they don't have to 
fight for health care or benefits when they return home. Those 
critical pieces of legislation will ensure the VA has the 
resources it needs to care for our veterans so our veterans 
have what they need. But we cannot stop there. We have to 
continue hearing from our veterans, troops and their families 
on the ground so that we can provide the resources and make the 
changes needed to provide the highest level of care possible, 
and that is why I'm holding today's hearing. Your stories and 
the information that we share today will help uncover the true 
cost of this war and the impacts it has had on our veterans and 
on our families.
    This is an official U.S. Senate hearing, and as such, we 
have to follow the same procedures that are used at hearings in 
Washington, DC. That means that testimony is limited to the 
invited witnesses. There are strict time limits, which these 
timing lights in front of me will indicate, and we have a court 
reporter here today who will create a formal record of today's 
proceedings. Unfortunately, that also means that we will not be 
allowed to take questions or comments from this audience, but I 
want to ensure everyone that is here today, you will have an 
opportunity to share your views. We do have a comment form that 
you can fill out. We also have a sign-up sheet so you can get 
updates from me as I continue to work for vets back in the U.S. 
Senate. And in addition, I want you to know I have created a 
section on my web site where veterans throughout our state can 
share their stories with me. The address of that is 
murray.senate.gov/veterans, and you will see a section under 
that called share story. Please use it. I want to hear from 
you.
    So with that, let me explain how today's hearing is going 
to work. Today we're going to hear from three panels of 
witnesses, the first panel that is before you now is consists 
of veterans, family members and advocates, and I, again, want 
to extend a very special thank you to each of our Panel I 
participants for their courage to come here and to speak out 
publically about some very personal issues. Each one of you is 
speaking out for someone who could not be here today, and for 
that, I thank you very much. The second panel will consist of 
officials from the federal VA, the State Department of Veterans 
Affairs, the Department of Defense and the Washington National 
Guard. They're going to give us a birds-eye view of what is 
happening with mental health care throughout the state and our 
country. Our third panel is going to consist of mental health 
professionals who work directly with our troops and veterans 
and who will be able to speak to the specific issues affecting 
the care of our wounded soldiers.
    Despite the quality of our witnesses and the many topics 
that they will discuss during their testimony, I know that 
there are more challenges we won't have time to talk about 
today. So if you do have a concern that we don't cover, I want 
you to write it down and give it to my staff members who are 
here. When I call on our first panel, each witness will have up 
to 5 minutes to present your testimony, and then I will ask you 
all questions. Of course, as you know, your full written 
statement will be entered into the Committee record, and when 
we're done with the witnesses on the first panel, I will then 
call on our second panel and our third panel. I do know that we 
have a lot of veterans in our audience today, and I want to 
take this time to thank each and every one of you for your 
service to our country.
    If you need any help from the VA, I want you to know we 
have representatives here on-site who can help you file a 
claim. You can meet with officials from the VA regional office, 
the Washington State Department of Veterans Affairs and the VA 
Hospital in a room that we have set up nearby. If you do need 
help with an existing claim, members of my staff are here and 
they can help you resolve a claim with the VA.
    Because of federal privacy rules, we will need a signed 
letter giving us permission to investigate your case before we 
can do anything else, so I invite anyone who is here with a 
claim, if you need help, please find one of our staff members 
and we are more than eager to help you.
    We also have two professional staff members who are here 
with us today from the Senate Committee on Veterans' Affairs, 
Patrick McGreevy from Chairman Danny Akaka's staff; and Lupe 
Wissel from Ranking Member Craig's staff are here if you want 
to raise your hand so we know who you are. They've traveled out 
here from Washington, DC, and I want to thank you very much for 
being with us today.
    With that we are now going to begin with our first panel. I 
am going to introduce them to you, and then they will each have 
5 minutes to testify and then I will ask questions. As I said, 
our first panel consists of veterans, family members and 
veteran's advocates, and we have a very distinguished panel in 
front of us today. Testifying before us on our first panel, and 
I will read the entire order and then we will go through you, 
we have Kathy Nylen, she is a Department Service Officer with 
the American Legion in Washington State. Next to her is Brandon 
Jones. Brandon is a member of the Washington Army National 
Guard and was deployed with the members of the 81st Brigade 
beginning in November of 2003. Sarah, his wife, was hoping to 
be with us to give a family perspective today, but like many 
family members, ran into a babysitting issue and because of 
that can't be here. Tell her we would love to have her 
testimony in writing if that is possible. We have Lieutenant 
Colonel Carol Seger, who is the State Family Programs Director 
for the Washington National Guard. Stephen Franklin has joined 
us. He returned from Iraq in 2005 after a year of deployment. 
We have Daniel Purcell who is a member of our Washington Army 
National Guard and deployed with his unit to Iraq in February 
of 2004. And our last one here is Ron Fry, he is the Deputy 
Commander of the Blue Mountain Veteran Coalition. Thank you all 
so much for being here today. And, Kathy, we will begin with 
you.
     Response to Written Questions Submitted by Hon. Patty Murray 
                   to Department of Veterans Affairs
    Veterans have long been frustrated by the combative VA benefits 
claims process. The Veterans Disability Benefits Commission is now 
studying the system and will recommend changes in a final report that 
is expected in October. In addition, the Institute of Medicine found 
that the VA's compensation system for emotionally disturbed veterans 
has little basis in science, is applied unevenly and may even create 
disincentives for veterans to get better.
    Question 1. How can we change the VA claims process so that it 
doesn't negatively impact the recuperation of veterans?
    Response: The Department of Veterans Affairs (VA) is continually 
striving to improve the compensation claims process and is evaluating 
all recommendations from authoritative sources. Mental disability among 
veterans is a major issue, especially Post Traumatic Stress Disorder 
(PTSD). VA is addressing the process for evaluating the severity of a 
veteran's PTSD symptoms and assigning an appropriate evaluation of 
disability compensation. We have revised the standardized examination 
format for PTSD for use by all examiners so that consistent and more 
useful information will be available for claims adjudication personnel. 
Additionally, VA is considering the recommendation of the Institute of 
Medicine of the National Academies that PTSD have its own specific 
multidimensional rating criteria, rather than being evaluated based on 
generalized criteria used for all mental disorders.

    Question 2. How many Iraq and Afghanistan war veterans have filed 
any type of VBA disability compensation or pension claim?
    Response: The information provided below is based on a match 
between Department of Defense (DOD) data on servicemembers deployed in 
support of the Global War on Terror (GWOT) for the period from 
September 11, 2001 through May 31, 2007, compared to VA data covering 
September 11, 2001 through September 30, 2007.
    This data match identified veterans who were deployed during their 
military service in support of GWOT, and who have also filed a VA 
disability claim either prior to or following their GWOT deployment. 
Many GWOT veterans had earlier periods of service, and filed for and 
received VA disability benefits before being reactivated.
    VBA's computer systems do not contain any data that would allow us 
to attribute veterans' disabilities to a specific period of service or 
deployment.
    For the period covered, 223,564 of 754,911 GWOT veterans filed a 
claim for disability benefits either prior to or following their GWOT 
deployment. Of those, 181,151 veterans were determined to have a 
service-connected disability, 17,371 were denied service-connection, 
and 23,042 veterans had original claims pending as of September 30, 
2007.

    Question 3. How many Iraq and Afghanistan war veterans have filed a 
claim for a mental health condition? How many were granted? How many 
were denied? How many are waiting for a decision?
    Response: VBA does not track information specific to mental health 
conditions claimed by GWOT veterans. We have compiled data on GWOT 
veterans for the 10 most prevalent service-connected disabilities 
granted, which includes PTSD. As of September 30, 2007, there were 
31,465 GWOT veterans service-connected for PTSD. This represents 4 
percent of the total GWOT veteran population, and 17 percent of those 
GWOT veterans who have been granted any service-connection. This data 
is based on veterans separated from military service on or before May 
31, 2007, as reported by DOD.

    Question 4. How many total claims does VBA expect from Iraq and 
Afghanistan war veterans? How many of those does VBA expect will be for 
any type of mental health condition? And how many for PTSD?
    Response: In fiscal 2007 the Veterans Benefit Administration (VBA) 
completed nearly 829,000 claims. Of those, just over 110,000 (13 
percent) were claims made by GWOT veterans. This information is based 
on GWOT veterans discharged through May 2007 as reported to VA by DOD 
and self-reported by GWOT veterans when they filed their disability 
claim. At the present time, we expect GWOT claims will continue to 
represent the same percentage of our overall workload in 2008 and 2009. 
Projecting future demand for the Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF) conflict remains extremely difficult for a 
number of reasons.
    First, many OEF/OIF veterans served in earlier periods, and their 
injuries or illnesses could have been incurred either prior to or 
subsequent to their latest deployment. We are unable to identify which 
OEF/OIF veterans filed a claim for disabilities incurred during their 
actual overseas OEF/OIF deployment.
    Second, we significantly expanded our outreach to separating 
servicemembers. Over the last 5 years, we conducted over 38,000 
briefings attended by over a 1.5 million active duty and Reserve 
personnel. Additionally, through the benefits delivery at discharge 
program, servicemembers are encouraged to file and assisted in filing 
for disability benefits prior to separation. Many servicemembers with 
disabilities are submitting disability claims earlier. However, the 
impact of these efforts on future application trends and benefits usage 
is not known.
    Third, VBA lacks historical data for claims activity by veterans of 
prior wars on which to base projections of benefits usage for OEF/OIF 
veterans. The only data available are the numbers and percentages of 
veterans currently receiving benefits by era of service.
    We continue to add veterans to our compensation rolls many years 
after their service. Many of these are a result of additional 
conditions presumed to be related to service in Vietnam. PTSD claims 
have also increased from Vietnam veterans. We have no basis for 
determining if service in Afghanistan and Iraq will result in similar 
claims patterns.

    Question 5. What is the average wait time for new war veterans 
compared to all other veterans, who wait 6 months for an initial 
decision?
    Response: In fiscal 2007, VBA completed nearly 825,000 claims, Of 
these, just over 110,000 were claims filed by GWOT veterans. Their 
claims were processed in an average of 179 days. The remaining claims 
were completed in 184 days.
    VA is continuously seeking ways to improve the timeliness of 
processing claims received from GWOT veterans. In February 2007, VA 
began providing priority processing of all OEF/OIF veterans' disability 
claims. This initiative covers all active duty, National Guard, and 
Reserve veterans who were deployed in the OEF/OIF theaters or in 
support of these combat operations, as identified by the DOD. 
Therefore, claims received from GWOT veterans before February 2007 were 
not processed on a priority basis. As a result of this initiative we 
expect to see improvements in our timeliness in FY 2008.
    VBA also added an indicator/flash in our VETSNET system to clearly 
identify GWOT veterans and improve the management of their claims. The 
system alerts the claims examiner that the case being processed is to 
be handled in a priority manner.
    VA does face challenges in assisting GWOT National Guard and 
Reserve members with their claims, due to difficulties in obtaining 
their active duty medical records. These members are sometimes 
mobilized with units other than their home unit. Their medical records 
created while on active duty may not get back to their home unit for 
some time, if at all.
    VA is taking a proactive approach in seeking to obtain medical 
records faster from the National Guard. VA met with the National Guard 
to discuss their health readiness records and electronic readiness 
records, and how the VA can have access to those records. The VA 
Regional Office in St. Petersburg, FL, is entering into a pilot program 
with the National Guard in order to receive medical records 
electronically.

        STATEMENT OF KATHY D. NYLEN, DEPARTMENT SERVICE 
     OFFICER, DEPARTMENT OF WASHINGTON, THE AMERICAN LEGION

    Ms. Nylen. Thank you, Senator. I would like to thank you 
for this opportunity to express the American Legion's views on 
the mental health needs of those men and women who have served 
our country and safeguarded our freedom. I would like to say 
that in light of the recent report in the Washington Post that 
the Army is now experiencing the highest suicide rate in 
history, I feel that this hearing could not have been held at a 
better time. As the Department Service Officer in Washington 
State, I am intimately aware of the types of claims and issues 
being raised by our clients to the Department of Veteran 
Affairs. I also serve on our national task force and have had 
the privilege of visiting polytrauma centers and Vet Centers 
throughout the country. I consider it an honor and privilege to 
be able to speak with for veterans who are unable to do so for 
themselves.
    I would like to highlight a few items in my written 
testimony. A recent study shows that 31 percent of OEF/OIF 
veterans seen at VA health care facilities are receiving mental 
health or psychosocial diagnoses. I would like to point out 
that quite often when we talk about mental health disorder, we 
always think PTSD, but I do want to make sure everybody is 
aware that there are many other mental health illnesses 
encompassed in that, that our troops are suffering from such as 
depression, anxiety and panic disorders among others. The early 
detection and intervention are necessary to prevent chronic 
mental illness disabilities. As you mentioned in your opening 
statement, according to the VA, one third of the veterans are 
being diagnosed and treated for mental health disorders making 
that the second most common medical problem of these war 
veterans.
    Funding is a continued concern. I would ask that we would 
continue to push for mandatory funding for the VA health care 
system and the VA in whole. Without funding, they will not be 
able to meet the challenges before them. One of the areas I 
have seen a downsizing of is within VA mental health services 
that are being contracted outside of the VA. I have received 
several complaints from veterans and counselors alike that 
their level of care being provided is being decreased from the 
one-on-one individual counseling to more use of the group 
counseling. In answer to this issue, VA has stated that the 
necessary care is being provided as needed; however, I'm here 
to tell you that the word on the street is one of 
disappointment and difficulty of adapting to the group 
counseling environment. The signature wound of the Global War 
on Terror is Traumatic Brain Injury. The American Legion is 
concerned that our veterans are often misdiagnosed resulting in 
errors both in medical treatment and disability compensation 
rating. The DOD policy of redeployment without allowing 
adequate time to determine if there are any physical or mental 
issues to address has placed our men and women at risk for 
significant long-term medical problems. We would like to see 
that all returning servicemembers are routinely evaluated for 
Traumatic Brain Injury and that a system be established to 
ensure the follow-up since some symptoms are not manifested 
immediately.
    Active duty members who are being placed on medical 
evaluation board proceedings here in Washington State are 
finding themselves waiting an inordinate amount of time for a 
decision. They're waiting months and in some cases nearly a 
year. They understandably get frustrated, and when they're 
offered the chance to be discharged, we see them accepting 
lower disability ratings from the med board process than what 
they are entitled to. I have personally assisted a number of 
clients once their VA rating has been established to go back 
and upgrade their military status to that of a medical retiree 
in order to receive those benefits they're entitled to. A major 
obstacle for veterans seeking mental health services or any 
other medical service is timely accessibility. Those who need 
care for readjustment or other mental health issues need 
immediate attention and not be placed on a wait list. Many do 
not seek the immediate assistance, and so, their mental health 
condition may be more advanced by the time they do decide to 
seek care, and again, they require quick response.
    The Department of Veteran Affairs has augmented staff at 12 
Vet Centers and is creating 23 new Vet Centers within the next 
2 years. I am pleased that Everett has been selected as a 
location for one of those Vet Centers here in Washington State. 
Vet Centers are a unique and invaluable asset for veterans 
seeking readjustment counseling. Vet Centers are community 
based. Veterans are assessed the day they seek services. They 
receive immediate access to care and are not subjected to wait 
lists. They are designed to provide services exclusively for 
veterans that serve in theaters of conflict or experience 
military sexual trauma, and they provide mental health 
counseling not just to the veteran, but to those who have been 
their support system, like the spouse and children.
    We are eagerly anticipating the budget proposed. We urge 
continued support for mandatory funding and ask that your 
colleagues be enlightened as to the need of mandatory funding 
for VA health care.
    In conclusion, the American Legion realizes the Department 
of Veterans Affairs faces many difficult challenges addressing 
the complex mental health issues of our Nation's heroes. The 
network of trained knowledgeable service officers of the 
American Legion and other veterans service organizations are 
ever ready to assist those individuals accessing their 
benefits. We are their advocates and we are here to work with 
them and to ensure that they receive the maximum that they're 
entitled to. We will continue to monitor and work closely with 
the VA to ensure they do receive those benefits.
    Senator Murray, for your accomplishments on behalf of 
Washington State veterans and their families, I thank you. I 
look forward to continuing this trend, and again, thank you for 
this opportunity to present our views on this critical issue.
   Prepared Statement of Kathy D. Nylen, Department Service Officer, 
             Department of Washington, The American Legion
    Senator Murray, Thank you for the opportunity to express The 
American Legion's views on the mental health needs of those men and 
women who have served our Country and safeguarded our freedom. As the 
Department Service Officer in Washington State for The American Legion, 
I am intimately aware of the types of claims and issues being raised by 
our clients to the Department of Veterans Affairs and consider it an 
honor and privilege to speak for those unable to do so for themselves.
    A recent study--entitled Mental Health Disorders Among 103,788 US 
Veterans Returning From Iraq and Afghanistan Seen at Department of 
Veterans Affairs Facilities--can be utilized to illustrate the 
importance of timely accessibility for those who suffer from mental 
health issues. Of 103,788 OEF/OIF veterans seen at VA health care 
facilities, 31 percent received mental health and/or psychosocial 
diagnoses. Mental health diagnoses were detected soon after the first 
clinic visit, approximately 13 days. Sixty percent of most initial 
diagnoses were made in mostly primary care settings. The youngest group 
of these veterans (age 18-24) had a greater risk for receiving mental 
health diagnoses. The study concluded that the co-occurring mental 
health diagnoses were detected early in the primary care setting. This 
early detection and intervention are needed to prevent chronic mental 
illness and disability. If those who seek care are forced to wait 
months to be seen for their appointments, opportunities for early 
detection of mental health issues will decrease, allowing the 
conditions to worsen and making them more difficult to treat.
    According to the Veterans Health Administration (VHA) Office of 
Public Health and Environmental Hazards, of the returning Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans who 
have sought care at VHA facilities, mental health problems are the 
second most common medical problem of these war veterans. There has 
been significant restructuring of VA mental health services during the 
past several years which has often resulted in a downsizing of in-
patient based care, and the shift of treatment programs from 
residential-based to ambulatory-based programs. I have received several 
complaints from veterans and counselors alike that the level of care 
being provided has been decreased from one-on-one counseling to more 
group counseling. In answer to this issue, VA has stated that the 
necessary care is being provided however, the ``word on the street'' is 
one of disappointment and difficulty adapting to the group-counseling 
environment.
    During the past several years, the number of veterans provided 
specialized substance abuse treatment has declined, while the funding 
for such treatment has been significantly decreased. The Veterans 
Health Administration now has more mental health patients seeking 
treatment with fewer mental health providers. However, as more OIF/OEF 
veterans return, many continue to need increased access to mental 
health services, including, but not limited to, Community Based 
Outpatient Clinics, Mental Health Intensive Case Management, Substance 
Abuse Disorder Programs, and Compensated Work Therapy Programs.
    The signature wound of the Global War on Terror is Traumatic Brain 
Injury and The American Legion is concerned that veterans are often 
misdiagnosed resulting in errors both in medical treatment and 
disability compensation ratings. The policy of redeployment without 
allowing adequate time to determine if there are any physical or mental 
issues to address has placed our young men and women at risk for 
significant long-term medical problems. We would like to see that all 
returning servicemembers are routinely evaluated for TBI and that a 
system be established to ensure follow-up evaluations since some 
symptoms are not manifested immediately.
    A common complaint heard from those servicemen and women being 
evaluated by a Medical Evaluation Board to determine eligibility for 
continued service is that they are waiting months, and in some cases 
nearly a year, for a decision. They understandably get frustrated and 
when offered the chance to be discharged, we see them accepting a lower 
disability rating than they are entitled to. We have assisted a number 
of clients in correcting their military status in order to receive the 
retirement benefits they are entitled to once the VA rates the same 
disabilities, which DOD rated at less than 30 percent.
    A major obstacle for veterans seeking mental health services--or 
any other medical service--is timely accessibility. Wait lists and 
staffing shortages affect the speed of delivery of care system-wide. 
Those who need care for readjustment or other mental health issues need 
immediate attention. Since many do not immediately seek assistance when 
their problems first manifest, their mental health condition may be 
more advanced by the time they decide to seek care--requiring quick 
response. I would like to reiterate the findings of the study in my 
opening and the concerns we have that if those who seek care are forced 
to wait months to be seen for their appointments--mental or physical 
health --opportunities for early detection of mental health issues will 
decrease, allowing the conditions to worsen and making them more 
difficult to treat.
    The Department of Veterans Affairs plan to augment staff at select 
Vet Centers and to create 23 new Vet Centers within the next 2 years, 
bringing the number of Vet Centers to 232, will improve access to 
readjustment services for many combat veterans and their families--some 
of which reside in underserved areas. Vet Centers are a unique, 
invaluable asset for veterans seeking readjustment counseling. Because 
Vet Centers are community based and veterans are assessed the day they 
seek services, they receive immediate access to care and are not 
subjected to wait lists. Designed to provide services exclusively for 
veterans who served in theaters of conflict, or experienced military 
sexual trauma, they provide mental health counseling to not just the 
veteran, but those in his or her support system--like the spouse and 
children. Services are provided in a non-clinical environment, which 
may appeal to those who would be reluctant about seeking care in a 
medical facility. A high percentage of the staff, more than 80 percent, 
are combat veterans and can relate to the readjustment issues 
experienced by those seeking services. We are pleased that Everett has 
been selected as one of the sites for a new Vet Center but see a need 
for additional sites in rural areas.
    In conclusion, The American Legion realizes the Department of 
Veterans Affairs faces many difficult challenges addressing the complex 
mental health issues of our Nation's heroes. We will continue to 
monitor and work closely with VA to ensure veterans receive the 
treatment and benefits they are entitled to.
    Thank you again for this opportunity to present our views on this 
critical issue.

    Senator Murray. Thank you very much, Kathy. We will turn to 
Brandon Jones. Thank you for being here to share your story.

            STATEMENT OF BRANDON D. JONES, MEMBER, 
                 WASHINGTON ARMY NATIONAL GUARD

    Mr. Jones. Senator Murray, thank you very much for the 
opportunity to be able to speak here today. My name is Brandon 
Jones. I served on active duty from 1994 to 1997 and have been 
a member of the Washington Army National Guard since January of 
2000. As a veteran of Operation Iraqi Freedom, I was deployed 
to the Middle East with the 3rd Brigade, 1st Cavalry Division 
in 1996. I was activated and deployed for Operation Iraqi 
Freedom for the 81st Brigade beginning 2003.
    I would like to share my experience and observations about 
the difficulties that my family and I faced during my 
activation in 2003-2004 and would also like to talk about what 
I saw other soldiers facing and experiencing which made the 
process of serving the Nation and the community a trying and 
sometimes emotional and financially overwhelming experience. In 
November 2003, I was called to full-time active duty with 81st 
Brigade and was given a very short notice when my unit was 
mobilized. In that time, I had to give up my civilian job and 
took an income loss of over $1,200 a month. My wife had to drop 
out of classes at Olympic College in order to be able to care 
for our children. I went from living at home and seeing my 
children on a daily basis to living on base, which is just one 
mile away from my home, and visiting my children periodically. 
To my kids I went from being their dad full time to being the 
guy that just dropped by the house every once in a while for a 
visit.
    The three months mobilization before my deployment were 
very stressful. We struggled financially, and although we 
reached out for help, we were told financial resources 
available were strictly available for active duty soldiers on 
Fort Lewis. It wasn't until we were threatened with eviction 
and repossession of our only vehicle that my wife was able to 
obtain a small amount of assistance that was, again, generally 
set aside for active duty soldiers. Our families helped us make 
up the rest. They covered about 60 percent of what we owed. The 
stress made it difficult for my wife and I to keep a positive 
attitude, for our children to feel comfortable, and for me to 
concentrate on the mission that was ahead. When my wife and I 
reached out for marriage counseling prior to our deployment, we 
were again made to feel like we were using up resources that 
were set aside for active duty soldiers on base.
    Let me remind you, this was all stuff that took place prior 
to my deployment. After 110 days in theater, I was MEDEVACED 
due to a heart condition.In MED Hold, myself and other soldiers 
were left to figure things out on our own. There was no 
information posted or available for incoming soldiers to where 
they could seek help or counseling for the issues they had 
experienced when they were downrange. I found this very 
surprising since some of the soldiers that were MEDEVACED were 
there after being injured in explosions, mortar attacks or 
other combat related incidents.
    During my first deployment to the Middle East in 1996, I 
developed a sleep disorder due to the stresses that I 
experienced while I was there. When I was MEDEVACED in 2004, I 
experienced many of the same disturbances in my sleep pattern. 
I explained that to my MED Hold platoon sergeant and I 
explained that my sleep disturbances may affect my performance 
and he helped me get referred to the community mental health 
clinic at Madigan. There I was seen by a mental health 
professional and was offered sleeping pills to get me through 
the disturbance, but was not offered any help to treat the 
underlying conditions that were causing the sleep disturbance. 
I, like many other soldiers, was threatened with UCMJ action 
when my sleep disorder and issues interfered with my duties as 
a soldier, like for instance, when I showed up late for 
formation or, on occasion, fell asleep during duty. My only 
saving grace is when I was counseled, I wrote in my statement 
that I tried to seek help for my sleep disorder and received 
nothing.
    My sleep disorder has continued to affect my civilian 
employment, and I thank God for my wife and her ability to be 
able to kick me out of bed in the morning when I'm running 
late. Another thing I observed on Med Hold is that soldiers 
were using alcohol and sometimes drugs, both prescription and 
illegal to treat themselves because they weren't aware of any 
services that may be available to them. While I was in Med Hold 
I perceived a mentality of, return them to duty or send them 
home. If anything caused disruption to this process by a 
soldier behaving in any unsoldierly manner with the use of 
alcohol or drugs, no time was taken to help the soldier but 
UCMJ action was started almost immediately.
    I was often frustrated by the fact that noncombat veteran 
soldiers were put in charge of taking care of combat veterans. 
I don't believe that it was a lack of sympathy or caring on 
their part, but rather a lack of sympathetic understanding and 
appropriate training on how to deal with the stress-related 
issues. Ultimately, this sort of lack of understanding, 
training and information resulted in the loss of life through 
suicide by a close friend of our family. My friend was 
MEDEVACED because of his inability to cope with the stresses of 
combat. After his suicide his wife informed us that he was 
supposed to have been on suicide watch, that he was supposed to 
have been receiving help and intervention in the form of 
counseling and medications, instead he was sent home alone. He 
was not released to the care of his family. He was sent to 
dwell in his own mind to a point that he couldn't handle it any 
longer. He put a gun to his head and took his own life. His 
widow and two stepchildren asked over and over again how this 
could have happened and what they could have done differently.
    I find myself asking the same questions whenever he comes 
to mind. More so, I find myself asking where was the 
appropriate care? Where were those that were assigned to look 
after his well-being and were the resources available? And did 
they have the appropriate training to recognize the mental 
health conditions the soldiers suffer from? Obviously there 
were not enough resources, not enough training and not enough 
information, otherwise he might be here today telling his 
story.
    I hope that something will be done to increase the 
communication of available resources for soldiers and their 
families. I hope more will be done to raise the awareness of 
Post Traumatic Stress Disorder and combat-related stresses, not 
only for the soldier that goes off to war, but for the families 
and children that bear the burden from having a loved one taken 
from their home.
            Prepared Statement of Brandon D. Jones, Member, 
                     Washington Army National Guard
    My name is Brandon Jones. I served on Active Duty from 1994 to 
1997, and have been a member of The Washington Army National Guard 
since January 2000, and am a Veteran of Operation Iraqi Freedom. I was 
deployed to the Middle East with the 3rd Brigade of the 1st Cavalry 
Division in 1996 and I was activated, and deployed with the members of 
the 81st Brigade beginning in November 2003.
    I want to share my experience and observations about the 
difficulties my Family and I faced during my activation in 2003, and 
also to talk about what I saw my fellow Soldiers' experience that made 
the process of serving our Nation and Community trying, and at times 
emotionally and financially overwhelming.
    In November 2003, when I was called to full time duty with the 81st 
Brigade. I was given a very short notice that my unit was being 
mobilized. In that time I had to give up my civilian job--an income 
loss of about $1,200 a month--and my wife had to drop out of classes at 
Olympic College to care for our children.
    I went from living at home and seeing my children on a daily basis 
to living on base--just one mile from home--and visiting my children 
periodically. To my kids, I went from being their dad to the guy who 
drops by the house for a visit once in a while.
    The three months of mobilization before my deployment were very 
stressful. We struggled financially. Although we reached out for help, 
we were told that the only financial resources available were strictly 
for active duty soldiers at Fort Lewis. It wasn't until we were 
threatened with eviction and repossession of our car that my wife was 
able to obtain a small amount of assistance generally reserved for 
Active Duty Soldiers. Our families helped us make up the rest. About 60 
percent of what we were in need of.
    The stress made it difficult for my wife to keep a positive 
attitude, for our children to feel comfortable and for me to 
concentrate on the mission ahead of me. When my wife and I reached out 
for marriage counseling prior to my deployment, we were made to feel 
that the few sessions we were given were a favor to us and that we were 
taking up a resource meant for active duty Soldiers from the base.
    Let me remind you that all of this happened before I was even 
deployed.
    After 110 days in theater, I was MEDEVACED due to a heart 
condition. In our MED Hold, soldiers were left to figure things out on 
their own. There was no information posted or available for incoming 
soldiers as to where they could seek help or counseling for issues 
related to their deployment. I found this very surprising, since some 
of these soldiers were MEDEVACED after being injured in an explosion, 
mortar attack, or other combat related incidents.
    During my first deployment to the Middle East in 1996, I developed 
a sleep disorder due to the stresses I experienced while I was there. 
When I was MEDEVACED in 2003, I experienced many of the same 
disturbances in my sleep pattern. I explained to my MED Hold platoon 
sergeant that my sleep disturbances may impact my performance, and he 
helped to get me referred to the community mental health clinic at 
Madigan.
    There I was seen by a mental health professional and was offered 
sleeping pills to get me through the disturbance, but was not offered 
any help to treat the underlying problem. I, like many other Soldiers, 
was threatened with UCMJ action when my sleep disorder interfered with 
my duties as a Soldier, like when I showed up late for formation or 
when I fell asleep during duty. My only saving grace was that when I 
was counseled, I wrote in my statement that I had tried to get help for 
my sleep disorder but had not received anything. My sleep disorder has 
continued to affect my civilian employment. I never get a full night's 
sleep and I thank God for my wife who pushes me out of bed if I do 
oversleep so that I can make it to work on time.
    Another thing I observed in Med Hold was that Soldiers were using 
alcohol and sometimes drugs--both prescription and illegal--to treat 
themselves. This was because they weren't aware of services available 
to help them. While on MED Hold I perceived a mentality of ``return 
them to duty, or send them home,'' and if anything caused disruption in 
that process by a Soldier having behavioral issues caused by using 
alcohol or drugs, no time was taken to help the soldier, but UCMJ 
action was immediately initiated.
    I was often frustrated by the fact that non-combat veteran Soldiers 
were put in charge of the care of combat Veterans. I do not believe 
that it was a lack of caring on the part of the leadership, and 
command, but rather a lack of sympathetic understanding, and lack of 
appropriate training of how to deal with combat related stress issues.
    Ultimately this sort of lack of understanding, and information 
resulted in the loss of life through suicide by a close friend of our 
family. My friend was MEDEVACED because of his inability to cope with 
the stresses of combat. His wife informed us that he was supposed to be 
on suicide watch. He was supposed to have been receiving help and 
intervention in the form of counseling and medication. He was sent home 
ALONE!!! He was not released to the care of his family, he was sent to 
dwell within his own mind to the point that he could not handle it any 
longer. He put a gun to his head and took his own life. His widow and 
two stepchildren asked over, and over again: ``how could this have 
happened, and what could we have done differently?''
    I find myself asking the same question whenever he comes to mind. 
More so I find myself asking where was the appropriate care? Where were 
those assigned to ensure his well-being, and were they aware of the 
resources available, and did they have the appropriate training to 
recognize the mental health conditions this Soldier suffered from? 
Obviously there were not enough resources, training, or information. 
Otherwise he might be here today, instead of me telling his story.
    I hope that something will be done to increase the communication of 
available resources for Soldiers AND their families. I hope that MORE 
will be done to raise awareness of PTSD, and combat related stresses, 
not only for the Soldier that goes off to war, but for the Families, 
and Children that bear the burden of having their loved one taken from 
their home.

    Senator Murray. Thank you very much. I really appreciate 
you sharing your story. Ms. Seger.

   STATEMENT OF LIEUTENANT COLONEL CAROL SEGER, STATE FAMILY 
              PROGRAMS DIRECTOR, WASHINGTON ARMY 
                         NATIONAL GUARD

    Ms. Seger. Senator Murray, distinguished guests and fellow 
citizens, my name is Lieutenant Colonel Carol Seger, and I've 
served in the Army National Guard for over 28 years. I'm 
currently assigned as the State Family Programs Director and my 
charter in that job is to assist military families, which 
include our servicemembers and our veterans in becoming self-
reliant through education and empowerment. Family assistance is 
provided before, during and after deployments.
    We can help our families when the soldier returns by 
helping them transition into civilian life. When they call us 
for help, we evaluate their circumstances and try to find the 
appropriate information and referral for them.
    Reintegration back into civilian life is complex and it 
takes time, and the entire family, as you heard from Mr. Jones, 
the entire family suffers when the mental health needs are not 
acknowledged and resolved. It can strain even strong marriages. 
PTSD and other mental health conditions are sometimes difficult 
for a servicemember to come to grips with. In some cases it can 
take years for them to admit that they have PTSD. After our 
veterans acknowledge that they need help, medical professionals 
must be made available to diagnose and treat them. The National 
Guard has no organic resources on mental health to help on 
weekends or otherwise.
    As the number of combat veterans continues to grow, so does 
the need for mental health coverage. Our mental health delivery 
system must be made available for our veterans when they 
realize they need help and they ask for it. The Network for 
Relief and Aid Organizations, Crisis Support, web sites for 
children, web sites for self-help, medical information, 
volunteer organizations among the commercial, federal, state, 
nonprofit and local services is a huge maze to sift through 
when the family may already be in crisis.
    As resources change, improve or disappear, we must be able 
to provide them with resources to help them during their 
crisis. Again, we must help them find those right solutions 
with knowledgeable and experienced assistance. The National 
Guard continues to help improving resources to our families, 
soldiers, airmen through reunion and reintegration briefings, 
family activity days, marriage retreats and a transition 
assistance program, but we have more work to do. One of the 
ways that the National Guard provides assistance to our 
families and combat veterans is through our Family Assistance 
Coordination Centers or FACCs. We have eight FACCs in the State 
of Washington, and they cover local communities in 12 towns. 
They are manned by temporary staff.
    We must keep this essential link to find the right 
resources for our families and veterans. The need for FACCs is 
abundantly clear in the number of inquiries they respond to in 
a month. They range from over 2,600 contacts in a month to over 
7,500 contacts in July this year, which included youth camps. 
Our assistance has helped members of every single component and 
branch except for the U.S. Coast Guard. The need for our FACC 
services is growing, and we need to ensure this resource for 
our veterans and their families is available. The funding for 
FACCs should not be tied to mobilization as it currently is, 
rather it should be a constant service provided to families, 
military members and combat veterans.
    Medical assistance should not be limited to the first three 
to six months after their return to their home when issues such 
as PTSD or TBI can take years or longer to manifest and 
resolve. The longer the problem is not treated, the more 
complicated the treatment becomes due to complications that 
arise from the lack of treatment. As a result, again, our 
families suffer, sometimes on a daily basis. We should be proud 
of the progress we've made so far and commit ourselves to the 
long term for our families and veterans. More robust medical 
and mental health care services and permanent staffing of our 
FACCs are needed to help our veterans and our families now and 
in the future.
    As we look ahead to continued deployments, I encourage 
everyone here to continue our collaborative efforts and improve 
services to care for those who have given so much. Thank you.
  Prepared Statement of Lieutenant Colonel Carol Seger, State Family 
           Programs Director, Washington Army National Guard
    Chairman Akaka, Senator Murray, Members of the Committee and 
distinguished guests, I am truly honored to be here today and to have 
this privilege to speak to you on behalf of my fellow Guard Family 
members, Soldiers, Airmen and Combat Veterans. My name is Lieutenant 
Colonel Carol Seger and I have served in the National Guard over 28 
years. I am currently the State Family Programs Director and I work to 
assist military Families, which includes our Servicemembers and 
Veterans, to become self-reliant through education and empowerment. We 
help our Families by helping the Soldier'/Airman/s transition to 
civilian life after returning from deployment. We evaluate their 
circumstances and provide the appropriate information and services. We 
help our Families regardless of their geographical dispersion or 
deployment status.
    Reintegration back into civilian life is complex and it takes time. 
The entire Family suffers when a Veteran's mental health needs are not 
acknowledged and resolved; it can strain even the strongest of 
marriages. PTSD and other mental health conditions are sometimes 
difficult for Servicemembers to come to grips with. In some cases it 
can take years for our Combat Veterans to admit they have PTSD--long 
after their access to medical treatment has expired. After our Veterans 
acknowledge that they need help, medical professionals must be 
available to diagnose and treat them. The National Guard has no organic 
mental health capability for weekend assistance or otherwise. As the 
number of Combat Veterans continues to grow, so does the need for 
mental health coverage. Our mental health delivery system must be 
available for our Veteran's when they realize they need help and ask 
for it.
    The network for Relief and Aid Organizations, Crisis Support, web 
sites for Kids, Self Help web sites, medical information, Volunteer 
Organizations among the commercial, Federal, state, non-profit and 
local services is a huge maze that is difficult to sift through when 
the Family may already be in crisis. As resources change or improve or 
disappear, we must be able to provide them with up-to-date resources. 
Again, we must help them find the right solutions with knowledgeable 
and experienced assistance.
    The National Guard continues to improve providing resources to our 
Families, Soldiers and Airmen through Reunion and Reintegration 
Briefings, Family Activity Days, Marriage Retreats and the Transition 
Assistance Program; but we have more work to do.
    One of the ways the National Guard provides assistance to our 
Families and Combat Veterans is through our Family Assistance Center 
Coordinators or FACCs. We have eight FACCs in Washington, covering 
offices in 12 communities that are manned by temporary staff. We must 
keep this essential link to find the right resources for our Families 
and Veterans. The need for FACC services is abundantly clear in the 
number of inquiries they respond to in a month. They range from over 
2,600 contacts in a month to over 7,500 in July of this year, which 
includes support to Youth Camps. Our assistance has helped members of 
every component and branch except for the Coast Guard. The need for 
FACC services is growing and we need to ensure this resource for our 
Combat Veterans and their Families is available. As for the funding for 
FACCs, this should not be tied to mobilization; rather, it should be a 
constant service to be available to provide assistance to Families, 
Military members and Combat Veterans. Assistance should not be limited 
to the first three or six months after they return to their home 
stations when issues such as PTSD or TBI can take months or years 
longer to manifest and resolve. And the longer the problem is not 
treated, the more 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.
    We should be proud of the progress we've made so far and commit 
ourselves to the long term for our Veterans and their Families. More 
robust medical and mental health services and permanent staffing of our 
FACCs are needed to help our Combat Veterans and their Families now and 
in the future. As we look ahead to continued deployments, resources for 
our Veterans and their Families will need to continue. I encourage 
everyone here to continue our collaborative efforts and improve the 
services to care for those who have given so much. Thank you.

    Senator Murray. Thank you very much. Stephen Franklin. 
Thank you.

        STATEMENT OF SERGEANT STEPHEN FRANKLIN, MEMBER, 
                 WASHINGTON ARMY NATIONAL GUARD

    Mr. Franklin. Senator Murray, thank you for the opportunity 
to be here today. My name is Stephen Franklin. I am a sergeant 
in the Washington Army National Guard, and I returned from Iraq 
on December 15, 2005 after a one-year deployment. Approximately 
60 to 90 days after my return, I started having a difficult 
time adjusting to life at home. I found myself constantly 
checking doors and windows to see if they were locked. I cannot 
concentrate and was not comfortable around civilians. I was 
unable to sleep. I was not comfortable in my civilian job as I 
did not feel safe without the protection of my fellow soldiers 
around me. I returned to work for the National Guard. I went to 
the doctor at Madigan. The doctor prescribed me with sleeping 
pills to try to help me sleep, help me with my sleeping issues, 
but nothing to help my other issues. Needless to say, the 
sleeping pills made me too tired to function the next day.
    About a month later, a friend pulled me aside and told me 
that they had noticed a change in my behavior and work ethic 
and that they were concerned. I've become very short with 
people, easily drawn to anger and had to walk away from people 
so that I would not blow up. I wasn't this way before. I went 
to the VA at American Lake with my issues. The doctor diagnosed 
me with PTSD. The doctor prescribed me with depression pills 
and more sleeping pills. I told the doctor that I could not 
function in the morning after taking the sleeping pills. The 
doctor told me that she thought I should try both medicines.
    Once again, the medicines did not work. The depression 
pills brought on side effects that I could not stand, including 
nausea, vomiting and grogginess. The sleeping pills had the 
same negative side effects. I joined the PTSD group which met 
twice a week, anywhere from two to five members. There were 
veterans from OIF/OEF and Vietnam. I have attended the group 
for eight to nine months, and it seemed to work while I was 
there. But once I left, I was right back in the same rut that I 
had been trying to get out of for almost a year now. Over the 
course of many doctor visits in the past year and a half, I 
have told the doctor that I have felt the need for something to 
relax me, not knock me out cold. They continue to raise and 
lower doses of depression pills and sleeping medicine.
    Finally on July 25, 2007, the doctor at the VA finally 
listened to me and got me the right medication. I have been 
able to live with PTSD and my family can now live with me. 
Throughout my transition home, my PTSD made things very 
difficult on my family. I had become standoffish, short-
tempered. I was not able to give my wife or children the 
affection that they needed. I was extremely fortunate that my 
wife was so supportive, as it would have been so much harder 
for me to recover without her understanding. Overall, I feel 
that the care I received was good, but I am frustrated that the 
doctors would not listen to me sooner. If only the doctors 
could have listened to me, the soldier, and not just categorize 
me as another soldier with PTSD, I would have been feeling 
better a year and a half ago.
       Prepared Statement of Sergeant Stephen Franklin, Member, 
                     Washington Army National Guard
    My name is Stephen Franklin, and I returned from Iraq on December 
15, 2005, after a one-year deployment. Approximately 60 to 90 days 
after my return I started having a difficult time adjusting to life at 
home. I found myself constantly checking doors and windows to see if 
they were locked. I could not concentrate and was not comfortable 
around civilians. I was unable to sleep. I was not comfortable in my 
civilian job, as I did not feel safe without the protection of my 
fellow soldiers around, and returned to work for the National Guard.
    I went to the doctor at Madigan. The doctor prescribed me with 
sleeping pills to try and help my sleeping issue, but nothing to help 
with my other issues. Needless to say, the sleeping pills made me too 
tired to function the next day.
    About a month later, a friend pulled me aside and told me that they 
had noticed a change in my behavior and work ethic and they were 
concerned. I had become very short with people, easily drawn to anger, 
and had to walk away from people so that I wouldn't blow up. I wasn't 
this way before.
    I went to the VA at American Lake with my issues. The doctor 
diagnosed me with PTSD. The doctor prescribed me with depression pills 
and more sleeping pills. I told the doctor that I couldn't function in 
the morning after taking sleeping pills. The doctor told me that she 
thought I should try both medicines.
    Once again, the medicines didn't work. The depression pills brought 
on side effects that I couldn't stand, including nausea, vomiting and 
grogginess. The sleeping pills had the same negative side effects.
    I joined a PTSD group which met twice a week with anywhere from 2-5 
members. There were veterans from OIF/OEF and Vietnam. I attended the 
group for 8-9 months and it seemed to work while I was there, but once 
I left I was right back in the same rut that I had been trying to get 
out of for almost a year now.
    Over the course of many doctors visits in the past year and a half 
I have told the doctor that I felt I needed something to relax me, not 
to knock me out cold. They continued to raise and lower doses of 
depression pills and sleeping medicine.
    Finally, on July 25, 2007, the doctor at the VA finally listened to 
me and got me the right medication. I have been able to live with PTSD 
and my family can now live with me. Throughout my transition home, my 
PTSD made things very difficult on my family. I had become stand-
offish, short tempered, and was not able to give my wife or children 
the affection that they needed. I was extremely fortunate that my wife 
was so supportive, as it would have been so much harder to recover 
without her understanding.
    Overall, I feel like the care I received was good, but I am 
frustrated that the doctors wouldn't listen to me sooner. If only the 
doctors would have listened to me ``The Soldier'' and not just 
categorized me as just another soldier with PTSD I would have been 
feeling better a year and a half ago.

    Senator Murray. Thank you very much. We now turn to Dan 
Purcell.

         STATEMENT OF SERGEANT DANIEL PURCELL, MEMBER, 
                 WASHINGTON ARMY NATIONAL GUARD

    Mr. Purcell. Senator Murray, thank you for this 
opportunity. I truly appreciate it. Second I would like to say 
that as a Washington State Guardsman, I'm proud to serve. I'm 
proud of my duty, and I would certainly do it again. My story 
is approximately 3 years old and still counting, but it is not 
some anomaly. It is indicative of that which has happened to so 
many other returning veterans requiring medical attention for 
not only mental, but physical injuries incurred both on and off 
the battlefield. In my unit alone after our deployment, we lost 
two guardsmen for mental health reasons, one for self-
medicating and the other just lost it on his job one day; both 
were in their early 20's and neither were able to travel the 
necessary distances to get help from the VA.
    On May 29, 2004, while serving as an embedded Army 
photojournalist with the 1st Calvary Division in Sadr City, 
Iraq, I severely injured my left foot during a mission to bring 
in one of Muqtada Al-Sadr's lieutenants. Though the injury was 
not life threatening, without proper medical care it continued 
to plague me throughout the remainder of my deployment. Since 
my return home in February of 2005, I have spent the last two 
and a half years getting bounced from the active duty component 
to the VA health care system and back to the active duty 
component in search of medical treatment for my injury and its 
rapidly deteriorating condition. During this time I have also 
had to deal with post-deployment anxiety and depression issues, 
a majority of which was aggravated by the bureaucratic asylum I 
found myself in. Unlike Iraq where the mission and the enemy 
were clear, I was now faced with a new enemy called budget 
cuts, rationed resources and misplaced priorities. Rarely has a 
day passed that I have not been angry about the undignified way 
I have been treated by the institutions that are supposed to be 
here to ensure my medical recovery, or angry about the life 
I've had to give up in my almost futile quest to find medical 
redress for injuries, or angry for having to fear for a very 
uncertain future.
    Every day is a new day and another exercise in futility. We 
always have to fight for something, whether it's the right type 
of medical treatment, fair compensation for being found 
medically unfit for duty, or something as simple as the right 
to go home on pass to see your child. Imagine if Congress had 
to fight for the same things. I imagine they would be a little 
more empathetic toward better treatment for injured veterans. 
Support for our troops doesn't end with a 15-second soundbite. 
On June 19th of this year I finally received the surgery I 
desperately needed. It has been a long and arduous journey. My 
foot injury would not have survived another deployment or a day 
at the range for weapons qualification. Still there is no 
closure. Though the surgery was without complications, the 
doctor's prognosis was 60 to 80 percent chance of success with 
two caveats. The first is that I won't know for at least a year 
as to how successful the surgery was, and the other is that I 
may have to have another surgery in the next several years 
anyway.
    The initial injury could have been fixed quickly by casting 
the foot and stabilizing it for six to eight weeks, but because 
it was allowed to fester for 3 years, the injured bone had to 
be removed, and what was left of the tendon it had been rubbing 
on had to be reconstructed. In the last 3 years my career has 
languished. My daughter has grown all the more distant by our 
geographical separation. I have yet been able to reintegrate 
back into civilian society, and in the next year I stand to 
lose my current job as a military technician due to my injury 
and its uncertain prognosis. Sadly, I, like so many of my 
fellow veterans, have lost faith with the business as usual 
attitude of our current system.
    We went to war and were changed. Why can't our bureaucracy 
change too? We need fearless leadership willing to act on our 
behalf and not more good ideas that never leave the paper they 
are written on. We need people willing to put our needs above 
their own individual agendas and act just as we did in putting 
our country's need above all else when it mattered most. The 
fact of the matter is we are not tools that are to be casually 
discarded when broken or found to be no longer useful. We are 
also taxpayers who want to know what our elected 
representatives and their agents are going to do to correct 
this grievous unjustice.
    I know what is being done and what isn't, and I know that 
we have been denied a right that was a condition of our 
service. I know that it just doesn't make sense when Congress 
can allocate millions of dollars for new gym equipment and I 
can't get the $20,000 or $30,000 to correct an injury incurred 
on the battlefield. I also know we can do much better, and in 
truth, it really seems disingenuous to me that we should go to 
such great lengths to help the world when so many of our own 
people are left wanting for basics. Thank you for the 
opportunity.
        Prepared Statement of Sergeant Daniel Purcell, Member, 
                     Washington Army National Guard
    I, SGT Daniel Purcell, am a member of the Washington Army National 
Guard. I deployed with my unit to Iraq in February 2004. Our unit was 
assigned to the 1st Cavalry Division in Baghdad.
    Prior to my deployment I had worked at Boeing, Spokane and was 
going to school full time to obtain credentials to begin a second 
career as a medical assistant. At the time of my mobilization in 
January 2004, I had to withdraw from my college program.
    During my tour of duty, I both served as an embedded 
photojournalist and saw action during combat operations with the 2-5 
Cavalry Regiment in Sadr City from March to August 2004, and then I was 
sent to the 4th Brigade Combat Team area of operation at Camp Taji from 
September to December.
    On May 29, 2004, while on an early morning mission to capture one 
of Muqtada Al-Sadr's lieutenants I rolled my foot stepping off some 
stairs and injured my foot severely. By the time we returned to our 
base my foot was so swollen I was unable to walk and was taken to the 
aid station. The initial examination and x-ray did not indicate a 
broken bone so I was given 7 days of bed rest to allow the swelling to 
go down and then I was to report back to duty.
    In the months following the incident, my foot never healed properly 
and continued to plague me while on combat operations. Several visits 
to the aid station only netted me more Ibuprofen.
    Following my return to Washington State in February 2005, I brought 
my previous injury to the attention of the redeployment clinic at 
Madigan Army Medical Center. It was determined that my injury was 
nothing more than a bone spur despite my expressed concerns regarding 
the difficulty I was having in walking.
    I was told I could get it looked at while using my 6 months of 
TRICARE Transitional Assistance. In March I returned to Spokane and 
sought treatment at Fairchild AFB. I was told that I could go but would 
only be seen on a standby basis only. Without an appointment I opted 
not to go and sit all day in the waiting room to see if there was a 
cancellation and they could fit me in.
    In April I accepted a job offer working for the Washington Army 
National Guard at Camp Murray as a military technician. I took this job 
because for the most part it would put me next to the VA and MAMC where 
I thought I would have access to medical treatment for my foot. This 
was a very painful decision because I had already left my daughter for 
the year I was in Iraq, but now I had to leave again for some 
indeterminate period.
    After assuming the new job, I immediately tried to get seen at 
MAMC. First, I was told I had to go to the VA. Then when I was finally 
given an appointment for Podiatry I had to wait 3 months (May to July).
    Beginning with my first appointment in July, I was seen once in 
August and again in October. In November they finally did a bone scan 
and had determined what the issue was. When I tried to make a follow up 
appointment for a treatment plan, I was told my 6 months of TA was up 
and that I would have to go to the VA for further treatment despite my 
many protests.
    For the next year and a half I languished at the VA awaiting 
treatment or surgery for an injury that was now deteriorating rapidly.
    In July 2005, I was referred to the American Lake VA by a Dr. 
Colson (VA Psychiatrist) for a mental health intake interview. At the 
time I was experiencing severe panic attacks. Getting the appointment 
took only days, however, it took 4 months to actually get a follow up 
appointment with a counselor. I was eventually diagnosed with PTSD 
following another six more months of counseling.
    Since my return from Iraq in 2005, I have not been able to fully 
integrate back into civilian society. I place a large part of this 
problem on our government bureaucracy and its agents.
    Though I have been diagnosed with PTSD I have not been able to find 
relief. I have had to spend, literally, a majority of my time trying to 
find medical treatment for my injuries sustained in Iraq. I have been 
bounced from the Army to the VA back to the Army and almost bounced 
back to the VA again.
    I have had to wait, literally, for months at both the VA and 
Madigan Army Medical Center to be seen just for my foot injury. I have 
even gone so far as to use my personal insurance and money to get my 
other injuries looked at by civilian doctors.
    What kind of government and its agents vote to send its citizens to 
war, and all but refuse to treat their injuries when they return?
    Why do our elected officials have access to better medical 
treatment than the soldiers who protect and defend this country with 
their very lives? But more importantly, why are so many of the same 
elected officials so grievously unwilling to do the right thing by the 
same veterans they sent to war?

    Senator Murray. Thank you very much, Dan. I appreciate it. 
Mr. Ron Fry.

            STATEMENT OF RON FRY, DEPUTY COMMANDER, 
                BLUE MOUNTAIN VETERAN COALITION

    Mr. Fry. Senator Murray, I would like to begin by 
recognizing you for the battles that you have waged over the 
years on behalf of our Nation's veterans. When no one in the 
Veterans' Administration would listen to the cries for help 
from the veterans, Senator Murray did. She took off her tennis 
shoes, put on her combat boots and made good things happen for 
veterans, and she still is. Through her actions she saved three 
veterans hospitals in Washington State, caused the 
establishment of necessary Community Based Outpatient Clinics 
and was very instrumental causing much needed funding for 
veterans health care be increased to our Nation's veterans. 
Senator Murray, you are our hero.
    I'm Master Sergeant retired Ron Fry of the United States 
Army. I served my last 17 years out of 20 with Special Forces, 
2 years in Vietnam running special operations, wounded twice 
and a number of other things. I'm here to tell you after 36 
years of being away from the war, it's just as fresh in my mind 
as it was 36 years ago. The things that are being described by 
these people today happened to us back then, and I'm quite sure 
if you had a World War II veteran, or if you have a Korean War 
veteran, or a family member from back in those days, they would 
be telling you the same thing and having experienced the same 
kinds of problems that they have with themselves, and the same 
kinds of problems they're having with the VA, Congress and the 
Administration of getting the promised help that they earned 
when they went into military service and went through the 
combat.
    I would like to thank all of the Members of the Veteran' 
Affairs Committee, especially the panel members, and I would 
really like to thank all of the combat veterans who are here. 
We've got to stand up and fight for those who can't. The VA and 
the military under this current Administration has had an 
attitude of putting the dollar before the welfare of the 
veteran and his family or her family. That has got to cease, 
and I'm proud to say that a lot of that changed January 1 and 
we're getting more and more of the benefits sent to the veteran 
that needs it.
    The problem of mental health that our veterans have 
encountered is now recognized as Post Traumatic Stress 
Disorder. The illness didn't just happen. It was caused by 
American soldiers being sent, and I'm including all of the 
military branches, exposed to the horrors of war. Our 
servicemen were then upon being sent into those war zones were 
expected to do something our culture speaks against in our 
churches, in our homes, from our mothers, fathers, we were 
expected to go in and kill people, and we did. But it's not as 
simple as that. Once you have killed them, you stand over them, 
and I've been there and done that. You recognize that thing on 
the ground is a human being. One of them that I had the 
experience of being with had a diary on him and the diary was 
written to his wife and had drawings of her in it; that 
particular diary and that particular incident, one of many that 
haunts me day and night even today. The injustice of killing 
people to solve political and/or economical problems just goes 
beyond me.
    The veteran that is exposed to the horror of watching other 
veterans being killed, his friends, people he shares his time 
with, people that look out for him and people that he looks out 
for, those memories of those horrible things will last that 
veteran and be with them for the rest of his life, her life. 
There is no fading. I've talked to the to VA doctors about this 
and I have asked them in treatment, because I'm a patient there 
as well, will PTSD ever go away and leave me in peace? Their 
response universally has been, no, you will always have it, and 
in most cases you can probably expect it to increase in 
severity. I've talked with a gentleman who is going to speak 
today, and I am interested in hearing what he has to say, 
because he says there is a cure for PTSD. I don't think so. And 
so I would like to know what it is.
    The memories of those war-time experiences don't fade. You 
can smell the gunpowder. You can feel the explosions. You can 
hear the screams and the cries. They're here right now with us, 
not just in me, but other vets out there. Some of these 
veterans as well. Unfortunately, the return of the veteran does 
not meet with an understanding of what they experienced in 
combat. When I came back from Vietnam 36 years from my second 
tour, as was my first, I was given a wonderful plane ride home, 
served great food, had a couple cans of cold beer, and landed 
in McChord Air Force Base. When we landed there, I got off the 
airplane, took my bags, walked right straight through the 
lobby, got in a cab, rode to the bus station and went home. 
There was no counseling. There was no preparations to help 
defuse me, because in Vietnam just prior to that airplane ride, 
I was picked up on the battlefield in a helicopter. When I 
entered that helicopter, there were stacks of plastic bags with 
American soldiers' bodies in them like cords of wood. All I 
could do to get into the airplane was sit on them. That was my 
final exposure to Vietnam. Those are the kinds of things our 
veterans are experiencing in combat. Those are the kinds of 
things that most doctors, psychologists and others, I challenge 
them to able to understand that have not been there. It's one 
thing to learn what the schools teach. It's another thing to 
experience what your veterans are truly going through.
    Now, veterans when they come back, they don't know that 
they have PTSD. They just know that there is a lot of trouble 
that they're having with their life and their family. Veterans 
usually have to be told that they have a problem, and usually 
have to be carried to the VA or to a counselor somewhere who 
can treat that problem for PTSD. They procrastinate. They would 
rather go back in seclusion somewhere than deal with the 
problems. One way they do that is they go back into alcohol or 
they start alcohol, drug abuse to try to escape the memories of 
those things. While many of those who are responsible for 
treating that veteran and helping American families of those 
veterans to heal--thank you--so that they can become whole 
again. And I'm sorry about taking up too much of your time. I'm 
going to break off that and just run through this, because 
there are a couple of things here that we need to make sure 
that are taken care of.
    Senator Murray. Ron, I want you to know all of your written 
testimony will be part of the record and you have very 
compelling testimony, but if you can wrap up, I want to make 
sure that--
    Mr. Fry. Yes.
    Senator Murray [continuing].--we have time for testimony.
    Mr. Fry. I would suggest that you do get hold of a copy of 
my testimony, and probably that testimony could be assigned for 
almost all combat veterans who have had to serve in this 
country. We need less bureaucracy and more leadership like we 
get from senators like Patty Murray. We need that. We need to 
stop studying and start treating more. We need to increase the 
availability of medical staff to our veterans and not decrease 
it, and Senator Murray has been an advocate for that for the 
longest period of time. So let's get on the ball and quit being 
a bureaucrat with a priority of saving money as opposed to 
treating American veterans. Let's put Americans number one. 
Thank you, Senator.
           Prepared Statement of Ron Fry, Deputy Commander, 
                    Blue Mountain Veteran Coalition
    I would like to begin by recognizing Senator Murray for the battles 
she has waged over the years on behalf of this Nation's Veterans. When 
no one in the Veterans' Administration would listen to the cries for 
help from the Veterans Senator Murray did. She took off her tennis 
shoes and put on her combat boots and made good things happen for 
Veterans. Through her actions she saved three Veterans hospitals in 
Washington State, caused the establishment of necessary Community Based 
Outpatient Clinics and was very instrumental in causing much needed 
funding for Veterans health care to be increased. Senator Murray you 
are our hero.
    I would like to thank all Members of the Senate Veterans' Affairs 
Committee, panel members, guests and most important the Combat Veterans 
to include all Veterans that are here today. The Veterans truly 
appreciate the opportunity the Senate Veterans' Affairs Committee has 
given us to provide critical input on Veterans mental health issues and 
the problems facing our Veterans, thank you.
    The problem of mental health illness that our Veterans have 
encountered is now recognized as Post Traumatic Stress Disorder (PTSD). 
This illness didn't just happened, it was caused. American Soldiers, 
Sailors, Airmen, Marines and Coast Guardsmen were introduced to the 
horrors of war by our Nation. Our servicemen were then expected to kill 
the enemy by any means possible. They were expected to align the sights 
of their weapons upon another human being and make the final decision 
to pull the trigger and kill that human being. The act of killing or 
being killed begins the development of PTSD. The Veteran then is 
exposed to the horror of watching other Veterans being killed and/or 
maimed in such horrible ways that the memory lives on inside the 
Veteran the rest of his/her life.
    The memory of those war experiences will continue to fester 
themselves in the mind of the veteran and will begin to affect the 
veterans personality, his relationship with family members, friends, 
employers and society as a whole.
    The Veteran often turns to drinking in excess and in some cases to 
illegal drugs. He/she will withdraw from family, friends and society. 
The withdrawal will be misunderstood by those persons that have not 
gone through the same experiences the Veteran has in combat. Society 
will shy away from its heroes compounding the problem the Veteran has 
with PTSD illness.
    Veterans, when they finally learn about the Veterans' 
Administration PTSD Program, turns to the VA for mental health care. 
The VA mental health Professionals examine the Veteran and make a 
diagnosis of PTSD that is service connected and begins treatment. The 
VA treatment facility requires the Veteran to submit a copy of his/her 
military discharge commonly known as a DD-214 which shows the Veteran's 
war service.
    The disabled Veteran armed with the diagnosis of a service 
connected disability by a VA Doctor and his/her DD-214 can now apply to 
the VA benefits side of the VA for disability compensation. The empire 
built by the VA over the years through its delaying tactics of 
approving a Veteran's disability claim significantly increases the 
stress well above his/her current levels. Veterans needing disability 
assistance now are put through an unnecessary process that often 
includes an initial denial of benefits followed by probably another 
denial or the minimum award of disability rating. The VA during its 
review of the Veterans disability claim will require the Veteran to be 
seen by a civilian doctor even though a VA doctor has already examined, 
diagnosed and are treating the Veteran for the disability. What a waste 
of VA Funding! The amount of redundant paper work and the great amount 
of that paper work surly is one of the major causes of the long 
stressful delays causing the VA Claims process to take 6 months to many 
years to complete. While the long drawn out claims process runs its 
course disabled Veterans who cannot work due to their disability(s) 
suffer extreme hardships. Many are forced into bankruptcy and/or become 
homeless even though the VA doctors have diagnosed the Veterans 
disability(s). The VA spends huge amounts of money on the Veterans' 
Administration Benefits side of the VA determining disability 
eligibility that should have already been determined by the VA doctors 
and the Veterans DD-214.
    The Veterans' Administration Benefits and its Regional offices 
spend more time looking for bureaucratic type reasons to deny and/or 
delay the valid disability claim of our Veterans. I have worked on 
Veterans disability claims for the last 15 years and have read the 
responses sent by the VA back to the Veteran justifying denial of the 
claim. What a laugh you would get reading those denials if it weren't 
for the unjustified pain and stress they put on our Veterans. The first 
denial appears to discourage the already ill Veteran from continuing to 
seek his/her valid disabilities claims from the VA. Thank goodness the 
Veterans Service Organizations have the foresight to develop a network 
of trained Service Offices to help the Veteran fight for their 
disabilities benefits from the VA.
    Veterans have come to think, and justifiably so, that the VA itself 
is the major obstacle to the Veterans getting their rightful benefits 
for service connected disabilities. The current VA system forces the 
Veteran to go to a VA medical center or clinic which often is the first 
encounter the Veteran has with the VA. This first appointment with the 
VA begins with a screening process that concentrates on the Veterans 
financial status and the category of eligibility he or she falls into.
    The first step in determining a Veterans eligibility to receive 
health care through the VA is the completion of the VA Form 10-10EZ, 
Application For Health Benefits (Attachment 1). The VA collects 
financial information on the Veteran, the Veteran's spouse and for some 
reason on the Veteran's first child. The VA uses data on the Veteran's 
income, property, and all assets and that of the Veteran's spouse and 
first born. The information is then compared to the annually adjusted 
financial thresholds of the MEANS test to determine if the Veteran will 
have to pay for medical care as spelled out in the VA manual titled 
Federal Benefits for Veterans and Dependents, 2007 Edition. The MEANS 
test is a system applied by our government to force the Veteran to pay 
into the cost of his/her medical care. The Veteran has already earned 
his/her medical benefits through service to our Country.
    This form of stealing from Veterans who have loyally and honorably 
served this country and earned the right to health care is totally 
unacceptable. A Veteran is a Veteran and was categorized as such 
because of service in our Military and therefore should not be 
penalized because they were able to have some measure of success after 
their military service. The MEANS Test must be abolished! It is time 
our government made the people of the United States of America its 
number one priority instead of the putting so many other countries 
first. We need to take care of America first.
    I have listed below a few areas of concern to our Veterans which 
include:

    1. The budget for Veterans health care must be mandatory instead of 
the discretionary funding system used now. This system of funding 
Veterans health care has been a failure. Under this system of funding 
only a small portion of Veterans needing health care are able to get 
earned treatment through the VA.
    2. The VA, citing funding shortages, through its CARES initiative 
have either closed medical facilities or greatly reduce the 
availability of Veterans health care. The VA by reducing health care 
services at many of VA medical care facilities to 8 a.m.-3:30 p.m. with 
no services on weekends or holidays. The Veteran is left to forge for 
medical care on the civilian market. The Veteran who would have his 
health care paid by the VA but now is at a great risk of having to pay 
for the treatment that the VA is supposed to be responsible for paying. 
This problem is serious. The VA in its instructions to Veterans 
concerning payment of medical bills on the civilian market list 90 days 
for the VA to settle the bill. Unfortunately, the civilian medical 
facility holds the Veteran responsible for the bill instead of the VA.
    Consequently, when the VA makes a decision to pay the bill and it 
exceeds the 90-day period as it usually does, the civilian medical 
agency turns the account over to collections . Veterans that have had 
this happen to them experienced a negative credit report and seizure of 
bank accounts and some have had to file for bankruptcy. The VA's 
response to this problem is to hold the Veterans responsible through 
current payment procedures for the bill. The VA has in effect forced 
the Veterans needing health care after hours, weekends and holidays to 
pay for health care that would have been available at VA Medical 
facilities had they not been shut down. The copayments that a Veteran 
pays at the VA has now turned into full cost on the civilian market.
    3. The VA headstone provided for a deceased Veteran cannot be 
placed upon his/her grave until the bill for the burial services has 
been paid in full. I talked to one family that cannot afford to pay for 
those services and has been carrying their father's headstone in the 
trunk of their car for the past two years. The Veteran who served his/
her country honorably deserves better.
    4. The red tape of the VA to Veterans holds no valid place in the 
Veterans need for medical and mental health care. The red tape is 
viewed as a make work job by some bureaucrat for job security as 
opposed to a real justifiable need of the Veterans. One example is how 
long it takes the VA to process the plans and design of a new VA 
medical hospital or clinic. That process adds years to the time of 
sending the request for a medical facility or clinic to Congress to be 
funded. That long drawn out process must be shortened so medical care 
needs of the Veteran can be met. The Walla Walla Veterans Medical 
Center is a good example of the problems created by the VA system. The 
VA had initially set 2009 for the major construction proposal for the 
Walla Walla Medical Center. That date has now been pushed by the VA 
forward to 2012. Congress is waiting on the request for funding but the 
VA process continues to hinder access to medical care needed by our 
Veterans.
    5. In a discussion I had with a VA mental health professional about 
the probability of all Veterans who have served in combat having some 
degree of PTSD. The mental health professional said that all combat 
veterans have PTSD from their combat experiences.
    6. The Veterans PTSD illness is having a profound effect upon the 
families of veterans and especially the families of Veterans that have 
been sent to combat zones on multiple tours. The Veteran that returns 
from combat will never be the same person to the spouse and children as 
when he/she left for the war. The Veteran will return home where he 
will exhibit the the symptoms of PTSD that has led to abuse of the 
spouse and children, paranoia, distancing of ones self, high number of 
divorces, drug and/or alcohol abuse, trouble with the law, suicide and 
so many more. The Veteran has trouble holding a steady job, he often 
moves around a lot, has trouble getting along with people, and is 
extremely uncomfortable in a crowd. Due to the Veterans PTSD illness 
he/she will have a much lower income producing capability. Thus emerges 
homelessness of the Veteran and/or family. The Veteran has not chosen 
to be mentally ill with PTSD but was sent to war by his/her country.
    The Veterans of the United States without question picked up their 
weapons and marched off to war to protect our families and the freedoms 
we enjoy. The civilian peer that did not have to march off to war is 
able to pursue a stable and more financially secure life for his/her 
family. The Veteran and family will have to suffer the effects of 
combat for the rest of their lives.

    Senator Murray. Thanks, Ron, very much. Thank you to all of 
our panelists today, and again, I really appreciate your coming 
and sharing your personal stories, and I know it's difficult. 
And as I said in my opening statement, my staff and I had a 
very hard time getting men or women to come and give their 
personal experiences. They weren't comfortable discussing them 
publically, and it all goes to the stigma of mental illness, 
and I hear that time and time again. It's one thing not to be 
able to come here and speak publically, that is hard, but if we 
want soldiers to be able to get treated, it seems to me we have 
to get past the stigma. And I wanted to ask our three 
servicemembers who are here, Dan, Brandon and Stephen, what can 
we do to address the cultural issues of serving in the military 
so that men and women who serve can get past that and get the 
help they need? And maybe, Dan, if I could start with you.
    Mr. Purcell. Could I get some clarification on cultural----
    Senator Murray. Interpret it any way you want to. You're 
all in the military. You are taught to fight. You come home and 
then you are supposed to talk about having a mental illness. 
How can we help soldiers deal with that? Or are we dealing with 
that or not or what can we do better?
    Mr. Purcell. I think one of the things that we could do 
better is to acknowledge that war is a different animal. And as 
I stated earlier, we went to war and we were changed. We were. 
Can't tell you how. We just are, and I think that we really 
need to acknowledge that we are not the same people that went 
forward. And when we come back on--I believe it was Brandon who 
pointed out in his testimony--it was like, well, what do we do 
with them? Well, let's give him an Article 15. We don't know. 
But if we could acknowledge that, yes, we do have something 
wrong, and maybe we do have to look at it and step outside this 
paradigm, step outside the box and say, OK, we really do have 
to look at this differently, and we have to acknowledge that 
they are not the same and find ways of treating them, get them 
the help, advise them appropriately. As Mr. Fry here mentioned, 
instead of talking about it, we need to actually act on this 
and start getting these veterans the help that they need. We 
need to be open. And what we're doing here right now, we're 
talking about it, and what we need to do now is start putting 
stuff in place. I wish I could be more eloquent about--write it 
down.
    Senator Murray. You did great. Let me ask, Stephen, how 
hard was it for you to ask for help?
    Mr. Franklin. It was extremely hard, Senator. It was 
different for me. I didn't know what was taking place within my 
own mind. VA said that there is help and once the symptoms 
started to show, I was able to talk with other veterans who had 
the same symptoms and problems, that's when I was able to step 
out of my shell and actually seek the help that I needed.
    Senator Murray. When you were in the service, did anyone 
ever say to you, your experiences here may complicate your life 
when you get home and there is help for you if that occurs?
    Mr. Franklin. No one ever told me that, Senator. I never 
knew that until things that were normal to me before I left 
started to become a problem to me after I returned, and I was 
finding a problem dealing with the normal things.
    Senator Murray. When you came home and separated from 
service, did anybody give you any information that you may be 
having trouble sleeping or anything else, did they tell you you 
could get help?
    Mr. Franklin. No one ever informed me of that either, 
Senator. Friends and family started to say, my you have a 
problem. And then the doctors at the VA honed right in it was 
PTSD.
    Senator Murray. Brandon, you gave us a very eloquent story 
about a friend who did commit suicide. We're hearing a lot 
about that. There was a recent study that came out in the last 
several days. Your friend, a terrible loss to all of us. Do you 
know if anybody ever reached out to him to give him help?
    Mr. Jones. I know that friends and family tried to, but the 
stigma that is attached to saying or admitting the fact that 
you are actually experiencing some sort of stress or a problem, 
automatically assigns a weakness to the person in the eyes of 
the people that are supposed to be helping them. Everybody gets 
this idea, like, people like Rambo, that it's just going to go 
nuts and go crazy, won't be approachable. And I know from 
talking to his wife that she did everything that she could to 
try to help him, but eventually just couldn't. Everybody did 
try to help him. He pushed further away because he was 
concerned about what would happen to his career.
    Senator Murray. To his career? And for you, you had a 
sleeping disorder. You had a lot of stress going on and you 
said when you were called up, you lost $1,200 a month income. 
You were close to losing your house, your car. A lot of stress 
going on in your family before you were even deployed, and what 
was it like for you? You are in training. You are being trained 
to go and fight in the Rambo that you just talked about, and 
yet, you are struggling with an illness that is so opposite of 
being Rambo. How did you get in your own mind to a place where 
you could deal with that?
    Mr. Jones. I personally just had to learn how to reassign a 
lot of it and stuff like that and try to make them 
constructive. It still makes it difficult to focus sometimes on 
the job that I have to perform. Some are more understanding 
than others as far as dealing with it. I still personally think 
it's more difficult for a person to admit their own 
shortcomings than it is for me--it's much easier for me to tell 
the story of my friend who killed himself.
    Senator Murray. I want you to know as we talked to Brandon 
about his testimony, he only wanted to talk about his friend 
and not about himself, and so, I appreciate your doing that. So 
for the three of you, you found help for yourself. How many 
people are out there that have not?
    Mr. Purcell. In my narrative, I mentioned two people in my 
unit, but these people seeing it happen, and you're trying to 
give them guidance where to go and there are these geographical 
distances that these young men would have to travel, et cetera, 
et cetera. So a lot of times they just give up because of the 
distance and the time. I stayed with it. But it took me three 
years, Senator.
    Senator Murray. So it was bureaucracy and paperwork that is 
part of the challenge----
    Mr. Purcell. Absolutely.
    Senator Murray [continuing].--get past the stigma and ask 
for help, and then you've got paperwork you have to deal with. 
Is that an issue?
    Mr. Purcell. Sure. And sometimes it can be as much as like 
going in and say, OK, I've got these two issues. And they look 
at you and it's, like, well, we can only deal with one at a 
time. And it's, like, wow, which one is it going to be, is it 
going to be A or B? I was paying out of my pocket with my own 
civilian insurance and my copays to go get B. I had to 
prioritize and prioritize in my case was my foot injury, but 
the physical and the mental, these are all intertwined, and 
it's just utter frustration where people just say, I've had 
enough and they go away.
    Senator Murray. What about denial of benefits? I've heard 
stories of soldiers with a gun in one hand and there is another 
gun in the other. Is that anything any of you have heard about?
    Mr. Fry. You'll find in my prepared statement that I have 
been a veterans service officer, of sorts. For over 15 years 
I've processed claims. I've had an opportunity to look into a 
lot of them. The pattern seems to be that the first time the 
claim is sent in, and you can ask the veterans in the audience 
for their opinion, the pattern has been that they're going to 
expect a denial the first time. It doesn't matter, in many 
cases, how well it's written or how well it's documented. And 
that denial is going to come back and they're going to want 
more information, and you've already given everything you 
possibly could. It goes back in so there becomes a mountain of 
paperwork. It's very confusing, very complicated. And I don't 
understand why when the veteran goes in to get treatment for 
his or her mental health problem, or any treatment at the VA 
facility, the first thing they do is screen them. They take a 
copy of his DD-214, his discharge document, which has on it his 
war time service, his medals and what have you, and they screen 
that to see where they're eligible in that hierarchy of things. 
And then they send them in for a diagnosis with the VA doctors, 
one of those would be a mental health doctor. When VA diagnosed 
that person with PTSD, the claim is then prepared and sent 
forward usually by a veterans service officer. When it gets to 
VA, they're going to schedule after they go through all these 
denials of things, they call up a pension hearing. Of all 
things they're going to have them go right back to some doctor 
that the VA is paying for on the veterans benefits side of the 
house to tell them whether this veteran has what the VA doctor 
has already diagnosed them with the illness.
    Senator Murray. It seems to me that it's not only cultural, 
but once you get to the point where you're willing to ask, 
there is so much paperwork to go through, it's almost denial is 
the real issue.
    Mr. Fry. Yes, and over time----
    Senator Murray. Ron, you'll have to finish up real quickly 
and then I'll move to Kathy.
    Mr. Fry. OK. Over time it seems as though the VA has 
structured--and it's not just the VA, the Social Security 
Office does the same thing--such an obstacle to the veteran 
getting the benefits claim through, particularly in a timely 
fashion that it's become almost ineffective.
    Senator Murray. Kathy, did you want to comment on that.
    Ms. Nylen. Yes, ma'am. I also work extensively with the 
claims process, and while I will not agree that it is an 
automatic denial the first time a claim is submitted, I work 
well enough with the VA to know that that is not true; however, 
when those claims are denied, the common pattern is the 
unverifiable stressors. Not every mental health disorder needs 
a stressor statement for one thing, and we quite often get 
asked to provide a statement. We see mental health and we start 
talking PTSD stressor verification when in many cases it's 
simply just questions which goes a different path to be service 
connected.
    However, the verification of the stressor itself I feel 
could be better improved again by better recordkeeping between 
the DOD and the individual's private medical records so that we 
can go back and verify the events that caused the underlying 
stressor. But a real problem I think is the rubber stamping 
that's done when--I'm a sailor, so I am used to saying sailor--
a soldier, be that a man or woman, starts having difficulty, is 
not the same soldier they were, we see them being treated and 
discharged with the label of having a personality disorder. 
Personality disorders are looked at automatically as 
congenital, hereditary, not caused by service, therefore, you 
are not going to get service connected benefits, and we never 
look beyond to see what happens. As Mr. Fry and Mr. Purcell 
mentioned these other men if you go to war, you're changed, and 
it's just not combat. There is a high incidence now of sexual 
trauma and rape while on active duty. That's an additional 
issue, but I do think the stigma and the attitude of anybody 
that is dealing with a veteran who is claiming that they 
experience a stressful event, we must be more aware and open to 
all possibilities, not ever try to put it into a box, because 
it's a very individual situation. But the use of a personality 
disorder on the discharge papers is a huge hurdle to overcome.
    Senator Murray. Unfortunately, we have to move to our next 
panel, but I will use what all of you have talked to me about 
to ask some questions. Do we have anything available for family 
members? I'm certain that some of the issues you have gone 
through has impacted your families directly, were they given 
any kind of support while you were going through this? I will 
ask our three veterans.
    Mr. Purcell. No, Senator, not in my particular case, I 
didn't see.
    Senator Murray. Steve?
    Mr. Franklin. Nothing that I am aware of that's readily 
available to parents or children that was easily accessible.
    Senator Murray. Well, thank you to this panel. I'm sure 
that if we had more time, I'd ask you more questions, but we 
have two more panels, and we need to move to them. Thank you so 
much.
    We would like our second panel to come forward. Testifying 
on our second panel today are Dr. Antonette Zeiss, the Deputy 
Chief Consultant in the Office of Mental Health Services, 
Department of Veterans Affairs in Washington, DC. Diana Rubens, 
the Western Area Director of the Veterans Benefit 
Administration from Phoenix, Arizona; accompanied by Carol 
Fillman, who is the Regional Director of the Veterans Benefits 
Administration here in Seattle. Dennis M. Lewis is the Director 
of the VA Northwest Health Network (VISN 20). Accompanying Mr. 
Lewis is Stan Johnson, who is the Director of the VA Puget 
Sound Health Care System in Seattle. Major General Timothy 
Lowenberg, the Adjutant General of Washington. Brigadier 
General Sheila Baxter, the Commander of Madigan Army Medical 
Center. And finally, John Lee, who is the director of the 
Washington State Department of Veterans. I want to thank all of 
our panelists who are now here before us and for your 
participation today, and we are going to begin on my far left 
with Dr. Antonette Zeiss. Thank you very much for coming here.

       STATEMENT OF ANTONETTE ZEISS, Ph.D., DEPUTY CHIEF 
         CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES, 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Zeiss. Good morning, Senator Murray. I'm pleased to be 
here today to discuss how the Department of Veterans Affairs is 
addressing mental health care needs of our veterans. We have 
seen returning veterans from prior eras to the current 
Operation Enduring Freedom and Operation Iraqi Freedom conflict 
who have injuries of the mind and spirit as well as the body. 
Our goal is to treat a veteran as a whole patient, to treat a 
patient's physical as well as any mental disorders.
    Since the start of OEF/OIF, over 717,000 servicemembers 
have been discharged and become eligible for VA care. Of those, 
35 percent have sought VA medical care. Among those veterans, 
mental health problems are the second most commonly reported 
health concern. As was mentioned previously, we have now almost 
38 percent reporting symptoms suggesting a possible mental 
health disorder. The diagnosis of Post Traumatic Stress 
Disorder topped the list for possible mental health diagnoses, 
but depression and nondependent abuse of substances also have 
high rates, and there are many other problems that people bring 
to us as well, so it's important not just to assume PTSD but to 
do careful evaluations of the full spectrum of possible mental 
health problems.
    VA data show that the proportion of new veterans seeking VA 
care who have a possible mental health problem has increased 
over the past two years. For example, the proportion with 
possible mental health problems at the end of FY 2005 was 31 
percent, but that is compared to nearly 38 percent in the most 
recent report released in April of 2007. PTSD diagnoses during 
the same time frame went from 13 percent to almost 18 percent.
    Funding resources are available for a VA mental health 
initiative that supports implementation of our comprehensive 
Mental Health Strategic Plan, and that plan is based on the 
President's Freedom Commission report on mental health. Using 
mental health initiative funding, we have done many things to 
establish many programs, but one statistic, for example, is 
that we have hired over 3,000 new mental health professionals 
in the last 2 years, with another 1,000 or so hires in the 
pipeline and more that will be funded now with the new 
supplemental budget, which included 100 million for mental 
health and 20 million for substance abuse.
    In addition to our mental health specialty care sites in 
our medical facilities, we have expanded mental health services 
in the Community Based Outpatient Clinics with onsite staffing 
and by telemental health. We have enhanced PTSD, homelessness, 
and substance abuse specialty care services. We developed a 
military sexual trauma support team to ensure that VA fully 
implements military sexual trauma screening and treatment. We 
are fostering integration of mental health and primary care in 
medical facilities clinics and in the care of home-bound 
veterans who are served by VA Home Based Primary Care program. 
Moreover, the VA provides services for homeless veterans, 
including transitional housing paired with services to address 
social, vocational and mental health problems associated with 
homelessness.
    Focusing on concerns about suicide in veterans, the recent 
report was about active-duty military, but it is certainly a 
concern for us all. Those mental health needs, and things that 
have been described by the previous panel, may come to us in 
people seeking help from VA. We have funded a suicide 
prevention coordinator in every VA medical facility. A national 
hotline for suicide prevention is now available and functioning 
very effectively. I'm happy to provide more information about 
that if that would be helpful. The VA sponsored its first 
suicide prevention awareness day, which included every VA 
facility and will sponsor a VA suicide prevention awareness 
week September 9th through the 15th, in conjunction with the 
National Suicide Prevention Awareness Week.
    In addition to mental health services at VA facilities, 
VA's Vet Centers provide counseling and readjustment services 
to returning war veterans, and in some cases their family 
members, in a community setting. Vet Centers provide an 
alternative to traditional access for veterans who may be 
reluctant to come to our medical centers and the clinics. At 
Secretary Nicholson's direction, we have increased the number 
of staff in our Vet Centers by establishing outreach 
counselors, many of whom are Global War on Terror veterans 
themselves. You will hear more about Vet Centers I believe from 
another panelist as well.
    The VA continues to promote early recognition of mental 
health problems. Veterans are routinely screened in primary 
care for PTSD, depression, substance abuse, Traumatic Brain 
Injury, and military sexual trauma. Screening for this array of 
mental health problems helps support effective identification 
of veterans who need mental health services, and it promotes 
our suicide prevention efforts, a major priority for the VA. If 
anyone screens positive on any of the mental health issues, 
they get a further suicide prevention screening and then, of 
course, appropriate referral for services as identified to be 
needed.
    The VA will continue to serve the mental health needs of 
our veterans through progressive state-of-the-art programs. 
We're approaching mental health needs of veterans with an 
orientation that is designed to promote an optimal level of 
social and occupational function and participation in family 
and community life for our veterans--not just the treatment of 
symptoms, but the restoration of a full and meaningful life. 
Thank you again, Senator for inviting me here today. I will be 
happy to answer any of your questions.
Prepared Statement of Antonette Zeiss, Ph.D., Deputy Chief Consultant, 
    Office of Mental Health Services, Department of Veterans Affairs
    Good morning Senator Murray, I am pleased to be here today to 
discuss how the Department of Veterans Affairs (VA) is addressing the 
mental health care needs of our veterans.
    We have seen returning veterans--from prior eras to the current 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
conflict--who have injuries of the mind and spirit as well as the body. 
Our goal is to treat a veteran as a whole patient--to treat a patient's 
physical illnesses as well as any mental disorders.
    Since the start of OEF/OIF combat, 717,196 servicemembers have been 
discharged and have become eligible for VA care. Of those, 35 percent 
have sought VA medical care. Among those veterans, mental health 
problems are the second most commonly reported health concerns, with 
almost 38 percent reporting symptoms suggesting a possible mental 
health diagnosis. The diagnosis of Post Traumatic Stress Disorder 
(PTSD) topped the list for possible mental health diagnoses, and 
depression and nondependent abuse of substances also had high rates.
    VA's data show that the proportion of new veterans seeking VA care 
who have a possible mental health problem has increased over the past 
two years. For example, the proportion with possible mental health 
problems at the end of FY 2005 was 31 percent, compared to nearly 38 
percent in the most recent report released in April 2007. PTSD 
diagnoses during this same time frame went from 13 percent to almost 18 
percent.
    Funding resources are currently available for a VA Mental Health 
Initiative that supports implementation of our comprehensive Mental 
Health Strategic Plan that is based on the President's New Freedom 
Commission on Mental Health. Using Mental Health Initiative funding, we 
have improved capacity, access and hired over 3,000 new mental health 
professionals to date.
    In addition to our mental health specialty care sites, we have 
expanded mental health services in Community Based Outpatient Clinics, 
with onsite staffing or by telemental health. We have enhanced PTSD, 
homelessness, and substance abuse specialty care services. We developed 
a Military Sexual Trauma (MST) Support Team to ensure that VA fully 
implements MST screening and treatment. We are fostering integration of 
mental health and primary care in medical facility clinics and in the 
care of home-bound veterans served by VA's Home Based Primary Care 
program. Moreover, VA provides services for homeless veterans, 
including transitional housing paired with services to address social, 
vocational, and mental health problems associated with homelessness.
    Focusing on concerns about suicide in veterans, we have funded a 
Suicide Prevention coordinator in every VA medical facility. A national 
hotline for suicide prevention is now available and functioning very 
effectively. VA sponsored its first Suicide Prevention Awareness Day, 
which included every VA facility, and will sponsor a VA Suicide 
Prevention Awareness Week September 9-15, in conjunction with National 
Suicide Prevention Awareness Week.
    In addition to Mental Health services at VA facilities, VA's Vet 
Centers provide counseling and readjustment services to returning war 
veterans and, in some cases, their family members, in the community 
setting. These Vet Centers provide an alternative to traditional access 
for some veterans who may be reluctant to come to our medical centers 
and clinics. At Secretary Nicholson's direction, we have increased the 
number of staff in our Vet Centers by establishing outreach counselors, 
many of whom are Global War on Terror veterans themselves.
    VA continues to promote early recognition of mental health 
problems. Veterans are routinely screened in Primary Care for PTSD, 
depression, substance abuse, Traumatic Brain Injury, and Military 
Sexual Trauma. Screening for this array of mental health problems helps 
support effective identification of veterans needing mental health 
services, and it promotes our suicide prevention efforts, a major 
priority for VA.
    VA will continue to monitor the mental health needs of our veterans 
through progressive, state-of-the-art programs. VA is approaching the 
mental health needs of veterans with an orientation that is designed to 
promote an optimal level of social and occupational function and 
participation in family and community life for our veterans.
    Thank you again Senator for inviting me here today. I would be 
happy to answer any questions that you may have.

    Senator Murray. Thank you, Dr. Zeiss. Diana Rubens.

  STATEMENT OF DIANA RUBENS, DIRECTOR, WESTERN AREA, VETERANS 
     BENEFIT ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

    Ms. Rubens. Senator Murray, I appreciate the opportunity to 
testify today on the Veterans Benefits Administration's 
response to the mental health care and needs of veterans. I am 
accompanied today by Carol Fillman, the Director of the VA 
Regional Office in Seattle. At the heart of our mission is the 
Disability Compensation Program, which provides monthly 
benefits to veterans who are disabled as a result of injuries 
or illness incurred during their military service. Today there 
are more than 7 million veterans of all periods of services 
receiving compensation benefits. With the focus on mental 
health needs of our returning veterans, I'm going to talk a 
little bit about the process for establishing service 
connection for Post Traumatic Stress Disorder as well as our 
efforts to expedite the processing of claims from veterans of 
Operations Iraqi Freedom and Enduring Freedom, including our 
expanded outreach to current servicemembers, as well as our 
national hiring initiative and our Benefits Delivery at 
Discharge program.
    The number of veterans submitting claims for PTSD has grown 
dramatically. From 1999 to 2007, the number of veterans 
receiving compensation for PTSD has increased from 120,000 to 
more than 280,000 veterans covering all periods of service. Our 
OIF/OEF returning veterans number 28,000. Granting service 
connection for PTSD presents a unique processing complexity 
because of the evidentiary requirements. Service connection 
requires medical evidence diagnosing the condition, as well as 
evidence of a link between the current symptoms and an in-
service stressor. And then of course we also need supporting 
evidence that in-service stressor occurred.
    Our VA regulation established three categories, combat/
prisoner of war, personal assault, or noncombat. The majority 
of these in-service stressors are combat related. Combat status 
may be established through receipt of certain recognized 
military citations or other supporting evidence. If the 
stressful evidence is not easily linked to combat or POW 
status, we require the veteran submit information to help 
substantiate the incident and, in conjunction with the Joint 
Services Records Research Center, we use all resources 
available in addition to the veteran's military records to 
verify the claimed stressor occurred. Reasonable doubt is 
always resolved in the favor of the veteran.
    Evidence of a stressor is relevant to establishing service 
connection for PTSD; however, it is not a factor in evaluating 
the severity of the disorder. A VA examination is requested 
once credible supporting evidence has established that the 
claimed in-service stressor has occurred. Competent medical 
evidence is also required to provide a link between the 
stressor and the current PTSD diagnosis. As more veterans are 
returning from Iraq and Afghanistan, and they're turning to VA 
for both benefits and medical care, including care for PTSD, 
it's critical that our employees receive essential guidance, 
materials and tools to meet the increasingly complex demands of 
their decision-making responsibilities. To accomplish this 
goal, the Veterans Benefit Administration has deployed new 
training tools and centralized training programs to support 
accurate and consistent decision-making. New employees receive 
comprehensive training through a national centralized training 
program. This current curriculum consists of full lesson plans, 
handouts, student guides, instructor guides and slides for 
classroom instruction. Recognizing the importance of continuing 
education, all Veterans Service Center employees also complete 
a mandatory annual cycle of training consisting of 80 hours of 
course work.
    We've also developed job aids and training sessions to 
provide employees the skills and tools essential to render fair 
and timely decisions on PTSD claims. All of our Veterans 
Service Representatives, as well as the Rating Veterans Service 
Representatives are required to receive training on the proper 
development and analysis of PTSD claims. We've also established 
priority processing for the OIF/OEF veterans. Since the onset 
of combat operations in Iraq and Afghanistan, we've provided 
expedited case-managed services for all seriously injured OIF 
and OEF veterans and their families. This individualized 
service begins at the military medical facilities where the 
injured servicemembers return for treatment and continues as 
these servicemembers are medically separated and enter the VA 
medical care and benefit systems.
    The VA assigns special benefits counselors, social workers 
and case managers to work with these servicemembers and their 
families throughout the transition. Since February of 2007, VA 
has also provided priority processing of all OIF/OEF disability 
claims. This initiative covers all active-duty National Guard 
and Reserve veterans who were deployed in the theaters or in 
support of these combat operations as identified by the 
Department of Defense. We've also expanded our outreach 
programs for National Guard and Reserve components and our 
participation in the OIF/OEF community events and other 
information dissemination activities. In order to ensure that 
VA benefits information is provided to all servicemembers that 
are separating, including our Reserve and Guard members, we're 
working with DOD to expand our role in DOD's military pre-
separation process specifically providing claims workshops in 
conjunction with many of our VA benefits briefing for 
separating servicemembers. In these workshops, groups of 
servicemembers are instructed on how to complete VA application 
forms. Personal interviews are also conducted with anyone 
interested in applying for VA benefits.
    Expediting this process is critical to assisting these OIF/
OEF veterans in the transition from combat operations back to 
civilian life. We're continuing to focus on reducing the 
pending workload and providing more timely claims decisions to 
veterans of all periods of service. We've actively worked to 
develop relationships with the National Guard and Reserve to 
insure local regional offices are notified when the units 
return from deployments. Designated military service 
coordinators and OIF/OEF coordinators conduct regular briefings 
on VA benefits as part of the transition assistance program as 
well as the disabled transition assistance programs. They're 
jointly conducted by VA and DOD and Department of Labor at 
various military institutions around the country.
    In partnership with our Veterans Health Administration, the 
Seattle Regional Office provides these types of individualized 
case management services to the most seriously injured soldiers 
at Madigan Army Medical Center. As part of our Benefits 
Delivery at Discharge program, servicemembers can apply for VA 
service-connected disability compensation programs and benefits 
prior to separation so that VA can begin disability payments as 
quickly after their discharge as possible. Servicemembers who 
apply for disability compensation benefits under this Benefits 
Delivery at Discharge program undergo one medical examination 
instead of both the military separation exam and the VA exam 
for the disability claims. Timely decisions on servicemembers' 
disability compensation claims also help ensure the continuity 
of medical care for their service-connected disabilities. The 
goal of our BDD program is to deliver benefits within 60 days 
of discharge.
    Senator Murray. Again, all of your testimony will be 
submitted for the record, so if you can sum up, I'd appreciate 
it.
    Ms. Rubens. I think the last thing that I'd like to mention 
is the national hiring initiative. We, of course, have received 
authority to hire more than 3,000 employees over the course of 
the next year. We've already added more than 800 new employees 
since April. The Seattle Regional Office has been authorized up 
to 53 additional employees, and with these additional 
resources, the Regional Office will continue to make great 
strides in improving the delivery of services to the veterans. 
This concludes my testimony. I appreciate being here today and 
look forward to answering any of your questions.
      Prepared Statement of Diana Rubens, Director, Western Area, 
    Veterans Benefits Administration, Department of Veterans Affairs
    Senator Murray, I appreciate this opportunity to testify today on 
the Veterans Benefits Administration's (VBA) response to the mental 
health care needs of veterans. I am accompanied today by Carol Fillman, 
Director of the Seattle Regional Office, and Tim Clark, Veterans 
Service Center Manager at the Seattle Regional Office.
    At the heart of our mission is the Disability Compensation Program, 
which provides monthly benefits to veterans who are disabled as a 
result of injuries or illnesses incurred during their military service. 
More than 2.7 million veterans of all periods of service currently 
receive VA compensation benefits. With the focus of today's hearing on 
the mental health needs of returning veterans, I will discuss the 
process for establishing service connection for Post Traumatic Stress 
Disorder (PTSD). In addition, I will address our efforts to expedite 
the processing of claims from veterans of Operations Iraqi Freedom and 
Enduring Freedom (OIF/OEF), including our expanded outreach to current 
servicemembers. Finally, I will speak about VBA's national hiring 
initiative and the Benefits Delivery at Discharge (BDD) program.
                     post traumatic stress disorder
    The number of veterans submitting claims for PTSD has grown 
dramatically. From FY 1999 through June 2007, the number of veterans 
receiving disability compensation for PTSD increased from 120,000 to 
more than 280,500. The 280,500 veterans receiving disability 
compensation benefits for PTSD represent veterans of World War II 
(24,268), the Korean Conflict (11,520), the Vietnam Era (200,876), 
Peacetime (10,038), and the Gulf War Era (33,855). The Gulf War Era 
number includes approximately 28,000 OIF/OEF veterans.
    Granting service connection for PTSD presents unique processing 
complexities because of the evidentiary requirements to substantiate 
the event causing the stress disorder. Service connection for PTSD 
requires medical evidence diagnosing the condition, medical evidence of 
a link between current symptoms and an in-service stressor, and 
credible supporting evidence that the in-service stressor occurred. VA 
regulations establish three categories of in-service stressors: combat/
prisoner of war (POW), personal assault, and non-combat. The majority 
of in-service stressors are combat related. Combat status may be 
established through the receipt of certain recognized military 
citations and other supportive evidence. If the evidence establishes 
that a veteran engaged in combat or was a POW and the stressor relates 
to that experience, the veteran's lay testimony alone may establish an 
in-service stressor for purposes of service-connecting PTSD.
    If the stressful event is not linked to combat or POW status, VA 
requests that the veteran submit information to help substantiate that 
the incident occurred. In conjunction with the Joint Services Records 
Research Center (JSRRC), VA uses all resources available, in addition 
to the veteran's military records, to verify that the claimed stressor 
occurred. Reasonable doubt is always resolved in favor of the veteran.
    Evidence of a stressor is relevant to establishing service 
connection for PTSD; however, it is not a factor in evaluating the 
severity of the disorder. A VA examination is requested once credible 
supporting evidence establishes that the claimed in-service stressor 
occurred. Competent medical evidence is required to provide a link 
between the in-service stressor and the veteran's current PTSD 
diagnosis.
    Recognizing that the delay involved in processing complex PTSD 
claims can inadvertently impact veterans already suffering from stress, 
the Veterans Health Administration (VHA) offers all returning OIF/OEF 
veterans professional clinical care. VBA is also expediting the claims 
process for all OIF/OEF veterans.
                           training programs
    As more veterans returning from Iraq and Afghanistan are turning to 
VA for benefits and medical care, including care for PTSD, it is 
critical that our employees receive the essential guidance, materials, 
and tools to meet the increasingly complex demands of their 
decisionmaking responsibilities. To accomplish this goal, VBA has 
deployed new training tools and centralized training programs that 
support accurate and consistent decisionmaking. New employees receive 
comprehensive training through the national centralized training 
program called ``Challenge.'' The current curriculum consists of full 
lesson plans, handouts, student guides, instructor guides, and slides 
for classroom instruction. Recognizing the importance of continuing 
education, all Veterans Service Center employees complete a mandatory 
cycle of training, consisting of 80 hours of annual coursework.
    VBA has developed job aids and training sessions to provide 
employees the skills and tools essential to render fair and timely 
decisions on PTSD claims. All Veteran Service Representatives (VSRs) 
and Rating Veteran Service Representatives (RVSRs) are required to 
receive training on the proper development and analysis of PTSD claims. 
The training materials include medical and military references and pre-
recorded video broadcasts pertaining to PTSD development and records 
research. Recently published PTSD guidance includes ``Handling PTSD 
Claims Based on Stressors Experienced During Service in the Marine 
Corps'' dated June 2005, ``Military Sexual Trauma Training Letter'' 
dated November 2005, and ``JSRRC Stressor Verification Guide'' dated 
January 2006. Additionally, VBA introduced the PTSD Training and 
Performance Support System (TPSS) module for VSRs and RVSRs in 2006. 
The TPSS module is an interactive learning tool in which employees 
complete self-guided lessons on PTSD development and verification of 
in-service stressors. Due to the success of the TPSS learning system, a 
second PTSD module titled, ``Rate a Claim for PTSD'' was released in 
July 2007.
                priority processing for oif/oef veterans
    Since the onset of the combat operations in Iraq and Afghanistan, 
VA has provided expedited and case-managed services for all seriously 
injured OIF/OEF veterans and their families. This individualized 
service begins at the military medical facilities where the injured 
servicemembers return for treatment, and continues as these 
servicemembers are medically separated and enter the VA medical care 
and benefits systems. VA assigns special benefits counselors, social 
workers, and case managers to work with these servicemembers and their 
families throughout the transition to VA care and benefits systems, and 
to ensure expedited delivery of all benefits.
    Since February 2007, VA has provided priority processing of all 
OIF/OEF veterans' disability claims. This initiative covers all active 
duty, National Guard, and Reserve veterans who were deployed in the 
OIF/OEF theaters or in support of these combat operations, as 
identified by the Department of Defense (DOD). This allows all the 
brave men and women returning from the OIF/OEF theaters who were not 
seriously injured in combat, but who nevertheless have a disability 
incurred or aggravated during their military service, to enter the VA 
system and begin receiving disability benefits as soon as possible 
after separation.
    We designated our two Development Centers in Roanoke, Virginia and 
Phoenix, Arizona, as well as three of our Resource Centers, as a 
special ``Tiger Team'' for processing OIF/OEF claims. The two 
Development Centers assist regional offices in obtaining the evidence 
needed to properly develop the OIF/OEF claims Medical examinations 
needed to support OIF/OEF veterans' claims are also expedited.
    We expanded our outreach programs for National Guard and Reserve 
components and our participation in OIF/OEF community events and other 
information dissemination activities. An OIF/OEF team at VBA 
Headquarters addresses OIF/OEF operational and outreach issues at the 
national level and provides support to the newly designated OIF/OEF 
managers at each regional office. The OIF/OEF team is also coordinating 
the development of national memoranda of understanding (MOUs) with each 
of the Reserve Components to formalize relationships with them, 
mirroring the agreement between VA and the National Guard Bureau signed 
in 2005. Having an MOU with each Reserve Component will help ensure 
that VA is provided service medical records and notified of ``when and 
where'' reserve members are available to be briefed during the 
demobilization process and at later times.
    In order to ensure that VA benefits information is provided to all 
separating servicemembers including Reserve and Guard members, we are 
working with DOD to expand our role in DOD's military pre-separation 
process. Specifically, we are now providing ``Claims Workshops'' in 
conjunction with many of our VA benefits briefings for separating 
servicemembers. At such workshops, groups of servicemembers are 
instructed on how to complete the VA application forms. Personal 
interviews are also conducted with those applying for VA disability 
benefits.
    Expediting the claims process is critical to assisting OIF/OEF 
veterans in their transition from combat operations back to civilian 
life. We are also continuing to focus on reducing the pending workload 
and providing more timely claims decisions to veterans of all periods 
of service.
                                outreach
    Veterans returning from Iraq and Afghanistan are eligible for a 
full array of benefits offered through VBA. Educating veterans on the 
resources available to them is accomplished through numerous outreach 
activities held at military bases, VA Medical Centers, and Reserve and 
National Guard units.
    VA has actively worked to develop relationships with National Guard 
and Reserve to ensure local regional offices are notified when units 
return from deployments. Designated Military Service Coordinators and 
OIF/OEF Coordinators conduct regular briefings on VA benefits as part 
of the Transition Assistance Program (TAP) and Disabled Transition 
Assistance Program (DTAP). These programs are jointly conducted by VA 
and the Departments of Defense and Labor at various military 
installations around the country. In addition to providing benefits 
information at the TAP and DTAP briefings, VBA coordinators help 
servicemembers complete benefits claims.
    In partnership with the Veterans Health Administration, the Seattle 
Regional Office provides individualized case management services to the 
most seriously injured soldiers at Madigan Army Medical Center.
                 benefits delivery at discharge program
    The Benefits Delivery at Discharge (BDD) program is a jointly 
sponsored VA and DOD initiative to provide transition assistance to 
separating servicemembers who have disabilities related to their 
military service.
    Under the BDD program, servicemembers can apply for VA service-
connected disability compensation and related benefits prior to 
separation from service, which allows VA to begin payment of benefits 
as soon as possible after discharge. Servicemembers who apply for 
disability compensation benefits under the BDD program undergo one 
medical examination instead of both a military separation exam and a VA 
exam for the disability claim. Timely decisions on servicemembers' 
disability compensation claims also help ensure continuity of medical 
care for their service-connected disabilities. The goal of the program 
is to deliver benefits within 60 days of discharge.
    The Seattle Regional Office operates BDD sites at the Ft. Lewis/
McChord Air Force Base and in Bremerton, Washington. Over the past 6 
months, the Seattle Regional Office completed 1,133 BDD claims.
                       national hiring initiative
    I am pleased today to be able to discuss with you our national 
hiring initiative. We have already added more than 800 new employees 
since April, and our plans call for adding a total of 3,100 new 
employees by the end of next year. These employees will be placed in 
critically needed positions in our regional offices throughout the 
Nation.
    Along with the multitude of activities involved in a recruitment 
program of this magnitude, we have begun the critical tasks of 
training, equipping, and acquiring space to house our new employees. We 
are accelerating the training of these employees and focusing in 
specialized areas of claims processing in order to have them ``on-
line'' and productive within a few months. This will be followed by 
ongoing, carefully structured, and progressively complex training until 
full journey expertise is achieved.
    As a result of this hiring initiative, the Seattle Regional Office 
has been authorized to hire 53 additional employees. With these 
additional resources, the Regional Office will continue to make great 
strides in improving the delivery of benefits and services to the 
veterans of Washington.
    Senator Murray, this concludes my testimony. I greatly appreciate 
being here today and look forward to answering your questions.
                                 ______
                                 
 Response to Written Questions Submitted by Hon. Patty Murray to Diana 
   Rubens, Director, Western Area, Veterans Benefits Administration, 
                     Department of Veterans Affairs
    Veterans have long been frustrated by the combative VA benefits 
claims process. The Veterans Disability Benefits Commission is now 
studying the system and will recommend changes in a final report that 
is expected in October. In addition, the Institute of Medicine found 
that the VA's compensation system for emotionally disturbed veterans 
has little basis in science, is applied unevenly and may even create 
disincentives for veterans to get better.
    Question 1. How can we change the VA claims process so that it 
doesn't negatively impact the recuperation of veterans?
    Response: The Department of Veterans Affairs (VA) is continually 
striving to improve the compensation claims process and is evaluating 
all recommendations from authoritative sources. Mental disability among 
veterans is a major issue, especially Post Traumatic Stress Disorder 
(PTSD). VA is addressing the process for evaluating the severity of a 
veteran's PTSD symptoms and assigning an appropriate evaluation of 
disability compensation. We have revised the standardized examination 
format for PTSD for use by all examiners so that consistent and more 
useful information will be available for claims adjudication personnel. 
Additionally, VA is considering the recommendation of the Institute of 
Medicine of the National Academies that PTSD have its own specific 
multidimensional rating criteria, rather than being evaluated based on 
generalized criteria used for all mental disorders.

    Question 2. How many Iraq and Afghanistan war veterans have filed 
any type of VBA disability compensation or pension claim?
    Response: The information provided below is based on a match 
between Department of Defense (DOD) data on servicemembers deployed in 
support of the Global War on Terror (GWOT) for the period from 
September 11, 2001 through May 31, 2007, compared to VA data covering 
September 11, 2001 through September 30, 2007.
    This data match identified veterans who were deployed during their 
military service in support of GWOT, and who have also filed a VA 
disability claim either prior to or following their GWOT deployment. 
Many GWOT veterans had earlier periods of service, and filed for and 
received VA disability benefits before being reactivated.
    VBA's computer systems do not contain any data that would allow us 
to attribute veterans' disabilities to a specific period of service or 
deployment.
    For the period covered, 223,564 of 754,911 GWOT veterans filed a 
claim for disability benefits either prior to or following their GWOT 
deployment. Of those, 181,151 veterans were determined to have a 
service-connected disability, 17,371 were denied service- connection, 
and 23,042 veterans had original claims pending as of September 30, 
2007.

    Question 3. How many Iraq and Afghanistan war veterans have filed a 
claim for a mental health condition? How many were granted? How many 
were denied? How many are waiting for a decision?
    Response: VBA does not track information specific to mental health 
conditions claimed by GWOT veterans. We have compiled data on GWOT 
veterans for the 10 most prevalent service-connected disabilities 
granted, which includes PTSD. As of September 30, 2007, there were 
31,465 GWOT veterans service-connected for PTSD. This represents 4 
percent of the total GWOT veteran population, and 17 percent of those 
GWOT veterans who have been granted any service-connection. This data 
is based on veterans separated from military service on or before May 
31, 2007, as reported by DOD.

    Question 4. How many total claims does VBA expect from Iraq and 
Afghanistan war veterans? How many of those does VBA expect will be for 
any type of mental health condition? And how many for PTSD?
    Response: In fiscal 2007 the Veterans Benefit Administration (VBA) 
completed nearly 829,000 claims. Of those, just over 110,000 (13 
percent) were claims made by GWOT veterans. This information is based 
on GWOT veterans discharged through May 2007 as reported to VA by DOD 
and self-reported by GWOT veterans when they filed their disability 
claim. At the present time, we expect GWOT claims will continue to 
represent the same percentage of our overall workload in 2008 and 2009. 
Projecting future demand for the Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF) conflict remains extremely difficult for a 
number of reasons.
    First, many OEF/OIF veterans served in earlier periods, and their 
injuries or illnesses could have been incurred either prior to or 
subsequent to their latest deployment. We are unable to identify which 
OEF/OIF veterans filed a claim for disabilities incurred during their 
actual overseas OEF/OIF deployment.
    Second, we significantly expanded our outreach to separating 
servicemembers. Over the last 5 years, we conducted over 38,000 
briefings attended by over a 1.5 million active duty and Reserve 
personnel. Additionally, through the benefits delivery at discharge 
program, servicemembers are encouraged to file and assisted in filing 
for disability benefits prior to separation. Many servicemembers with 
disabilities are submitting disability claims earlier. However, the 
impact of these efforts on future application trends and benefits usage 
is not known.
    Third, VBA lacks historical data for claims activity by veterans of 
prior wars on which to base projections of benefits usage for OEF/OIF 
veterans. The only data available are the numbers and percentages of 
veterans currently receiving benefits by era of service.
    We continue to add veterans to our compensation rolls many years 
after their service. Many of these are a result of additional 
conditions presumed to be related to service in Vietnam. PTSD claims 
have also increased from Vietnam veterans. We have no basis for 
determining if service in Afghanistan and Iraq will result in similar 
claims patterns.

    Question 5. What is the average wait time for new war veterans 
compared to all other veterans, who wait 6 months for an initial 
decision?
    Response: In fiscal 2007, VBA completed nearly 825,000 claims, Of 
these, just over 110,000 were claims filed by GWOT veterans. Their 
claims were processed in an average of 179 days. The remaining claims 
were completed in 184 days.
    VA is continuously seeking ways to improve the timeliness of 
processing claims received from GWOT veterans. In February 2007, VA 
began providing priority processing of all OEF/OIF veterans' disability 
claims. This initiative covers all active duty, National Guard, and 
Reserve veterans who were deployed in the OEF/OIF theaters or in 
support of these combat operations, as identified by the DOD. 
Therefore, claims received from GWOT veterans before February 2007 were 
not processed on a priority basis. As a result of this initiative we 
expect to see improvements in our timeliness in FY 2008.
    VBA also added an indicator/flash in our VETSNET system to clearly 
identify GWOT veterans and improve the management of their claims. The 
system alerts the claims examiner that the case being processed is to 
be handled in a priority manner.
    VA does face challenges in assisting GWOT National Guard and 
Reserve members with their claims, due to difficulties in obtaining 
their active duty medical records. These members are sometimes 
mobilized with units other than their home unit. Their medical records 
created while on active duty may not get back to their home unit for 
some time, if at all.
    VA is taking a proactive approach in seeking to obtain medical 
records faster from the National Guard. VA met with the National Guard 
to discuss their health readiness records and electronic readiness 
records, and how the VA can have access to those records. The VA 
Regional Office in St. Petersburg, FL, is entering into a pilot program 
with the National Guard in order to receive medical records 
electronically.
                                 ______
                                 
   Additional Information Requested by Hon. Patty Murray from Diana 
   Rubens, Director, Western Area, Veterans Benefits Administration, 
                     Department of Veterans Affairs
    1. Total claims filed by Global War on Terrorism (GWOT) veterans--
222,424.
    2. Total claims denied--17,414.
    3. Total claims currently pending--27,440 first-time claims and 
9,948 reopened.
    4. We do not have data on the number of mental health claims that 
have been filed or that are pending. Our data does show that 30,005 
GWOT veterans are service-connected for Post Traumatic Stress Disorder 
(PTSD). Determining the total number who are service-connected to some 
degree for ``mental health'' issues would require that we do a special 
data run for the full range of diagnostic codes that relate to mental 
health.

    Senator Murray. Thank you very much. Dennis Lewis.

         STATEMENT OF DENNIS M. LEWIS, FACHE, NETWORK 
       DIRECTOR, VISN 20, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Lewis. Yes, good afternoon, Senator. I would like to 
thank you for this opportunity to discuss what the Department 
of Veterans Affairs, Northwest Health Network is doing. I am 
accompanied by Stan Johnson, the director of the Puget Sound 
Health Care System, and I'd like just to take a moment to thank 
all the active-duty service personnel and the veterans of the 
audience for the sacrifices you and your families have given on 
behalf of our country. The VA really only exists for one 
reason, and that is to provide services to you.
    Veterans Integrated Service Network, VISN 20 is fortunate 
to employ some of the most respected health care professionals 
in the country. Through their efforts and with the support of 
our dedicated staff and with your help, we have expanded mental 
health capacity and programs tremendously in recent years. 
Since FY 2005, we have increased mental health programs 
staffing by over 20 percent, 125 FTE, 63 of those positions 
were added in Washington State. Throughout the VISN, these 
additions have allowed us to improve coordinated care delivery 
in such areas as Post Traumatic Stress Disorder, substance 
abuse, homelessness and Traumatic Brain Injury. In all, VISN 
has introduced more than 40 new mental health initiatives in 
Washington State, which have been supported by over $4 million 
since FY 2006 alone.
    We've also expanded mental health services at 23 Community 
Based Outpatient Clinics or CBOCs. In fiscal year FY 2006, VISN 
20 was first in Veterans Health Administration for mental 
health access in CBOCs. VISN 20 is also a national leader in 
care and coordination in telehealth, serving almost 1,700 
veterans with the latest technology. We've introduced 
telemental health to close to half of our CBOCs allowing us to 
evaluate the follow-up patients without them having to travel 
long distances. This treatment method is especially effective 
in rural areas and it's one that we are aggressively continuing 
to expand. Across the country there is a sense of urgency in 
reaching out to Operation Enduring Freedom and Operation Iraqi 
Freedom veterans. Through the end of FY 2006, VISN 20 
facilities had treated 12,164 OEF/OIF servicemembers and 
veterans. In FY 2006, 2,849 OEF/OIF veterans were seen in 
Washington State and 24 percent of those were diagnosed with 
PTSD.
    We are applying what we have learned through research and 
clinical experience about the identification and treatment of 
mental health conditions and other chronic or persistent 
courses of illness in such a manner that the staff is proud to 
say that VISN 20 delivers 21st century care to 21st century 
combat veterans. We are conducting aggressive outreach efforts 
to contact these soldiers. As early as 2004, the VA Puget Sound 
Health Care System pioneered a collaborative effort with eight 
agencies, including the Department of Defense, the State of 
Washington and other state and federal and community entities 
creating a memorandum of understanding focusing on coordinating 
services for returning veterans. These efforts have now been 
duplicated in Oregon and Idaho with much success.
    Our medical centers are also actively collaborating with 
State, National Guard and Reserve components to ensure that no 
returning veterans slips through the cracks. In 2005, VA Puget 
Sound activated the Deployment Health Clinic which consists of 
an integrated combat care team, which serves as entry points 
for returning veterans. VISN 20 has also established the 
regional Polytrauma System of Care. Again, VA Puget Sound has 
been designated the Polytrauma Network Site and works with VA's 
Polytrauma Rehabilitation Center in Palo Alto. Our Boise and 
Portland facilities have established Polytrauma Support Clinic 
Teams, and each of our facilities have designated a Polytrauma 
point of contact. Our Vet Centers provide readjustment 
counseling community outreach for combat veterans and their 
families, and as I believe you've already heard mentioned, by 
the end of 2007 a new center will be open in Everett, 
Washington.
    In summary, VISN 20 is committed to providing world class 
mental health care to all veterans, regardless of the era they 
have served in. We remain keenly aware of the importance of our 
mission and the challenges that lie ahead. I believe that our 
current and planned efforts go a long way toward meeting that 
challenge, and I am extremely proud of the staff and I thank 
you for your continued support.
    Senator, that concludes my prepared remarks.
    Prepared Statement of Dennis M. Lewis, FACHE, Network Director, 
                VISN 20, Department of Veterans Affairs
    Good morning Senator Murray. Thank you for the opportunity to 
discuss the Department of Veterans Affairs (VA) NW Health Network and 
the mental health services we are honored to provide our Nation's 
veterans. I would like to request my written statement be submitted for 
the record.
    Veterans Integrated Service Network (VISN) 20 is fortunate to 
employ some of the most respected mental health professionals in the 
country. Through their efforts, and with the support of our dedicated 
staff, we have expanded mental health capacity and programs 
tremendously in recent years. In fact, since Fiscal Year (FY) 2005, we 
increased mental health program staffing by over 20 percent, adding a 
total of 125 new positions.
    Sixty-three of these positions were added in Washington State. 
Throughout the VISN, these additions have allowed us to improve 
coordination care delivery in areas such as Post Traumatic Stress 
Disorder (PTSD), Substance Abuse, Homelessness, and Traumatic Brain 
Injury (TBI). In all, VISN 20 has introduced 40 new initiatives in 
Washington, supported by over $4 million in enhanced funding, since FY 
2005.
    We also expanded Mental Health services at each our 23 Community 
Based Outpatient Clinics (CBOCs). In FY 2006, VISN 20 was first in VHA 
for mental health access in CBOCs.
    VISN 20 is also a national leader in Care Coordination and 
Telehealth, serving almost 1,700 veterans with the latest technologies. 
We have also introduced tele-mental health at close to half of our 
CBOCs, allowing us to evaluate and follow patients without them having 
to travel long distances. This treatment method is especially effective 
in rural areas, and we will continue to expand it.
    Across the country there is a sense of urgency in reaching out to 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. 
Through the end of FY 2006, VISN 20 facilities have treated 12,164 OEF/
OIF service members and veterans. In FY 2006, 2,849 OEF/OIF veterans 
were seen in Washington, 24 percent of whom were diagnosed with PTSD.
    We are applying what we have learned through research and clinical 
experience about the identification and treatment of mental health 
conditions and other chronic or persistent courses of illness. VISN 20 
delivers 21st century care to 21st century combat veterans.
    We are conducting aggressive outreach efforts to contact these 
soldiers. As early as 2004, the VA Puget Sound Health Care System 
(PSHCS) pioneered a collaborative effort with 8 agencies--including 
DOD, the State of Washington and other state, Federal and community 
entities--creating a Memorandum of Understanding focused on 
coordinating services for returning veterans. These efforts have now 
been duplicated in Oregon and Idaho with much success. Our medical 
centers also actively collaborate with state National Guard and Reserve 
components to ensure that no returning soldier slips through the 
cracks.
    In 2005, VA Puget Sound activated a Deployment Health Clinic (DHC), 
which consists of an integrated combat care team who serves as entry 
points for returning veterans.
    VISN 20 also established a regional Polytrauma System of Care. 
Puget Sound has been designated the Polytrauma Network Site and works 
directly with VA's Polytrauma Rehabilitation Center in Palo Alto. Our 
Boise and Portland facilities have established Polytrauma Support 
Clinic Teams, and each of our facilities have a designated Polytrauma 
point of contact.
    Our Vet Centers provide readjustment counseling and community 
outreach to combat veterans and their families. By the end of 2007, a 
new Center will open in Everett, Washington.
    In summary, VISN 20 is committed to providing world class mental 
health care to all veterans, regardless of the era in which they 
served. We remain keenly aware of the importance of our mission and the 
challenges which lie ahead. I believe that our current and planned 
efforts go a long way toward meeting this challenge, I am extremely 
proud of our staff, and I thank you again for your continued support.
    This concludes my statement. At this time I would be pleased to 
answer any questions you may have.

    Senator Murray. Thank you very much. General Lowenberg.

         STATEMENT OF MAJOR GENERAL TIMOTHY LOWENBERG, 
             ADJUTANT GENERAL, STATE OF WASHINGTON

    General Lowenberg. Thank you. Senator Murray, I want to 
thank you for your leadership and commitment to these issues 
and for this opportunity to testify on behalf of National Guard 
soldiers and airmen and other Reserve component members. On 
Tuesday of this week, a State Department released a survey of 
its employees who had been assigned to unaccompanied tour 
locations. One out of six self-reported post assignment stress 
disorders and mental health problems, and these are not people 
like our soldiers and airmen who are shot at, who are subjected 
repeatedly to high-yield explosions and who are lured into 
booby trapped buildings while on forced security missions. 
Yesterday the Army released a report documenting the highest 
rate of soldier suicides in more than a quarter of a century, 
and that report shows that twice as many females serving in 
Iraq and Afghanistan committed suicide as female soldiers not 
sent to war.
    What do these statistics have to do with National Guard 
soldiers and airmen? If one out of six State Department 
employees currently serving in Bosnia, lived in Liberia and 
other unaccompanied tour locations report self stress-related 
adjustment disorders, then no one should question the problems 
faced by our soldiers, who just like their active-duty 
counterparts are subjected to live fire and explosive blasts 
that threaten their lives and the lives of their fellow members 
and who are repeatedly exposed to such trauma during their year 
to year and a half long deployments and during their recurring 
combat assignments.
    What distinguishes National Guard soldiers and airmen from 
their active-duty counterparts is not their capabilities or 
their importance to America's combat operations, or even the 
nature and severity of their recurring trauma, but rather the 
community and support network from which they deploy in the 
United States, and perhaps more importantly to which they 
return at the conclusion of their combat tour, and second, 
their eligibility for and access to physical and mental health 
care. With rare exception, active-duty personnel live on or 
near full-service military installations. Regardless of their 
duty location, they are eligible for year-round medical 
treatment. When they return from an overseas assignment, 
they're generally given a half day work schedule for the first 
month, and they and their fellow soldiers are together every 
day allowing them to individually and collectively normalize 
their combat experiences. They're also surrounded by family and 
friends who understand and who often themselves have 
experienced the same kind of trauma.
    Guard soldiers by contrast come from communities throughout 
the state. They are not surrounded before or after their 
deployment by family or community members who share their 
experiences, or who can appreciate or even conceptualize the 
trauma that they endured. Guard soldiers, unlike their active-
duty counterparts go through a 10-day demobilization process 
after returning to the U.S., and after that 10 days, they 
return to civilian life and have no contact with their unit or 
their fellow soldiers for 3 months. Another distinguishing 
factor is the Guard units are not authorized to treat our 
soldiers or airmen for any physical or mental condition before 
or after their active-duty tour. In fact, we don't even have 
psychologists or social workers available in the National 
Guard. We have medical officers, but they're authorized to do 
only two things: emergency examinations and fitness-for-duty 
physicals. The only time a Guard soldier is eligible for 
medical treatment is when they are on federal active duty, and 
even that eligibility ends three drilling assemblies after they 
rejoin their unit after demobilization.
    It's no wonder then that our soldiers' exposure to 
Traumatic Brain Injury and Post Traumatic Stress Disorder is 
often masked during these first few months post-demobilization. 
Regrettably, our study shows that in the months that follow 
when our soldiers and airmen are no longer eligible for 
military medical treatment, these conditions often blossom into 
intractable problems of unemployment, substance abuse, family 
separation and divorce.
    To correct these problems and inequities, I recommend four 
steps that would dramatically enhance the readiness of our 
force. First, Guard and Reserve members are an integral part of 
America's 21st century fighting force. Give our members the 
year-round physical and mental health treatment they need to be 
a combat ready force. Authorize Guard medical personnel to 
treat Guard members. Staff Guard medical units with 
psychologists and social workers and require mental health 
screening upon demobilization and periodically thereafter, and 
give hiring preference to military and VA medical workers who 
have combat experience.
    Second, recognize the Guard Reserve members live and work 
in communities that are often far removed from their own 
military units and from active duty and VA medical facilities. 
Approve and fund remote care near the member's hometown. Stop 
making our soldiers and airmen choose between no care and once 
again leaving behind their families and employers to obtain 
care at a distant military or VA medical facility.
    Third, fund and require returning Guard soldiers and airmen 
to drill with their units immediately upon being demobilized. 
This will enable them to readjust and normalize with their 
fellow unit members, just like their active-duty counterparts 
and fund and provide parallel readjustment activities for 
Guards, spouses and family members who can gather together and 
continue their support for one another concurrent with these 
initial training assemblies.
    Fourth, Guard transition assistance counselors do a 
terrific job, but as Carol Seger told you, there are far too 
few of them and the very program is designed to be a short-term 
program. We need to increase the number of transition 
assistance in each state and make the program permanent. Thank 
you for this opportunity to testify. I look forward to your 
questions.
        Prepared Statement of Major General Timothy Lowenberg, 
                 Adjutant General, State of Washington
    Thank you for the opportunity to appear before you today. Although 
I am a federally recognized, U.S. Senate-confirmed Air Force General 
Officer, I want to emphasize at the outset that I am testifying on 
behalf of the State of Washington and I am doing so as a state official 
in state status and at state expense. Unlike other military officers 
who typically appear before your Committee, nothing I say has been 
reviewed, edited or otherwise approved by anyone in the Department of 
Defense. My formal testimony, oral statement and responses to your 
questions should therefore be understood to be the independent 
``field'' input of a senior Reserve component commander.
               importance of full spectrum care for all 
                      military service components
    I am grateful for Congress' attention to Guard and Reserve matters 
in recent National Defense authorization bills, in support for the 
National Guard Yellow Ribbon Reintegration Program, and in studies to 
address the needs of National Guard soldiers and airmen following 
overseas combat tours.
    National Guard soldiers and airmen are serving in combat 
environments that put them at risk for trauma from blasts and 
debilitating and life-threatening physical injuries. The constant 
stress, fear, and vigilance required to survive in these conditions can 
create long-lasting consequences that later manifest as Post Traumatic 
Stress Disorder (PTSD). Repeated exposure to these stress conditions 
and repeated and extended combat tours exacerbate these problems. Guard 
men and women, like other combatants, are subjected to blasts from 
improvised explosive devices (IEDs) and other high yield explosives. 
Civilian studies of Traumatic Brain Injury (TBI) are instructive in 
dealing with brain trauma patients, but these studies are typically 
based on patients who have experienced a single traumatic blast 
exposure. Military personnel, on the other hand, especially ground 
forces, experience several TBIs in the course of a single combat tour 
and many Guard soldiers and airmen have served more than one combat 
tour or have had their tours of duty extended for up to a year and a 
half or longer at a time.
    Because extended tours and recurring combat tours are a recent 
phenomenon, we do not know what the long term effects will be on the 
mental health of Guard and Reserve combatants. Until recently, there 
was no routine screening for TBI upon completion of a Guard member's 
combat tour. Without proper screening, many mental health conditions 
are masked and go untreated. I urge you to require and fund a system 
that assures mental health screening takes place upon completion of 
each combat tour and at periodic intervals thereafter.
    Mindful of these soldier and airmen needs, the Washington National 
Guard has developed independent, State-specific networks of 
transitional support for returning servicemembers and their families. 
We have partnered with numerous state and Federal agencies, including 
the Washington Department of Veterans Affairs (WDVA) and the Federal 
Veterans Administration (VA), and private non-profit organizations to 
develop a model reintegration program and we have extended the 
program's services to all military Reserve components.
    The State of Washington was also the first state in the Nation to 
establish a state-funded Post Traumatic Stress Disorder (PTSD) and War 
Trauma Treatment Program (HB 2095). This law, enacted in 1991, allows 
the Washington Department of Veterans Affairs to offer readjustment 
counseling services to war-era veterans and their family members. These 
services include grief and counseling support for eligible state 
residents and family members, including National Guard and Reserve 
members who serve in times of conflict. The program's licensed mental 
health professionals offer a wide-range of specialized treatment as 
well as referrals to a variety of other services. That being said, 
there is still more that can and should be done to assist National 
Guard members by expanding and funding medical coverage, particularly 
mental health coverage, to a full spectrum of care.
           national guard and reserves--unique considerations
    The ongoing Global War on Terrorism has transformed National Guard 
and Reserve components from a strategic reserve to a fully capable, 
combat-ready operational reserve. This shift has occurred as much from 
necessity as from conscious policy objective. The simple fact is that 
we can no longer project or sustain American military power or 
influence anywhere in the world without relying upon and fully 
integrating National Guard and Reserve personnel into all aspects of 
Defense Department operations. DOD and VA benefits programs, however, 
especially those that address physical and mental health coverage, are 
still too often tied to the 20th century strategic reserve paradigm and 
fail to recognize or accommodate the unique needs of 21st century 
National Guard and Reserve members.
    The capabilities and operational integration of Guard and Reserve 
forces mask the fact that they are fundamentally different than active 
duty forces. Among these differences is the home-station environment 
from which our members deploy and to which they return at the 
conclusion of their combat tours. Another fundamental difference is the 
degree to which our members have access to physical and mental health 
care while in training status and upon completion of their active duty 
tours.
    When active duty personnel return from overseas combat tours, they 
are generally retained in their unit for a minimum of six months. 
During the first 30 days after return to home-station, they are given a 
half-day work schedule to allow them to decompress and gradually 
reintegrate with their family and friends. Active duty members and 
their families also typically live on or near their home-station and 
are therefore surrounded by a community that fully understands and 
shares their personal and professional experiences. Soldiers and airmen 
who experienced trauma together overseas still see each other every day 
and have an opportunity to individually and collectively ``normalize'' 
what they experienced in the combat zone. Military treatment 
facilities, physicians and other health care professionals are also 
readily available at home-station to address their medical needs.
    By contrast, National Guard members report to duty from, and return 
to, communities scattered throughout the state. The unit to which they 
are assigned for training is often geographically removed from the 
community in which they live and work. When called to active duty, they 
either mobilize as a member of the unit to which they commute for 
monthly training or as a replacement ``filler'' to ``round out'' 
another deploying unit from their state or some other state. Under past 
mobilization models, National Guard soldiers have spent 3 to 4 months 
preparing for combat, 12 to 18 months in the overseas theater of 
operations, and then a mere 5 to 10 days demobilizing at an active duty 
installation, followed by 5 days at their home town Readiness Center. 
Under the new model for mobilization, the goal is for National Guard 
soldiers to spend 1 to 1\1/2\ months preparing for combat, 10 months in 
the overseas theater, and then 5 days demobilizing at an active duty 
installation and 5 days as their home town Readiness Center.
    Upon release from active duty, National Guard soldiers return to 
their families and civilian work schedules with no opportunity to 
decompress or normalize their experiences. Their immediate family, 
which typically has no comparable combat experience, is their only 
sounding board. Their friends and neighbors in the surrounding 
community, unlike the friends and neighbors of most active duty 
personnel, also lack a common background or shared understanding of the 
Guard members' experiences. Under current policies, Guard members are 
also excused from participating in unit training for 90 days post-
demobilization and therefore have an extended break in contact with the 
other solders with whom they served overseas.
    National Guard and Reserve members also have far less access to 
medical care because of their dispersion in communities far from DOD 
and VA treatment facilities. TRICARE benefits end far too soon after 
release from active duty. Mental health issues, in particular, are not 
easily diagnosed and often surface long after the servicemember's six-
month post-deployment coverage and eligibility for health care ends. 
This results in Guard and Reserve personnel with PTSD and TBI needs 
having no access to military health care. Without approval and funding 
to seek civilian care through the TRICARE network they must wait until 
the overstressed Veterans' Administration mental health care program 
can provide assistance.
    Our members' post-deployment separation from fellow unit members 
and from access to medical care can cause small PTSD or TBI disorders 
to blossom into intractable patterns of unemployment, substance abuse, 
family separation and divorce. Even when these problems come to our 
attention, National Guard units have no organic military mental health 
providers nor are we authorized to provide direct medical care for our 
soldiers and airmen. Once demobilized, Guard members have virtually no 
access to health care unless a formal Line-of-Duty has been completed 
for the specific medical condition. Since mental health issues often 
fail to surface until long after the Guard member is released from 
active duty, such LODs are difficult to initiate, investigate and 
adequately document. Moreover, Guard members, unlike active duty 
soldiers and airmen, are often reluctant to seek help because of 
concern about the impact on their civilian employment. This is 
particularly true for law enforcement and other public safety 
employees. National Guard soldiers and airmen also tell us they don't 
report problems because of fear of being denied remote care (i.e., care 
near their place of employment or residence) and being required to 
leave their families to get care at a distant active duty installation.
               recommendations for enhancing support for 
                   national guard soldiers and airmen
    We owe National Guard and Reserve soldiers and airmen fully 
resourced, full spectrum care that is responsive to the unique medical, 
psychological, and family support needs of the Guard and Reserve force. 
One size does not fit all. Upon demobilization, members of the National 
Guard and Reserves transition back to a fundamentally different 
environment and have significantly different needs than their active 
duty counterparts. It is particularly important that we provide 
geographically dispersed health care where it can most readily be 
accessed by our combat veterans and their families.
    Although beyond the jurisdiction of this Committee, Congress should 
review the policy of excusing returning Guard members from attendance 
at unit training assemblies for the first 90 days post-demobilization. 
It would be better to fund unit assemblies during this period in which 
National Guard soldiers and airmen can reconnect with their colleagues 
and ``normalize'' in the company of their peers. It would also be 
desirable to have parallel meetings for the members' spouses and family 
members. This would somewhat replicate the support system provided for 
active duty personnel and help National Guard soldiers and airmen 
internalize their experiences and more effectively reintegrate into 
their home communities.
    The number of transition assistance advisors in each state also 
needs to be increased. Our advisors do an excellent job identifying the 
support needs of returning soldiers and airmen, but we simply don't 
have enough advisors to handle all the demands placed upon them.
    National Guard members require and deserve greater access to health 
care at military and Veterans' Administration facilities and these 
facilities themselves must be better staffed and funded. The National 
Guard and Reserves are now an integral part of America's combat forces 
and must have a commensurate level of access to health care. Mental 
health care, in particular, is dependent on access and on the 
availability of trained providers. Mental health staffing should 
include, to the maximum extent possible, providers with direct combat 
experience. National Guard units should also be staffed with clinical 
psychologists and social workers to provide care to Guard members on 
par with what is provided to active duty members before, during and 
after deployments. Such enhancements would go a long way toward 
ameliorating misdiagnosis and ``failure to treat'' problems. Full 
medical coverage, and especially mental health coverage, should 
continue for at least a year following a Guard member's release from 
active duty and a regime of subsequent periodic screening should also 
be authorized and adequately resourced.
                               conclusion
    National Guard and Reserve units are an integral part of America's 
21st Century fighting force. Current and future operations will 
therefore continue to expose Guard and Reserve forces to unprecedented 
trauma in protracted and recurring life-threatening situations. It must 
be recognized that while the exposure to trauma is the same throughout 
the force, members of the Guard and Reserves come from decidedly 
different environments than their active duty counterparts and they 
return to military programs and civilian communities that have far 
fewer resources and support systems than those enjoyed by active duty 
members returning to Federal military installations. These differences 
must be recognized and accommodated by designing, implementing and 
resourcing physical and mental health care for members of the Guard and 
Reserve that is equal to that received by active duty personnel.
    Thank you for considering the recommendations I have made for 
redressing current system deficiencies. I look forward to your 
questions.

    Senator Murray. Thank you. General Baxter.

         STATEMENT OF BRIGADIER GENERAL SHEILA BAXTER, 
        COMMANDER, MADIGAN MEDICAL CENTER, FORT LEWIS, 
                           WASHINGTON

    General Baxter. Good afternoon, Senator. Thank you for this 
opportunity and thank you for your leadership here in the State 
of Washington and the other Washington as well. I'm happy to be 
here. I am the Commanding General for Madigan Army Medical 
Center. Madigan has a proud history of innovative health care 
programs and dedicated staff professionals who are committed to 
the delivery of quality health care. I'm eager to talk today 
about our partnership between us and the VA and excited about 
the progress we're making toward providing comprehensive 
seamless care to our warriors and their families. We are 
particularly proud of our ongoing initiatives to reach out and 
support the psychological health needs of our servicemembers.
    Six months ago a series of stories published in the 
Washington Post caused all of us in the Army Medical Department 
to take an in-depth look at our outpatient services. 
Additionally, the acting Surgeon General of the Army dispatched 
a multi-disciplinary Tiger Team to assess the provision of 
health care services at 11 installations across the country, 
including Fort Lewis. The Tiger Team found several areas where 
we could improve performance while also identifying several 
best practices. In March of this year, Army leadership 
established the Army Medical Action Plan to examine problem 
areas, including staffing issues, facility concerns, 
bureaucratic processes and administrative delays in an effort 
to generate achievable solutions.
    Ultimately, the AMAP team produced an Army Operations 
Order. It was signed by the Vice Chief of Staff of the Army 
which directed the accomplishment of over 135 tasks. At Madigan 
we are working diligently to implement these changes. On July 
13 of this year at Fort Lewis, we established a Warrior 
Transition Unit. This new organization of structure provides 
every Warrior in Transition with a triad of support, which 
includes a squad leader, case manager and physician. The 
mission of this triad is to support the needs of the warrior 
and his family through the complexity of this healing process, 
and if necessary the medical board process.
    Additionally, we assigned an ombudsman to serve as an 
advocate for every Warrior in Transition and to help soldiers 
navigate through the medical evaluation process. An important 
element of the Army Medical Action Plan is the transition from 
the military health system to the Veterans Health 
Administration. We're focusing extra attention on the hand-off 
from DOD to DVA. For the past two years our part--our partners 
in the VA have had two social workers embedded at Madigan to 
facilitate the transition of warriors from DOD health system to 
the VA. Today these two VA social workers work side by side 
with our case managers to provide that seamless transition.
    For many of our warriors we understand that this is an 
uncertain time that we are taking steps to eliminate the 
uncertainty and to make the transition not only seamless, but a 
pleasant experience. I would like to briefly summarize some of 
the areas the Army has participated in to improve behavioral 
health services. In 2003, we revised the Post-Deployment Health 
Assessment originally developed in 1998. The same year we 
launched the first Mental Health Advisory Team into theater. 
Never before had the mental health of combatants been studied 
in a systemic manner during conflict. The psychologists on the 
team at that time was the Chief of Psychology at Madigan, 
Colonel Bruce Crow. This and subsequent Mental Health Advisory 
Teams have influenced our policies and procedures, not only in 
theater but before and after deployment as well. In 2005 the 
Army rolled out the Post Deployment Health Re-assessment, the 
PDHRA. The PDHRA provides warriors with an opportunity to 
identify any physical and behavorial health concerns they may 
be experiencing that may not have been present immediately 
after their redeployment.
    Madigan Army Medical Center expanded this basic program 
with a program we call the Soldier Wellness Assessment Pilot 
Project (SWAPP). SWAPP extends the basic PDHRA program to 
include a comprehensive physical and mental health screening 
and provides an opportunity for soldiers to have a face-to-face 
session with a credentialed behavorial health provider. This 
program has reduced stigma by requiring all soldiers and their 
leadership to participate, so every soldier that goes through 
the program sees their commander leader go through this 
program, and we know that that helps to reduce the stigma. This 
program has been recognized within the medical department as a 
best practice and continues to provide first class care to our 
Fort Lewis warriors, both prior to and after their redeployment 
90 to 100 days upon their redeployment.
    Additionally, we are utilizing new technologies in multiple 
ways as we develop online programs for post-deployment care and 
explore the expanded use of virtual reality treatments for 
PTSD. Before we can treat PTSD with these cutting edge 
modalities, they must first be recognized. Our staff is fully 
engaged and participating in the Army directed mild Traumatic 
Brain Injury and PTSD chain teaching, and by October 18, 2007, 
soldiers and leaders at all levels and in all organizations 
will complete this training designed to assist in recognizing 
PTSD and TBI, the hidden wounds of war. This training is 
currently being expanded to include an IPod version in videos 
for civilians and family members in both English and Spanish.
    Senator Murray, thank you for this opportunity to 
participate in this hearing. And in closing, Madigan and the 
Western Region are committed to providing a level of care that 
is equal to the quality of service that is provided by these 
great warriors. We recognize our challenges and we are striving 
every day to continue to improve the process.
   Prepared Statement of Brigadier General Sheila Baxter, Commander, 
          Madigan Army Medical Center, Fort Lewis, Washington
    Senator Murray, thank you for providing me the opportunity to 
participate in this important discussion. I am Brigadier General Sheila 
Baxter, Commanding General of the Western Regional Medical Command and 
Madigan Army Medical Center. Madigan has a proud history of innovative 
health care and a dedicated staff of first-rate health care 
professionals. I am eager to talk about the terrific relationship 
between Madigan and our VA partners and I am excited about the progress 
we are making toward providing comprehensive, seamless care for our 
Warriors and their Families. I am particularly proud of our ongoing 
initiatives to reach out and support the psychological health of our 
Servicemembers, Veterans, and their Family Members.
    Six months ago, a series of stories published in the Washington 
Post caused those of us in the Army Medical Department to take an in-
depth look at our outpatient processes. Additionally, the Acting 
Surgeon General of the Army dispatched a multi-disciplinary Tiger Team 
to assess the provision of health care services at eleven installations 
across the country, including here at Fort Lewis. We found many areas 
where we could improve performance. We also found some areas at Fort 
Lewis that were identified as ``best practices'' to be emulated across 
the Army. In March of this year, Army leadership established the Army 
Medical Action Plan (AMAP) Team to examine problem areas--be they 
leadership issues, facility concerns, bureaucratic processes, or 
administrative delays--and generate achievable solutions. Ultimately, 
the AMAP team produced an Army Operation Order, signed by the Vice 
Chief of Staff of the Army, which directed the accomplishment of over 
135 tasks. At Madigan, we are working hard to implement all of these 
actions. The biggest step was the establishment of the Warrior 
Transition Unit on 13 July. This new organizational structure provides 
every Warrior in Transition with a triad of support, which includes a 
squad leader, nurse case manager, and physician. The mission of the 
triad is to support the needs of the Warriors and their Families 
through the complexities of the healing and, if needed, medical board 
process.
    An important element of the Army Medical Action Plan is the 
transition from the military health system to the Veterans Health 
Administration. We are focusing extra attention on the hand-off from 
DOD to DVA. For the past two years, we have had two VA social workers 
placed at Madigan to facilitate the transition of Warriors from the DOD 
healthcare system to the DVA healthcare system. For many of our 
Warriors, this is a scary, uncertain time, but we are taking steps to 
eliminate the uncertainty and to make the transition not only seamless 
but a less-challenging experience.
    Our actions must consistently honor the service of our Warriors. We 
are committed to providing the best quality health care to our 
Servicemembers with physical injuries resulting from War. We are 
equally committed to saving and improving lives where the injuries are 
not so visible. Although robust behavioral health care services were 
available to our beneficiaries before the Global War on Terror began, 
they have steadily improved over the last 5 years as the needs of our 
population changed. The Army and the Department of Defense have made 
significant advances in the provision of behavioral health services 
since the attacks on 9/11.
    I would like to briefly summarize some of the areas the Army has 
participated in to improve our behavioral health services. In 2003, we 
revised the Post-Deployment Health Assessment, originally developed in 
1998. That same year we launched the first Mental Health Advisory Team 
(MHAT) into theater. Never before had the mental health of combatants 
been studied in a systematic manner during conflict. The psychologist 
on that team was, at that time, the Chief of Psychology at Madigan 
(Colonel Bruce Crow). This and subsequent MHATs have influenced our 
policies and procedures not only in theater but before and after 
deployment as well. In 2005, the Army rolled out the Post Deployment 
Health Reassessment (PDHRA). The PDHRA provides Warriors with the 
opportunity to identify any new physical or behavioral health concerns 
they may be experiencing that may not have been present immediately 
after their redeployment. Madigan Army Medical Center expanded on this 
basic program with a program I will speak to further in a minute.
    In 2006, the Army Medical Department (AMEDD) piloted a program at 
Fort Bragg, North Carolina intended to reduce the stigma associated 
with seeking mental health care. The Respect-Mil pilot program 
integrates behavioral healthcare into the primary care setting, 
providing education, screening tools, and treatment guidelines to 
primary care providers. It is now in the process of being implemented 
at fifteen other sites across the Army. Here at Fort Lewis, we have 
programs for primary care psychology support within our Soldier Family 
Medicine Clinics. Also in 2006, the Army incorporated into the 
Deployment Cycle Support program a new training program called 
``BATTLEMIND'' training. It is a strengths-based approach that 
highlights the skills that helped Warriors survive in combat instead of 
focusing on the negative effects of combat.
    The Army's efforts to address behavioral health continued in 2007 
as we expanded BATTLEMIND training with modules for pre-deployment 
training and for spouses; our Behavioral Health web site went live in 
March; our Behavioral Health Proponency Office and AMEDD Suicide 
Prevention Office both stood up in March; our new PTSD training course 
started in June; and recommendations from the Department of Defense's 
Mental Health Task Force were released in June. We are participating 
with our sister Services and Health Affairs to review the Mental Health 
Task Force recommendations, the Traumatic Brain Injury Task Force 
recommendations, the recommendations from the President's Commission on 
Care for the Wounded Warrior, and other recent thoughtful reviews to 
implement a coordinated program.
    Congress provided tremendous financial support to allow us to 
better understand and treat both PTSD and TBI. The funds provided in 
the Fiscal Year 2007 Emergency Supplemental will significantly jump 
start our improvements in behavioral health care.
    Shifting back to some of the key programs that we have here in 
Washington State, I would like to mention first our expanded version of 
the PDHRA program. Consistent with our approach of reaching out to all 
of our population, not just those who come into our clinical settings, 
we have created a program called the Soldier Wellness Assessment Pilot 
Program (SWAPP) that extends the basic PDHRA program to include a 
comprehensive physical and mental health screening and provides the 
opportunity for a face-to-face session with a credentialed behavioral 
health provider for all Warriors. This program has been recognized 
within the Medical Command as a Best Practice and continues to provide 
first-class care to Fort Lewis Warriors both prior to and as they 
return from deployment. We are utilizing new technologies in multiple 
exciting ways, as we develop online programs for postdeployment care 
and explore the expanded use of Virtual Reality treatments for PTSD.
    Senator Murray, thank you for the opportunity to participate in 
this important discussion with you and the Members of this Committee. 
The Army and the Army Medical Department are committed to providing a 
level of care--physical, emotional, spiritual--that is equal to the 
quality of service provided by these great warriors. We recognize our 
challenges and are striving daily to continue improving the quality 
care we provide to our Warriors and family members. Our Wounded 
Warriors and their Families deserve the best we have to offer and we in 
the Army Medical Command are honored to care for them. I look forward 
to your questions.

    Senator Murray. Thank you very much, General Baxter. John 
Lee.

STATEMENT OF JOHN LEE, DIRECTOR, WASHINGTON STATE DEPARTMENT OF 
                        VETERANS AFFAIRS

    Mr. Lee. Thank you, Senator. I would be remiss if I didn't 
join the chorus to your fan club here. Thank you for all that 
you do and that of your staff. I have to tell you, they are 
incredibly responsive, always there to help us with our issues 
and I want to thank them. You know, I have a sense that we're 
not here today for commercials on all the great stuff that 
we're doing. I want to point out, however, since we went to war 
since 2003 and the stories you heard today, we have done a 
tremendous amount of reshaping the kinds of things we do. I 
want to tell you that through the help of General Lowenberg, we 
have done outreach to every National Guard unit in the State of 
Washington taking benefits specialists and job specialists and 
counselors to those weekend events to assist people making 
access to all their stuff. Recently, General Baxter allowed two 
full-time staff of the Washington State Department of Veteran 
Affairs to be embedded, I will use that word, in the medical 
hold contingent so that now at the front end of people leaving 
active duty, we will be able to have a conversation with them, 
look them in the eye about the stuff that is available for them 
when they transition out of the military. But Brandon said, ``I 
hope something can be done to increase the communication 
available to the services that we earned in our service to our 
country.''
    And, so, in closing, Senator, I will tell you that I have 
some ideas, and I would like to work with you and your staff, 
because one of the greatest obstacles government faces is this 
idea that we cannot share private information about the 
veterans and family members we are obligated to serve without 
some kind of high-level, complicated database, or incredibly 
complex legal documents. And I'm here to tell you that that 
offends me. I think we can move beyond that and the men and 
women that are serving our country that we are obligated to 
provide services to expect us to do no less. Thank you.
    Senator Murray. Thank you very much. Thank you to all of 
our panelists. You know, you all had an opportunity to listen 
to our first panelists speak today talking about the stigma, 
talking about how difficult it was to come home and ask for 
care, the challenge to their families, the bureaucratic 
nightmares they get in, the denials of service that creates 
more difficulties for them as they try to deal with mental 
health. I assume all of you are concerned as I was as we 
listened to that panel that we have so many people today who 
are not accessing mental health care. Would anybody like to 
comment?
    General Lowenberg. Frankly, I found the testimony to be 
heart wrenching, not surprising, but very disturbing. As John 
Lee just pointed out, I think we have done a great deal since 
the 81st Brigade returned from Iraq to provide a more obvious 
and readily available network of support, but we still have 
soldiers and airmen who fall through that network and that 
unity of effort. More needs to be done, and as I pointed out to 
you, there are several systemic problems with Reserve 
components at large to included the National Guard that really 
limit what we can do to really help our--
    Senator Murray. What's surprising to me, General, because 
you say you don't have mental health experts available for 
National Guard and Reserve when we have men and women who have 
been not called up ones or twice, but even three and four times 
now, and yet, you don't have that. Have you asked for that?
    General Lowenberg. Well, the Congress and the Defense 
Department, they have not made the shift from a 20th century 
strategic Reserve to a 21st century operational Reserve.
    Senator Murray. Does that take an act of Congress?
    General Lowenberg. Yes, it does. It requires authorization 
and appropriation to the Armed Services Committees for those 
kinds of positions.
    Senator Murray. Mr. Lewis, were you surprised by the panel 
and--
    Mr. Lewis. I don't think surprise is the word, more 
disturbed. Despite the improvements that have been made and all 
of the systems that are put together, it's very clear that 
we're still failing. No matter how much we communicate, the 
word still doesn't get out. As you know, at VA we can provide 
some very limited services to families if the family 
accompanies the veteran to a session, but we can't provide 
something single. And given the various legislative mandates 
under which each of our different organizations operate, each 
one of us is trying to do what we can within those, but there 
are still these wide gaps between all of us, and the best thing 
would be to close those gaps.
    Senator Murray. General Baxter, you've heard about the 
culture and stigma within the Army. You served in the Army. 
What--what do we have to do to change that stigma?
    General Baxter. Yes, ma'am, and as I mentioned here at Fort 
Lewis, I've got to tell you, LTG Dubik was very instrumental in 
leading the charge in reducing that stigma. We developed the 
Soldier Wellness Assessment Program, we also, two years ago 
started what we call the senior wellness stress seminar for 
senior leaders. We have generals who come in and talk about 
their stress, because we feel that if you see general officers 
and Sergeants Major and their spouses come in and talk about it 
at the highest level, and we meet quarterly, and so, those 
leaders set the example in helping to reduce the stigma. I have 
to tell you that leaders are taking this seriously. It was 
unfortunate to hear those stories this morning. I can tell you, 
Senator, that we are making improvements daily. The triad that 
I mentioned, with the squad leader and the case manager, 
wrapping around the soldier to navigate them through the MEB--
Medical Evaluation Board process. We are hiring additional 
personnel--I have 100 mental health providers working at 
Madigan. We're hiring an additional 14 mental health providers.
    Senator Murray. Do you think there is still a culture 
within the services despite all of that that says, you're a 
macho soldier, mental health is not part of being macho?
    General Baxter. Yes, ma'am, and I think that as we continue 
to educate the cadre--as we continue to educate our war 
fighters in how to deal with PTSD and TBI, I think we will see 
a change in culture. But what we're doing right now with the 
chain teaching programs, I think that will help, and the Army 
has driven that from the top down.
    Senator Murray. Let you ask you, General Baxter, the Army's 
report on suicide which came out yesterday which was part at 
Madigan, and I assume you were part of writing that?
    General Baxter. Yes, ma'am.
    Senator Murray. 99 confirmed suicides among active duty 
soldiers during 2006.
    General Baxter. I'm sorry, I was not a part of writing that 
article that you are talking about.
    Senator Murray. You were part of the report, participation 
in the report?
    General Baxter. Which report?
    Senator Murray. The report that came out yesterday on 
suicide.
    General Baxter. No, ma'am, I was not a part of that report.
    Senator Murray. Well, the report was that there were 99 
confirmed suicides among active-duty soldiers during 2006. Do 
we know how many unsuccessful suicide attempts there were?
    General Baxter. I don't have that information, ma'am, but I 
have my chief of psychology here. He may be able to answer 
that.
    Colonel Gahm. And perhaps the next panel--
    Senator Murray. I'll ask him on the next panel and I want 
to know what counts as a suicide and that, so if you could be 
ready to answer that question, I would appreciate it. Well, let 
me ask you this, General Baxter, because I've heard when the 
report came out, the Army responded broken marriages and Dear 
John letters were one of the main factors behind suicide. It 
seems to me that PTSD and brain damage are significant as well. 
Can you explain why the report distances itself from those 
factors.
    General Baxter. No, ma'am, but I can tell you that we have 
a number of services that we provide to soldiers including our 
chaplains as part of those teams that are embedded with the 
units. We have retreats that we provide here at Fort Lewis for 
soldiers who have come back from deployment, and their spouses 
are a part of that. There are a number of services out there, 
we are now going to embed social workers in the barracks. We 
were just down at the Navy facility in Balboa a week ago. One 
of the things that we noticed as a great model is that they 
have their behavorial health technicians live in the barracks 
with the soldiers, and they're finding that the number of 
complaints in terms of how they adjust when they come back go 
down.
    Senator Murray. Well, we know the report yesterday just 
talked about suicide within the services. Dr. Zeiss, I assume 
that report did not include soldiers who committed suicide once 
they were separated from the units?
    Dr. Zeiss. That's my understanding.
    Senator Murray. Does the VA keep the numbers for those 
additional suicides?
    Dr. Zeiss. We certainly are trying to develop better 
mechanisms of capturing suicides. We're working with the 
National Death Register to get that information so that we can 
get information about all veterans. There is also research 
going on trying to extend the information, so we track the 
number of suicides that occur that are known to the system, 
that is, that has been reported back.
    Senator Murray. Do you have any numbers you can share with 
me on that?
    Dr. Zeiss. I don't have them with me. I can certainly get 
that--
    Senator Murray. I would like you to give them to me as part 
of the record, and I have to tell you, it's extremely troubling 
to me, because as I travel around and talk to veterans often 
around the state, I inevitably have someone come up to me 
afterwards to share a story with me. In fact, this week we had 
an incident where we were at one of the clinic openings, and a 
veteran came up to me. He had been denied benefits, denied 
benefits, denied benefits and denied benefits, and he asked for 
my help. I had one of my staff members stay with him 
afterwards, and he actually told my staff member that he had a 
rifle sitting at home, and if he couldn't get help from us 
talking to him that day, he was going to end his life. That is 
really disturbing to me. He had actually been separated for a 
number of years, I think it was 26 years. We have a lot of 
stories like that out there of people who don't know who to 
access, who have been denied benefits, are tired of trying to 
work through the system. I would ask, Mr. Lewis or Dr. Zeiss, 
what are we doing to reach out and help these young kids, or 
even older adults who may have served many decades ago before 
we see these kinds of statistics come out?
    Mr. Lewis. I can't speak from the national level, but I can 
speak from a local level. The suicide prevention coordinators 
of course are the newest position that have been put in place. 
Numbers of social workers, psychologists, psychiatrists that 
have been put in place not only at the facilities but also down 
at the CBOC levels now in addition to the telemental health 
initiatives, we've outreached to the local community 
facilities, hospitals. Our CEOs are meeting with their CEOs. 
Our mental health professionals are meeting with their mental 
health professionals to talk about ways when a veteran comes in 
we're notified that there is someone there in need. And, of 
course, we communicate constantly with the veterans groups, the 
VSOs and ask them to notify us and let us know as well.
    Senator Murray. Well, the person I'm talking about, similar 
to many stories I've heard, I've tried over and over and over 
again and had been denied services. Dr. Zeiss, let me ask you: 
If a veteran comes into a VA Hospital with a headache or not 
sleeping or family issues or anything, will that veteran see a 
PTSD expert that day?
    Dr. Zeiss. That would depend on the process of screening. 
Assuming they're coming into primary care, which I assume from 
your description, they would be screened for PTSD that day. And 
if there is a positive screen for PTSD or for any other mental 
health problem, they would be seen within 24 hours for an 
evaluation for the urgency of the need for--
    Senator Murray. If somebody comes in and says, I'm having 
headaches, are they seen that day, do you know?
    Dr. Zeiss. Yes.
    Mr. Lewis. There are no mental health waiting lists in 
Washington State.
    Senator Murray. Well, it is difficult, because the stories 
I hear out there are different than that. So how do we 
understand what is happening out there with people who say they 
can't get in or are denied care, they're told to come back? How 
do we rectify that?
    Mr. Lewis. If it's on a specific case, I can answer. When 
I'm presented with the generalities, I can give you what we 
attempt to do and how we attempt to outreach to veterans. And 
we're there and we're no longer expecting them to come to us. 
We're trying to get out to them as much as possible.
    Senator Murray. Well, let me change how I'm asking this 
question. I hear a lot that the VA claims process is something 
that contributes highly to the stress of individuals who are 
already under stress. What can we do to change that process so 
it doesn't become part of the stress that they are in?
    Ms. Rubens. The claims process is undoubtedly a complex 
process. There are many laws and regulations. To the degree 
that we can work to expedite, and we have changed our process, 
expedite the process for those new and returning, particularly 
for OEF/OIF veterans. We have done that in the regional office. 
We have a team established to address those as quickly as they 
come in. I think the other thing that we have tried to do, 
because it is a complex process, is ensure we have got more 
quality trained workforce so that we're doing a better job 
looking for consistency in our determinations so that as 
veterans in Washington State are treated, it would be the same 
as any other state and working to quite honestly reach them 
more quickly in our BDD system and partnering with DOD in an 
effort to, if you will, get them in and get their records more 
quickly so that years don't go by where we now have to go back 
out and search for records on military service.
    Senator Murray. How many Iraq and Afghanistan war veterans 
have actually filed any types of BDA claims?
    Ms. Rubens. I don't have the exact number of how many have 
filed. I can tell you we have roughly pending 45,000 now.
    Senator Murray. You have 45,000 pending?
    Ms. Rubens. Correct.
    Senator Murray. And how many of those are for mental 
health?
    Ms. Rubens. That I don't know. I can get that----
    Senator Murray. Can you give me an estimate.
    Ms. Rubens. I can see if we can get the specifics on how 
many of those claims involve mental health issue.
    Senator Murray. How many claims or grants--
    Ms. Rubens. I don't know. I don't have----
    Senator Murray. Do you know how many were denied?
    Ms. Rubens. No, I don't.
    Senator Murray. Do you know how many are waiting for a 
decision?
    Ms. Rubens. Roughly--we have roughly 45,000----
    Senator Murray. 45,000 waiting.
    Ms. Rubens. In process right now.
    Senator Murray. OK. I would like to know from you how many 
of our Iraq and Afghanistan veterans--I mean, we can go back 
previous wars, but let's just ask that question. Can you get 
back to me for the record how many have filed the claim, how 
many have been denied a claim, how many are waiting and how 
many were for mental health.
    Ms. Rubens. OK.
    Senator Murray. And if you could just guess for me, what is 
the average wait time for veterans coming in state from any war 
to get services.
    Ms. Rubens. For veterans benefits or for----
    Senator Murray. Just an initial appointment or decision.
    Dr. Zeiss. If you are asking about being able to get an 
appointment for mental health services from the Veterans Health 
Administration side of the house, as I said earlier, the 
standard now is that if anyone requests or is referred for 
mental health services, they will see someone or talk on the 
phone with someone (if they're a bit more distant and don't 
want to drive in) within 24 hours. And within 14 days, they 
will have a full evaluation with a treatment plan developed.
    Senator Murray. General Baxter, let me go back to you. In 
the last 6 years, the Army has diagnosed and discharged more 
than 5,600 soldiers because of personality disorders, and those 
numbers are continuing to increase. I'm told that it's unlikely 
that a member of the Armed Forces would display symptoms of 
personality disorder after they were sent to combat that is not 
already evident during extremely stressful training that they 
go through. Shouldn't it be obvious to the military that the 
servicemember has a personality disorder by the time they are 
sent to combat?
    General Baxter. What we're doing now, ma'am, is we have a 
number of assessment tools that we're using for soldiers, and I 
can just speak for Fort Lewis. We have what we call the pre- 
and post-deployment assessment program of soldiers. To give you 
an example, we had a soldier in the engineering unit six months 
before deployment, who walked into the pre-deployment progress 
and said, ``I just put a gun to my wife's head last night.'' We 
were able to get him in to see a psychiatrist immediately. I 
can only speak for the Fort Lewis process.
    Now we are doing pre-deployment assessments on soldiers. We 
have an opportunity as they are assessed in their unit for 
commanders to identify that, and I go back to the chain 
teaching requirement that we're all going to get here in the 
next 90 days that will help to identify the symptoms if a 
soldier is having those types of personality disorders.
    Senator Murray. We are running out of time, but I want to 
ask one other question, and it disturbed me. I saw an AP that 
the study on the suicide rates said that about 20 percent had 
been diagnosed with a mood disorder such as bipolar disorder 
and depression, 8 percent had been diagnosed with anxiety 
disorder, including Post Traumatic Stress Disorder, which is 
one of the signature wounds of this war. Can someone tell me 
why we're sending men and women into combat with those kinds of 
conditions in the first place. General Baxter?
    General Baxter. Again, Senator, all I could say is that I 
don't have those numbers in front of me, and I'll let my 
psychologist speak to it in the next panel. That is his field. 
I can just tell you what we're doing at Fort Lewis, as I just 
mentioned, to try and alleviate the issues of sending soldiers 
and, as you know, some of these symptoms do not appear until 
three or four months down the road. Now, we do have stress 
management teams in theater. We have psychologists, 
psychiatrists in theater to assess soldiers as they go to war, 
so I've got to tell you, there are two stop gaps here, before 
they leave Fort Lewis, and when they get into the theater, we 
have combat stress teams throughout the theater, both 
Afghanistan and Iraq to assess soldiers as well.
    Senator Murray. General Lowenberg, how about in the 
National Guard and Reserves?
    General Lowenberg. Once again, Senator, we have no internal 
resources by which we can do any of those assessments.
    Senator Murray. So you may well be sending somebody into 
combat that should not be sent to combat, simply because of the 
lack of mental health professionals?
    General Lowenberg. Once the soldier or airman is mobilized, 
they are removed entirely from our command and control and 
become a member of the Army or Air Force, and they are entirely 
subject to the administration of those systems from that time 
until they deploy, throughout their deployment and until they 
actually demobilize. So all of those resources are in the 
active Army and Air Force. They are not provided to the 
National Guard.
    Senator Murray. Well, we have a lot of issues that we need 
to look at from bureaucracy nightmares, times and waits that 
people have in getting through paperwork, rejections of their 
claims, obviously our combat troops on the ground, the entire 
stigma how we get through our cultural issues for mental health 
is something that we're going to keep working on, and I 
appreciate all of your testimony today. I do have more 
questions that I will submit to you that I'll ask for you to 
answer to submit to the record. I do want to get to our third 
panel of experts as well, so I want to thank all of you for 
coming today and I'd ask that our third panelists come forward 
at this time.
    We do have our final panel. Everybody has been very 
patient. We want to make sure we get to them. These are our 
mental health professionals, and with us today are Dr. Miles 
McFall, the Director of PTSD Program at the VA here in Seattle; 
Colonel Greg Gahm, Chief of the Department of Psychology at 
Madigan; Robert Ramsey, the Team Leader at Tacoma Vet Center; 
and Dr. Anthony Barrick who is a licensed mental health 
counselor and now practices in Seattle. He formally worked with 
the Navy and Army. And, Dr. McFall, we will begin with you.

  STATEMENT OF MILES McFALL, Ph.D., DIRECTOR, PTSD TREATMENT 
          PROGRAMS, VA PUGET SOUND HEALTH CARE SYSTEM

    Dr. McFall. Thank you, Senator Murray, for the privilege of 
appearing before you today and thank you for all you do for 
veterans and the VA. I will briefly review the VA Puget Sound 
Health Care System's specialized mental health programs for 
veterans with stress-related mental health problems and then 
discuss briefly our efforts in outreach as well as research. VA 
Puget Sound Health Care System hosts an array of six 
complementary clinical treatment programs tailored to the 
unique needs of veterans from all eras of military service. 
First let me discuss our PTSD outpatient clinics that exist at 
both divisions of VA Puget Sound Health Care Systems, each of 
which offer a full array of psychotherapeutic treatment, 
medication or pharmacological treatments, as well as case 
management interventions.
    During FY 2006, these two PTSD outpatient clinics treated 
more than 3,400 veterans, and also evaluated and triaged an 
additional 1,000 veterans, approximately 15 percent are women 
veterans. Our women veterans are cared for by a specialized 
team of therapists from our Women's Trauma Program, which is 
embedded into our PTSD outpatient programs at each division of 
VA Puget Sound Health Care System. Secondly, our PTSD inpatient 
program that is located in Seattle is a 12-bed inpatient 
program for veterans that serves veterans throughout the four-
state region of VISN 20. This PTSD inpatient program provides 
comprehensive intensive inpatient psychiatric and medical care, 
and during FY 2006 we served over 259 veterans with PTSD and 
related problems. Incidentally, veterans from Iraq and 
Afghanistan increasingly use this inpatient PTSD program. We 
have seen more than 110 so far. They rely on this program 
because we're capable of providing a platform for treating 
those who have both PTSD as well as TBI-related injuries. It 
gives us access to the Polytrauma Program while they reside in 
our PTSD inpatient program.
    Third, our PTSD Domiciliary at American Lake campus serves 
about 100 veterans annually. It provides extended care for 
veterans discharged from the PTSD inpatient program that I just 
mentioned. It's also an alternative to intensive inpatient care 
for veterans who don't need an initial stay in an intensive 
inpatient program. Veterans receive rehabilitation and 
recovery-oriented interventions typical to help them gain 
stability, cope with chronic symptoms, avert homelessness, 
engage in activation oriented and socialization programs and to 
access to case management services to help with finances and 
housing and this kind of thing.
    Fourth, our deployment health clinics that you heard about 
earlier are really the hub of specialized post-combat care for 
most Iraq and Afghan veterans at our facility. The Deployment 
Health Clinic provides primary medical care and mental health 
services provided by the PTSD program staff detailed to that 
setting. In a single setting, organizing care in this way with 
deployment clinics, both at American Lake and the one in 
Seattle improves access to care and allows the VA to coordinate 
care with the essential support services, which include the 
polytrauma program, and pain service, which is very, very 
important. The Seattle deployment health clinic has seen about 
700 veterans, and the American Lake deployment health clinic 
has seen about 500 veterans thus far.
    Fifth, our VA Puget Sound Health Care System liaisons and 
our PTSD programs staff collaborate actively with Madigan Army 
Medical Center, our Vet Centers and the Washington State 
Department of Veterans Affairs, supporting an integrated system 
of care for veterans with military-related stress disorders. 
I'll describe a few examples of integrated and collaboration of 
our VA PTSD program with other agencies. First, we detail 
psychiatrists to our three Western Washington Vet Centers which 
don't have medical personnel so that these Vet Centers can 
provide medication management onsite for patients who are 
concurrently enrolled in psychotherapy at the Vet Centers. And 
our psychiatrists follow up patients using telemedicine 
technology so that the veterans don't have to travel to the VA. 
They can get all their care at the one site at the Vet Centers. 
A second example is that active-duty servicemembers utilize our 
VA clinical care programs, particularly our inpatient PTSD 
programs that I mentioned earlier in Seattle, and they also 
use, of course, the deployment health clinics, polytrauma 
program, and other services upon referral from Madigan or other 
DOD installations.
    Let me move on a little bit to our outreach efforts. VA 
Puget Sound Health Care System PTSD mental health personnel and 
other staff from our facility have partnered with the 
Washington State Department of Veterans Affairs, the Washington 
State National Guard and a host of other federal and state 
agencies to conduct an aggressive outreach program for OIF/OEF 
veterans because we believe early intervention for Iraq/Afghani 
vets is really the best method of preventing normal 
readjustment responses from evolving into chronic PTSD. Mental 
health staff at these VA facilities in Western Washington have 
provided screening, counseling and education to nearly 3,000 
active-duty servicemembers during 32 family activity day events 
since 2005 that were organized by the Washington State 
Department of Veterans Affairs and National Guard.
    I also want to mention that PTSD research is a vital 
component of providing the best care possible to our veterans 
and servicemembers. VA Puget Sound Health Care System PTSD 
research investigators have amassed over $23 million thus far 
in competitive research funds from the VA, Department of 
Defense and National Institutes of Health and have published 
more than 60 scientific papers on underlying mechanisms and 
treatment approaches for PTSD.
    This concludes my testimony. Again, thank you for the 
opportunity to appear here today before you.
         Prepared Statement of Miles McFall, Ph.D., Director, 
       PTSD Treatment Programs, VA Puget Sound Health Care System
    Good Morning, Senator Murray. Thank you for the opportunity to 
discuss VA Puget Sound Health Care System's service to veterans with 
stress-related mental disorders. I would like to request my statement 
be submitted for the record. I will begin by discussing our medical 
center's specialized mental health programs, then later move to our 
outreach and research plans.
    VA Puget Sound hosts an array of complementary clinical treatment 
programs uniquely tailored to the needs of veterans from all eras of 
military service.

    1. Our Post Traumatic Stress Disorder (PTSD) Outpatient Clinics 
offer a full spectrum of care including pharmacological, 
psychotherapeutic, and case management interventions. During FY06 we 
treated more than 3,400 veterans, approximately 15 percent of whom were 
women. Our women veterans are cared for by a specialized team of 
therapists from our Women's Trauma Program.
    2. The PTSD Inpatient Program is a 12-bed inpatient PTSD program 
for veterans in VISN 20. The PTSD Inpatient Program provided 
comprehensive intensive inpatient psychiatric and medical care to 259 
veterans with PTSD and related disorders in FY 2006. OIF/OEF veterans--
more than 110 so far--increasingly rely on this program because it 
simultaneously evaluates and treats both PTSD and Traumatic Brain 
Injury (TBI), in collaboration with our Polytrauma program.
    3. The PTSD Domiciliary serves about 100 veterans annually, 
provides extended care for veterans discharged from the PTSD Inpatient 
Program, and is an alternative to intensive inpatient care. Veterans 
receive rehabilitation and recovery-oriented interventions designed to 
help them gain stability, cope with chronic symptoms, avert 
homelessness, engage in activation-oriented programs to counter social 
isolation, and access case management services.
    4. Deployment Health Clinics (DHC) are the hub of specialized post-
combat care for most OIF/OEF veterans at our facility. The DHC provides 
primary medical care and mental health services (provided by PTSD 
program staff) in a single setting, improves access to care, and allows 
VA to coordinate care with essential support services. The Seattle DHC 
has seen about 700 veterans and the American Lake DHC has seen about 
500 veterans.
    5. VAPSHCS Liaisons and PTSD Program staff collaborate with Madigan 
Army Medical Center, Vet Centers and the Washington Department of 
Veterans Affairs (WDVA) to support a system of care for veterans with 
military-related stress disorders. Recently, VA Puget Sound PTSD 
programs deployed psychiatric staff to three Vet Centers in western 
Washington and used telemedicine to follow patients in these settings. 
Additionally, active duty servicemembers utilize our PTSD programs, 
particularly the PTSD Inpatient Program and DHCs, after referral by 
Madigan Army Medical Center and other DOD installations.

    VA is conducting aggressive outreach with WDVA, the Washington 
State National Guard, and a host of other Federal and state agencies 
because early intervention for OIF/OEF veterans is the best method for 
preventing normal readjustment responses which can, in certain 
instances, solidify into chronic PTSD. Mental health staff from VHA 
facilities in Washington provided screening, counseling, and education 
to nearly 3,000 active duty servicemembers during 32 ``Family Activity 
Day'' events since 2005.
    PTSD Research is vital to providing the best care possible to our 
veterans and servicemembers. VA Puget Sound research investigators have 
amassed over $23 million in competitive research funds from VA, the 
Department of Defense (DOD), and the National Institutes of Health 
(NIH) and have published more than 60 scientific papers on underlying 
mechanisms and treatment approaches for PTSD.
    This concludes my testimony. Thank you for the opportunity to 
appear before you today, Senator Murray. I would be happy to answer any 
questions you may have.

    Senator Murray. Thank you very much. Colonel Gahm.

         STATEMENT OF COLONEL GREGORY A. GAHM, CHIEF, 
  DEPARTMENT OF PSYCHOLOGY, MADIGAN ARMY MEDICAL CENTER, FORT 
                       LEWIS, WASHINGTON

    Colonel Gahm. Senator Murray, thank you for this 
opportunity as well. It's important for us to have this 
opportunity to speak to the important programs that we're doing 
at Fort Lewis, many of which have been recognized by the GAO, 
by the DOD Mental Health Task Force, and by the Military Child 
Education for the innovative and forward reaching. 
Nevertheless, we realize that it's important for us to continue 
to move forward to develop more programs that expand the 
services that we are operating. One of the programs that 
General Baxter mentioned was our Soldier Wellness Assessment 
program. The DOD has mandated for all servicemembers a 90 to 
180 post-deployment mental health evaluation, and we took that 
further. We ensured that for every soldier we have at Fort 
Lewis they get a face-to-face mental health visit with a 
credentialed mental health counselor, even if they deny they 
have problems at that time.
    We feel that this approach helps to address the issues of 
stigma, because everyone has to see the mental health, so no 
one knows--no one has to worry about why am I going to mental 
health. It addresses the comfort level of seeing them, because 
even if that person doesn't really need that care that day, 
they now are familiar with what mental health care is, and it 
allows us to ensure that we in case findings identify 
individuals with needs. We've expanded the program in addition 
to being a more comprehensive program all to do with pre-
deployment, so we can collect at pre-deployment the resilient 
skills and how we can help soldiers better deploy and better 
prepare for the future.
    At this time I briefed a couple of initiatives that we have 
ongoing at Fort Lewis. Besides the SWAPP, we have programs 
reaching out to the community through the school system where 
we're working with all the school districts in the local area 
to train--work directly with the student, as well as work with 
the teachers and counselors to help them prepare--help them 
address the deployment issues with their students with 
themselves and help them better prepare for the challenges they 
face should bad things happen. We have programs working with 
case managers where we embedded them to address some of the 
concerns that were mentioned here before to ensure that we 
really have mental health providers successful to getting 
anyone wherever they need to--wherever they want to be seen.
    And then in addition to the physical presence, we've 
leveraged technology to reach out beyond where we can have 
people available to build an online Internet based service 
program for after appointment needs. I was directed by Congress 
and the National Defense Authorization Act 2006, and Madigan is 
leading this initiative, which is a broad DOD NDA partnership 
to build services that will be available to both military 
beneficiaries, but anyone else who would access this, because 
it's a non-opportunity to achieve preclinical care to help them 
identify what their problems may be, to help identify who maybe 
we would suggest should get face-to-face care and who can 
benefit from online services. This is an initiative we're very 
proud of. We have been working hard for quite a while now, and 
we're going to be unveiling a pilot version in September of 
this year.
    As mentioned also we're exploring the use of virtual 
reality technology, which is really just a tool that we can use 
in exposure therapy to allow servicemembers to re-experience in 
a controlled environment the stressors they experienced in 
deployment and to have a therapist available to help them 
adjust and decondition essentially to the negative impact 
they've had from that. And in the interest of time--one final 
thing is that in our primary care clinics, we've also moved 
psychologists to primary care clinics so that we have--working 
directly with consults--consultants to the primary care 
providers. We don't have to have the soldiers go over to mental 
health clinic even. If the primary care provider identifies a 
potential need for services, they can pull the person aside, 
walk them right over and say, yeah, I'd like to get you to talk 
to this person today, one more avenue we have for ensuring that 
care is available as much as it can be. And with that, I would 
like to conclude pending your questions.
  Prepared Statement of Colonel Gregory A. Gahm, Chief, Department of 
    Psychology, Madigan Army Medical Center, Fort Lewis, Washington
    Senator Murray and distinguished Members of the Committee, thank 
you for providing me the opportunity to address the broad range of 
mental health concerns affecting our Servicemembers and Veterans. As 
Chief of the Department of Psychology at Madigan Army Medical Center, I 
am proud to oversee the delivery of care provided by my psychologists 
to the Servicemembers and Family Members served by Madigan. I am also 
proud of our ongoing initiatives to reach out and support the 
psychological health of Servicemembers, Veterans, and their Family 
Members. While our work at Fort Lewis has been recognized by the recent 
DOD Mental Health Task Force report, the Government Accountability 
Office, the Military Child Education Council, and positively reviewed 
in the press, we also recognize that we must continue to expand the 
services we offer and ensure that we remain committed to improving the 
compassionate care we provide.
    Our actions must consistently honor the service of our Soldiers. 
Concerns regarding Soldiers separated for personality disorders, 
especially given the potential impact on future care for the 
psychological injuries of these veterans, are being addressed by the 
Army. The media and Congress have alleged that Soldiers have been 
unfairly discharged under Chapter 5-13, Personality Disorders (PD), 
when they should have been afforded the opportunity to undergo a 
Medical Evaluation Board. The acting Army Surgeon General directed a 
review of all Soldiers discharged for personality disorders in 2006 who 
had served in OIF or OEF. The results of this review still need to be 
presented to Army leadership, but some initial guidance for behavioral 
health providers has already been issued to the field.
    Additionally, the Government Accountability Office (GAO) is in the 
process of auditing the Department of Defense with regard to the issue 
of administrative separation for a personality disorder diagnosis. To 
prepare, the GAO chose to visit Fort Lewis last month, not to address 
concerns, but rather to visit a positive model and consult with our 
psychologists, psychiatrists, and attorneys to learn about our 
processes in order to plan for their audit. While we strive to 
consistently act in the best interest of the Soldier, we agree with 
Army leadership that ``even one misdiagnosis is too many.'' As our 
Surgeon General testified to the House Committee on Oversight and 
Government Reform in May, we recognize we are an imperfect 
organization, and are actively striving to ensure every Soldier 
receives the respect and outstanding care they deserve.
    One of the many recognized initiatives that exemplify outstanding 
care to Servicemembers is Fort Lewis' implementation of the DOD's Post 
Deployment Health Re-Assessment, or PDHRA. The PDHRA process identifies 
physical and psychological health concerns for Servicemembers 90 to 180 
days following redeployment. The PDHRA process at Fort Lewis is called 
the Soldier Wellness Assessment Pilot Program, or SWAPP. This program 
goes well beyond the DOD's basic mandated PDHRA process to provide a 
reset of the Soldier physically, spiritually, and mentally. Of 
particular note, every Soldier who completes SWAPP is provided the 
opportunity to meet that same day with a psychologist or master's level 
clinician. The Soldier and mental health provider work collaboratively 
to define needs, address concerns, assist with smooth redeployment, and 
connect the Soldier with any additional resources that might be needed.
    After evaluating the process, we can say without question that 
``SWAPP works.'' Barriers to care fall. Every Soldier connects with a 
behavioral health clinician--there are no dead end referrals. As 
evidence of this, utilization rates for Fort Lewis' Stryker Brigade 
following redeployment in Fall 2005 reached the same Behavioral Health 
utilization rates (31 percent) in 6 months as was observed in one year 
in a population study completed by Colonel (Dr.) Charles Hoge and 
colleagues in 2006. In addition, Post-SWAPP Soldiers made an average of 
5.3 visits during that time compared to an average of 3.4 visits found 
in the same one-year naturalistic study. Hoge, et.al, (2006) reported 
that only 50 percent of those who were referred based on positive PDHA 
responses were seen by a Behavioral Health provider, versus 100 percent 
of those who are seen through the SWAPP process.
    Perceived stigma regarding mental health care drops when every 
Soldier follows the same process and meets with a behavioral health 
clinician. Dr. Hoge's 2004 New England Journal of Medicine study 
identified mental health stigma as the most significant barrier to care 
for Soldiers. Preliminary local analysis suggests that there is a drop 
in perceived mental health stigma for those individuals who are seen 
immediately after SWAPP compared to those who are seen prior to SWAPP 
or those who were seen later than a month after SWAPP. Additionally, 
SWAPP satisfaction survey data suggests that 13 percent of Soldiers 
seen in SWAPP were uncomfortable seeking mental health care prior to 
the SWAPP process, a number that was cut to less than half that 
following SWAPP.
    SWAPP goes beyond addressing the needs of returning Soldiers. At 
Fort Lewis, this same process is provided to all Soldiers prior to 
their deployment as well. Pre-deployment SWAPP addresses the specific 
needs of Soldiers prior to their departure and seeks to buttress the 
resiliency of the Soldiers preparing to face the rigors of deployment. 
We are excited to continue SWAPP at Fort Lewis and look forward to 
working with the Army Medical Department to bring SWAPP to additional 
Army facilities.
    In addition to SWAPP, Fort Lewis has many initiatives to reach out 
to Soldiers and their families. These include programs linking up our 
psychologists with the local schools to offer both programs for the 
students directly and training and support for the teachers and 
counselors in helping to deal with the effects of deployment. We are 
providing mental health care managers in numerous settings including 
our Warrior Transition Brigade to insure Soldiers have ready access to 
the helping resources.
    We are also leveraging technology in several exciting ways. One of 
our efforts involves the development and deployment of an Internet 
based resource to reach out to all Servicemembers and their families to 
assist them after deployment. The National Defense Authorization Act 
(NDAA) for Fiscal Year (FY) 2006 authorized a pilot project of 
Internet-based tools aimed at identifying and treating Post Traumatic 
Stress Disorder (PTSD) and other mental health conditions. The Office 
of the Assistant Secretary of Defense (Health Affairs) has designated 
the Army as the project lead and I'm pleased that the Army Behavioral 
Health Technology Office (ABHTO) at Madigan Army Medical Center is 
leading the DOD project team. Partners in this very important 
initiative include the VA's National Centers for PTSD in Massachusetts, 
California, and Hawaii, the Center for Deployment Psychology, and other 
military organizations and sites. The web application we are 
developing, afterdeployment.org, addresses multiple critical variables 
in caring for the military family. The significant incidence of post-
deployment mental health problems is exacerbated by limited provider 
availability, geographic proximity to services, scheduling challenges, 
and stigma. Afterdeployment.org offers a quality service that in many 
cases will provide an alternative to traditional face-to-face care. 
Afterdeployment.org is designed as a modularized and highly engaging 
self-care, online solution. The need for this tool has been highlighted 
by recent reports that a significant percentage of servicemembers and 
their families do not seek help despite meeting the criteria indicating 
a need for mental health services. Afterdeployment.org helps fill the 
gap by delivering tailored assessments and portable services available 
online anytime and anywhere. User anonymity is a key component, and 
will facilitate user comfort when engaging with the range of 
psychoeducational materials, self-assessment tools, and workshop 
exercises that the site will provide.
    The programs available through the web site target the following 12 
areas: (1) combat stress and triggers, (2) conflict at work, (3) re-
connecting with family and friends, (4) moods, (5) anger, (6) sleep, 
(7) substance abuse, (8) stress management, (9) resiliency of kids, 
(10) spiritual guidance, (11) living with physical injuries, and (12) 
health and wellness. The web site design was tested in structured 
interviews with servicemembers in February and some modifications were 
made as a result of the feedback. The afterdeployment.org pilot version 
will be released for user testing in September 2007 with continuing 
development through FY 2008.
    In order to further improve our ability to reach out to all of our 
beneficiaries, the AMEDD, in coordination with OSD Health Affairs (HA), 
is expanding our capacity to deliver tele-behavioral health care. 
Madigan Army Medical Center was recently approved to become a ``hub'' 
for regional telebehavioral health care and I have been asked by HA to 
work with them to initiate a National Center for TelePsychological 
Health & Technology. These services will augment the care available to 
our Servicemembers and Veterans and improve access to those in 
underserved areas.
    Virtual Reality treatments for PTSD represent another area where we 
are leveraging new technologies in exciting ways to help our Soldiers. 
Building upon development efforts supported by the U.S. Army Medical 
Research and Materiel Command's Telemedicine and Advanced Technology 
Research Center (TATRC) and the Office of Naval Research we have worked 
collaboratively with the Institute for Creative Technology (ICT) at the 
University of Southern California to initiate both research and 
treatment programs utilizing this technology. While still in its early 
stages, this technology offers great promise for improving the 
treatments we offer our Soldiers.
    Fort Lewis has consistently been a leader in Army efforts to 
provide the best possible care to our Soldiers. In 2005 we initiated 
open access mental health clinics. In an effort to insure that every 
barrier to care was removed, we converted our primary behavioral health 
clinic access for Soldiers from one that required an appointment to one 
that allowed Soldiers to walk-in and be seen the same day. To 
efficiently support this, we again leveraged technology to automate the 
capture of patient data via kiosks using the locally developed 
Automated Behavioral Health Clinic (ABHC) program which allows for more 
comprehensive data gathering while supporting providers in efficiently 
reviewing and considering this data in providing care. In 2006, we 
further extended this availability by opening our Soldier Readiness 
Clinic out of the main hospital, which made it easier for Soldiers to 
access. In addition, we initiated a primary care consultation model 
within our Soldier Family Medicine Clinics to directly support the 
primary care provider in their delivery of comprehensive health care 
and to provide an additional venue by which behavioral health care is 
available to our Soldiers.
    Senator Murray, thank you for the opportunity to participate in 
this important discussion with you and the members of this Committee. 
Thank you for holding this hearing and thank you for your continued 
support of the Army Medical Department and the Warriors that we are 
honored to serve.

    Senator Murray. Thank you very much. Mr. Ramsey.

  STATEMENT OF ROBERT R. RAMSEY, LICSW, TEAM LEADER, TACOMA, 
    WASHINGTON VET CENTER, READJUSTMENT COUNSELING SERVICE, 
 VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Ramsey. Good afternoon, Senator Murray. I appreciate 
the opportunity to discuss the role of the Tacoma Vet Center 
plays in providing services within the Puget Sound Health Care 
System in our service area. I would like to request that my 
written statement be submitted into the record. The VA's 
authority to provide readjustment counseling to eligible 
veterans was established by law in 1979, and we believe that 
the Tacoma Vet Center was the first in the Nation to offer 
these services to veterans returning from Vietnam War. 
Readjustment counseling consists of beyond medical, a holistic 
system of care, that provides professional help to veterans 
coping with psychological traumas and other readjustment 
problems related to their military service. Vet Centers are 
located conveniently within the community and provide services 
tailored to the specific needs of the local veteran population.
    Veterans are welcome to visit their local Vet Center any 
time. The Tacoma Vet Center has no waiting list, and the 
veteran may be seen by a counselor on his or her initial visit. 
Veterans immediate family members are also eligible for care at 
the Tacoma Vet Center and are included in the counseling 
process to the extent necessary to treat the veteran's 
readjustment issues. The Vet Center offers bereavement 
counseling to surviving family members of Armed Forces 
personnel who died while on active duty in the service of their 
country. The Tacoma Vet Center staff currently consists of a 
Team Leader, three Readjustment Mental Health Counselors, an 
Office Manager, a Global War on Terrorism Outreach Technician 
and Marriage and Family Therapists. These last two positions 
were recently added.
    The entire staff actively engages in community in a variety 
of ways to increase program visibility and to access services.
    We provide briefings to the Army at Fort Lewis on a weekly 
basis and to the Air Force at McChord Air Force base on a 
biweekly basis where a member of our staff presents information 
regarding stress management, Post Traumatic Stress Disorder and 
Vet Center services. Since 2003 the Tacoma Vet Center has 
provided outreach to nearly 5,000 veterans and clinical 
services to more than 800 Global War on Terrorism veterans and 
their family members. Our Global War on Terrorism Outreach 
Technician meets with local Ministerial Associations, every 
college and university in our area. We work closely with local 
community organizations such as substance abuse programs and 
Pierce County Sexual Assault Center.
    Every week we visit the Hospitality Kitchen, a local soup 
kitchen in downtown Tacoma to meet with homeless veterans. We 
support many of these veterans there, encourage them to use the 
help offered at our Vet Center and the services offered at VA 
Medical Center programs. Our Vet Center sexual Trauma counselor 
recently presented training for the sexual assault resource 
centers at both McChord Air Force Base and Fort Lewis. She also 
collaborates with the VA Medical Center staff to provide 
classes dedicated to women receiving treatment. One of our 
counselors, and Alaska Native, has proven very successful in 
reaching out to various ethnic groups, including American 
Indians, Pacific Islanders and Hispanic Americans. He has 
filled an essential role by expanding our capacity to go where 
our clients are, rather than waiting for them to come to us.
    And our Office Manager, who is not a clinically trained 
person, creates a welcoming, respectful and professional 
environment. She works with several volunteers to ensure that 
they explain a full range of services offered within the VA and 
community social service organizations to anyone who calls. 
Well over 80 percent of our time is spent providing services to 
veterans. We are one of the busiest Vet Centers in the Nation 
and we are very proud of our work. Our clients report being 
very satisfied with our work and the services we offer. We are 
very fortunate to be supported by a wide array of clinical and 
administrative staff in the Puget Sound Health Care System. 
Working in a Vet Center is very intense, very rewarding and we 
consider it a privilege to serve combat veterans and sexual 
trauma survivors. Senator Murray, this concludes my prepared 
statement. I'm happy to answer questions you may have.
  Prepared Statement of Robert R. Ramsey, LICSW, Team Leader, Tacoma, 
Washington Vet Center, Readjustment Counseling Service, Veterans Health 
             Administration, Department of Veterans Affairs
    Good Afternoon, Senator Murray. I appreciate the opportunity to 
discuss the role the Tacoma Vet Center plays in providing services 
within the Puget Sound Health Care System and our service area. I would 
like to request my written statement be submitted for the record.
    VA's authority to provide readjustment counseling to eligible 
veterans was established by law in 1979. We believe the Tacoma Vet 
Center was the first in the Nation to offer these services to veterans 
returning from Vietnam.
    Readjustment counseling consists of a ``beyond medical,'' holistic 
system of care that provides professional help to veterans coping with 
psychological traumas and other readjustment problems related to their 
military service. Vet Centers, located conveniently within the 
community, provide services tailored to the specific needs of the local 
veteran population. Veterans are welcome to visit their local Vet 
Center anytime. Vet Centers have no waiting list and veterans may be 
seen by a counselor on the day of their first visit.
    Veterans' immediate family members are eligible for care at Vet 
Centers and are included in the counseling process to the extent 
necessary to treat the veteran's readjustment issues. Vet Centers also 
offer bereavement counseling to surviving family members of Armed 
Forces personnel who died while on active duty in service to their 
country.
    The Tacoma Vet Center staff consists of a Team Leader, three Mental 
Health Counselors, an Office Manager, a Global War on Terrorism (GWOT) 
Outreach Technician, and a Marriage and Family Therapist. This staff 
actively engages the community in a variety of ways to increase program 
visibility and access to services.
    We provide briefings to the Army at Fort Lewis on a weekly basis 
and to the Air Force at McCord AFB on a biweekly basis. A member of our 
staff presents information regarding stress management, Post Traumatic 
Stress Disorder (PTSD) and Vet Center services.
    Since 2003, the Tacoma Vet Center has provided outreach to nearly 
5,000 veterans and clinical services to more than 800 Global War on 
Terror (GWOT) veterans and their family members.
    Our GWOT Outreach Technician meets with Ministerial Associations 
and every college and university in our area. We work closely with 
local community organizations, such as Substance Abuse programs and the 
Pierce County Sexual Assault Center.
    Every week we visit the ``Hospitality Kitchen,'' a local soup 
kitchen, to meet with homeless veterans. We support many of the 
veterans there and encourage them to avail themselves of the help 
offered at our Vet Center and services offered by other providers.
    Our Vet Center Sexual Trauma Counselor recently presented training 
for the Sexual Assault Resource Center at both McCord AFB and Ft. 
Lewis. She also collaborates with VA Medical Center staff to provide 
classes to women receiving treatment.
    One of our counselors, an Alaskan Native, has proven very 
successful in reaching out to various ethnic groups, including American 
Indians, Pacific Islanders, and Hispanic Americans. He has filled an 
essential role by enabling us to go where our clients are, rather than 
waiting for them to come to us.
    Our Office Manager creates a welcoming, respectful, and 
professional environment. She works with volunteers to ensure they can 
explain the full range of services offered to anyone who calls.
    Well over 80 percent of our time is spent providing services to 
veterans. We are one of the busiest Vet Centers in the Nation and we 
are very proud of our work.
    Our clients report being very satisfied with our work and the 
services we offer. We are very fortunate to be supported by a wide 
array of clinical and administrative staff in the Puget Sound Health 
Care System. Working in a Vet Center is very intense, but very 
rewarding, and we consider it a privilege to serve combat veterans and 
sexual trauma survivors.
    Senator Murray, this concludes my prepared statement. I am happy to 
answer any questions you may have.

    Senator Murray. Thank you very much. Dr. Barrick.

STATEMENT OF G. ANTHONY BARRICK, Ph.D., LICENSED MENTAL HEALTH 
                 COUNSELOR, SEATTLE, WASHINGTON

    Dr. Barrick. Senator Murray, thank you for the opportunity 
of addressing the important needs of mental health issues for 
military family members as well as the servicemembers. I am a 
Washington State licensed mental health counselor. I have 
worked in my civilian career as a government service employee 
with the Department of the Army, Department of the Navy and the 
Department of the Air Force. I mostly recently retired a month 
and a half ago from Naval Station Everett serving there as the 
Director of Clinical Services at the Fleet Family Support 
Center. In that position I worked with the Navy at Naval 
Station Everett and the region to establish what we call the IA 
program, the Individual Augmentee program. So frequently we're 
accustomed to the big units deploying and returning and 
services based around that, but we also have another population 
of people who go off one by one and are embedded in Army units 
or other Marine units providing services. Frequently there are 
military policeman or employee disposal ordinates, officers or 
construction battalion units.
    The program that we developed was pre- and post-deployment 
to work with the servicemembers and their families. When the 
servicemember would return post-deployment, then we made sure 
that we met with that particular servicemember and we invited 
always the spouses to come in, and these were educational 
outreach efforts, and they were mandatory for the servicemember 
to attend basically before they went away on requested leave so 
that we could talk with them about how they were doing, what 
their experiences were. We had mandatory follow-ups 60, 90 and 
120 days later in these employee assistance individual 
augmentee groups. Not surprisingly most of the IA returnees 
minimized and denied experiencing traumatic events. A handful, 
however, did share stories and current impacts on their lives 
such as sleeping disturbances, nightmares, increased impatience 
and anger and relationship problems with their families. Some 
were experiencing symptoms of PTSD and others of traumatic 
stress. I've worked with the IA sailors in separate counseling 
when the sailors desired it, however, this was very rare. It 
was my experience that most active-duty sailors viewed mental 
health counseling to be a stigma, a stigma against their 
personhood and/or their military career. They were reluctant to 
seek mental mental health counseling. They tended to view it as 
a threat rather than as a tool to assist in their well-being 
and assist in their career.
    This reticence was prevalent even within the educational 
part that we were doing, not just coming to counseling, but 
just trying to educate. That sort of reticence and stigma was 
prevalent there. In my 3 years with the IA program at Naval 
Station Everett, approximately 75 sailors were deployed and 
returned, and of those about 30 tended at least one of the IA 
returning and readjusting meetings. Three sailors requested 
supplemental counseling assistance. Others could have benefited 
from mental health counseling as a result of their deployment 
experiences. They declined follow-up services. I believe they 
were afraid of the stigma attached to seek counseling, the fear 
that other military members would become aware of their 
counseling and the fear that their military careers would be 
threatened, and the anxiety that most people have when they 
have been traumatized. That is a fear that something is wrong 
with them, and that is difficult to deal with, and it's, for 
many of those people that feel that something is wrong with 
them, living uncomfortably with that fear is less scary than 
admitting to themselves and others that something was wrong and 
reaching out and seeking help.
    There is stress on military families and acute stress on 
families where the servicemember is in harm's way. Mental 
health services obviously can help. I would like to make some 
recommendations to reduce the stigma and increase the access 
rate of mental health counseling services:

    1. Increase availability of mental health education to 
military members and their families, increase the education 
piece.
    2. Increase the leadership participation in and referrals 
of military family members to educational programs. Leadership 
needs to be visible.
    3. Increase leadership referrals of military members to 
mental health counseling when the servicemembers are exhibiting 
early signs of stress.
    4. Increase opportunities for servicemembers to remain 
anonymous when seeking mental health service.
    5. Allow servicemembers to go directly to TRICARE rather 
than through the on-base referral manager.
    6. Allow TRICARE to provide marital and couples counseling. 
Spouses typically experience the secondary effects of their 
partner's trauma and may be influential in getting early 
treatment for their military spouses.
    7. Promote congressional action to remove decision referral 
and supervision requirements for mental health counselors 
seeking TRICARE. This would increase the pool of qualified 
clinicians for the surge of people who are needing assistance.
    8. Augment TRICARE with a specialized employee assistance 
program that retains some form of anonymity.
    9. Rapidly implement the employment of licensed mental 
health counselors to be mental health professionals at veteran 
affairs facilities.

    Finally, the process of healing is long-term. We must 
continue to simplify and demystify the mental health process 
for servicemembers and their families providing support 
resources and educating and planning seeds of renewal. Thank 
you for seeking ways to support our families.
           Prepared Statement of G. Anthony Barrick, Ph.D., 
         Licensed Mental Health Counselor, Seattle, Washington
    Senator Murray and Committee, thank you for the opportunity of 
addressing mental health needs of military members and their families 
who are dealing with the stress of service in this time of war.
    I am a Washington State Licensed Mental Health Counselor in private 
practice in Seattle. I have over 30 years of experience, including 
civilian service as a Supervisory Psychologist, U.S. Navy, and 
Counseling Psychologist, U.S. Army.
    I helped establish the Individual Augmentee (IA) Support Program at 
Naval Station Everett, and the IA Support Program for Navy Region 
Northwest (NRNW). These programs provided education for Pre-Deployment 
Sailors and Family Members about their upcoming separation issues, 
potential effects of being exposed to traumatic events, and local 
support resources. For Post-Deployment support, we provided initial IA 
Returning and Readjusting Meetings (IARM) for Sailors and Family 
Members within 5 days of the Servicemember's return. Subsequent to the 
initial meeting, Sailors were required to follow-up in IARM Groups at 
60, 90, and 120-day intervals, for a total of four sessions.
    Not surprisingly, most of the IA returnees minimized and denied 
experiencing traumatic events. A handful, however, did share their 
stories and current impact on their lives, such as sleeping 
disturbances, nightmares, increased impatience and anger, and 
relationship problems with their families. Some were experiencing 
symptoms of Post Traumatic Stress Disorder (PTSD) and others Traumatic 
Stress. I worked with IA sailors in separate counseling when the 
sailors desired it. This, however was very rare.
    It was my experience that most active duty sailors viewed mental 
health counseling to be a stigma against their personhood and/or their 
military career. They were reluctant to seek mental health counseling, 
viewing it as a threat, rather than a tool to assist in their well-
being and their career.
    This reticence was prevalent even within the educational IARM 
Groups.
    In my 3 years with the IA program at Naval Station Everett, 
approximately 75 sailors were deployed/returned, and 30 of those 
attended at least one IA Returning and Readjusting Meeting. Three 
sailors requested supplemental counseling assistance. Others could have 
benefited from mental health counseling as a result of their deployment 
experiences. They declined follow-up services. I believe they were 
afraid of the stigma attached to seeking counseling, the fear that 
other military members would become aware of their counseling, the fear 
that their military careers would be threatened, and the anxiety that 
most people who have been traumatized have: the fear that something is 
wrong with them. Living uncomfortably with fear was less scary than 
admitting to themselves and others that something was wrong.
    There is stress on military families, and acute stress on families 
where the servicemember is in harm's way. Mental health services can 
help. I would like to make some recommendations to reduce the stigma 
and increase the access rate of mental health counseling:

    1. Increase availability of mental health education to military 
members and their families.
    2. Increase leadership participation in and referrals of military 
and family members to educational programs.
    3. Increase leadership referrals of military members to mental 
health counseling when servicemembers exhibit early signs of stress.
    4. Increase opportunities for servicemembers to remain anonymous 
when seeking mental health services.
    5. Allow servicemembers to go directly to TRICARE rather than 
through the on-base referral manager.
    6. Allow TRICARE to provide marital and couples counseling. 
(Spouses typically experience the secondary effects of their partner's 
trauma, and may be influential in getting early treatment.)
    7. Promote Congressional action to remove physician referral and 
supervision requirements for mental health counselors treating TRICARE 
beneficiaries. This would increase the pool of qualified clinicians for 
the ``surge'' in need.
    8. Augment TRICARE with a specialized ``Employ Assistance Program'' 
that retains anonymity.
    9. Rapidly implement employment of licensed mental health 
counselors to be mental health professionals at Veteran Affairs 
facilities.

    Finally, the process of healing is long-term. We must continue to 
simplify and demystify the mental health process for servicemembers and 
their families--providing support and resources, educating and planting 
seeds of renewal.
    Thank you for seeking ways to support our military families.

    Senator Murray. Thank you, Dr. Barrick. Excellent 
suggestions, and I thank all of our panelists for testifying 
today. Colonel Gahm, let me start with you. Were you part of 
writing the study about suicide that was released yesterday?
    Colonel Gahm. I was, ma'am.
    Senator Murray. So that said that there were 99 confirmed 
acts of suicide. Can you tell us how many unsuccessful suicide 
attempts there were.
    Colonel Gahm. The challenge with the question of 
unsuccessful--of suicide attempts is we don't--we can never 
know really how many people attempted suicide and didn't 
complete it. We do track in the Army known attempts, that is, 
those attempts that result in hospitalization, but other 
attempts where perhaps someone said, you know, yesterday I was 
driving and I was going to try to kill myself and just last 
minute swerved back, we don't know--we don't know.
    Senator Murray. You don't know all of them, but I'm 
assuming that the number you gave us were suicides that 
occurred. Can you tell us how many were attempted that you know 
of.
    Colonel Gahm. I don't have that number at my fingerprints 
tips, ma'am, but we do have that number.
    Senator Murray. I mean, is it a large number?
    Colonel Gahm. It's a larger number--the number that we 
track is a large number. I believe it's as many as seven times 
the number of completed suicides, but I don't want to--I can 
get you a number and I'd rather----
    Senator Murray. I would--I would like you to get me the 
number. So it is possible there were 99 suicides. It could have 
been as many as 700 attempts?
    Colonel Gahm. Most fully likely. The civilian literature 
has suggested that there are as many as 25 attempts for every 
completion, so that's just civilian population wise.
    Senator Murray. Now, I want to ask you what I asked General 
Baxter in terms of those folks who are diagnosed with mood 
disorder or bipolar, depression. Why are we sending those 
people to conflict?
    Colonel Gahm. Well, there are two comp--I would like to 
separate that from the suicide piece.
    Senator Murray. That's fine.
    Colonel Gahm. The return of individuals who have at one 
time had a psychiatric diagnosis to active duty and then to 
deployment, really it's a challenge, because as we talk about 
destigmatizing mental health, and we want to ensure that people 
who have had mental health diagnoses can return to a fully 
functioning status in the military, they will then be subject 
to deployment. If they have a condition that is not well 
treated, they should not be deployed, but most of the 
conditions that fall into the mental health spectrum are 
treatable, including PTSD. And individuals who have been 
treated, we want them de-stigmatized and we want to include 
them in society, they will now be included within the 
population who will deploy and do other things.
    Senator Murray. Well, Dr. Barrick, do you agree that we 
should consider them treated and OK'd to serve in combat?
    Dr. Barrick. That would have to be made on a case-by-case 
basis, yes, people who have been able to stabilize can return 
to combat.
    Senator Murray. Mr. McFall?
    Colonel Gahm. Again, I agree on a case-by-case basis. I 
certainly know individuals who were redeployed and had a 
positive experience for it, and to prevent them from being 
redeployed would have left them with guilt about abandoning 
their unit and so forth. And in other cases it may not be a 
good idea, so it really does have to be--but it's not 
universally the case that it's a bad idea to be deployed. In 
many cases we note that it's what's considered to be a 
favorable experience.
    Senator Murray. Colonel Gahm, can you tell me in your 
opinion what accounts for the large number of soldiers who have 
been discharged for personality disorder.
    Colonel Gahm. It's a large and obviously relative term. I 
believe the number you quoted was one that I have seen over te 
last 6 years I believe, something like 6,000----
    Senator Murray. 5,600.
    Colonel Gahm. Right, but for the million or so--we're not 
talking a large percentage, and if you look at--and I don't 
have these numbers at hand, but the percentage of individuals 
in society that would be diagnosed with a person who does have 
personality disorder, my assumption would be that it would 
exceed that number of individuals that we discharge from the 
military. The military draws from a broad spectrum of society, 
um, in many cases it's a good fit and individuals who may have 
difficulty functioning not in the military do better in the 
military. In other cases, the military is not a good fit and 
sometimes we have a number of different ways of separating 
those individuals.
    I think personality disorder is one category that fits with 
that--it is a psychiatric diagnosis that has specific criteria. 
Those criteria do need to be followed when discharges are used 
that way. We are engaged in a systematic review in the Army of 
all of the known personality disorder discharges. I believe it 
was completed for the 2006 and is planned to extend further, in 
order to ensure that we can say with certainty what happened to 
those cases.
    Senator Murray. So you have that completed for 2006? Can we 
get the results of that yet?
    Colonel Gahm. It's actually, to my understanding, it has 
been completed, but it's under the review in the Army right 
now.
    Senator Murray. So we can expect to see that sometime soon?
    Colonel Gahm. Yes, ma'am.
    Senator Murray. We heard a lot in the first panel about the 
stigma of mental health. We know that that's an issue. 
Yesterday when the report came out on suicide and the high 
number of suicides, highest in 26 years, the Army response was 
that broken marriages and Dear John letters were one of the 
main factors behind the suicides. I don't know if that came 
directly from the report or it was just the response. Colonel 
Gahm, doesn't that play into the stigma issue if we're just 
dismissing it as Dear John letters?
    Colonel Gahm. I can't say who made those comments, but one 
thing that is known is that the relationship failures are one 
of the highest correlations of completed----
    Senator Murray. Well, are the relationship failures as a 
result of post traumatic stress syndrome, Traumatic Brain 
Injury, other injuries along the point or the other way around?
    Colonel Gahm. Right, those are all reasonable questions. I 
think it's not unreasonable to expect that separating spouses 
who have in many cases only been married for a couple of 
months--I mean, there are numerous cases where for different 
reasons people get married right before deploying, and in that 
case where you're gone 15 months, it's not unreasonable to 
expect it to stress the relationship.
    Senator Murray. Well, I guess would it be disconcerting to 
give a message to people out there who are suffering from 
mental health care that this is just a result of a failed 
relationship rather than perhaps something physical occurred 
that you need help with?
    Colonel Gahm. To my knowledge, if you are asking me is 
there a biological determinative of suicide----
    Senator Murray. No, I'm asking the message that is received 
by military members, that perhaps the high rate of suicide as a 
result of Dear John letters is not a good message to them when, 
in fact, it's highly likely that it was post traumatic stress 
syndrome as a result of their service, doesn't that add to the 
stigma and make it more difficult for them to be able to access 
care if they don't want somebody to think they have a failed 
marriage?
    Colonel Gahm. I certainly can't tell you what effect it has 
done on society, but I can say with confidence that that's not 
the intended message that went forward.
    Senator Murray. Dr. McFall, do you have anything----
    Dr. McFall. I don't have anything to add on that, no.
    Senator Murray. We are way over time. I do want to ask a 
couple of questions, one is about family members. We heard from 
our first panel are men and women who are struggling with post 
traumatic stress syndrome, injuries, physical injuries, 
Traumatic Brain Injury, no support for their families, what's 
happening to a young kid who sees their parent going through 
all of this and we don't--we're not reaching out and supporting 
them? Should we be doing that as part of our policy in this 
country, Dr. McFall?
    Dr. McFall. Yes, we should. Well, we do have structures in 
place to do family counseling at the VA, the Vet Center. With 
those structures it doesn't mean we can't do a better job.
    Senator Murray. Well, didn't you hear all three of our 
soldiers today say that there was no support whatsoever for 
their families?
    Dr. McFall. Yes.
    Mr. Ramsey. I would comment on that. I think the biggest 
problem we have is not getting the word out, and I think that's 
really what Vet Centers are about, doing all we can to get the 
word out. It's not uncommon for me to have a Vietnam veteran 
come into my office and tell me that the first time he's told 
his story is in my office after 40 years. And now these younger 
veterans have similar kinds of experiences where they are 
reluctant to come in. They don't want to participate in 
treatment for a variety of reasons, and so, getting the word 
out there that we have services available, that we can help 
family members, that we've recently hired someone to do 
marriage and family treatment at the Vet Center is difficult. 
And it's amazing how difficult it is to clearly communicate 
that to the community.
    Senator Murray. I would assume that you'd all agree that 
not only--it's not just within the military, not just within 
the VA, but within society as a whole we have to address the 
stigma that is attached to mental health----
    Mr. Ramsey. Absolutely.
    Senator Murray [continuing].--in order for people to get 
the help that they need to be able to be healthier. Correct?
    Dr. Barrick. Yes.
    Senator Murray. One last question and we are going to have 
to adjourn for the day. I think it was Kathy Nylen on the first 
panel spoke about the issue of military sexual trauma. We've 
not heard much about that in the media, in Congress. It seems 
to me that there is a hidden issue here in terms of military 
sexual trauma contributing to much of what we're seeing today. 
Would any of you like to comment on whether or not my guess is 
correct or if we're doing anything. Is there an issue of 
military sexual trauma as a result of the current climate?
    Dr. McFall. Yes, military sexual trauma does exist. There 
are estimates about problems of that that are published. I'll 
let Dr. Gahm speak from DOD's standpoint. As you know from your 
recent visit we do have women's trauma treatment teams at our 
facility that primarily address military sexual trauma in our 
veterans who come to us. We're also doing some other additional 
things to expand these efforts there as well. For example, 
we've just been approved to hire a new MST, military sexual 
trauma coordinator for our facility, and we're very excited 
about her pending arrival.
    We also are doing screening to detect MST in the patient 
population that we serve through a clinical reminder system 
which will allow us to identify these individuals early on and 
get them in the hands of this MST coordinator as well as 
specialized PTSD mental health care if needed. And the Vet 
Centers are also doing good work in this area of MST as well. 
We work collaboratively.
    Senator Murray. Is this an underreported issue? I see four 
heads nodding here, just for the record. Colonel Gahm, would 
you like to comment.
    Colonel Gahm. On this clear greater awareness--I mean, 
sexual trauma is something that should not be tolerated. It's 
not an acceptable behavior. It's not an acceptable thing that 
we just want to say, well, it's OK. Is there underreporting? 
Most likely because you don't know what you don't know. Are we 
taking an aggressive approach to helping those individuals who 
do report and trying to find ways that they can report and get 
support without--either anonymously or ensure that they go 
through the system? Yes, we are. So I think we're engaged in 
this. We're taking it seriously. I personally definitely do not 
believe that there is any attempts to cover this up or any huge 
hidden situation with us, but it's not my area of expertise and 
I don't want to----
    Senator Murray. Dr. Barrick, do you want to comment.
    Dr. Barrick. Yes, in the Navy there was a considerable 
amount, more so than other places, of sexual assault. Over the 
years that I worked in that system, the attitudes began to 
change as the programs were implemented to address it. But it's 
still kind of like institutional racism, there is institutional 
sex that still is operating where people deny it and will not 
respond to it. And people are afraid to come forward because 
they believe they'll only be traumatized again by a system that 
doesn't want to hear it or will not believe them honestly. So 
great inroads in have been made, and the service of that I do 
believe we are making progress, but we need to continue to 
emphasize that.
    Senator Murray. We are way over time, unfortunately we have 
to end now. I will have some questions for our panelists that I 
will submit to you and ask for your response in writing. I want 
to again thank all of our panelists who appeared today and 
participated. I know some of my questions were rather sharp, 
but I think we have to really find the answers to this. My job 
and the job of Congress is to provide the resources and the 
right policies, and by asking the questions we can get to that.
    I want to thank all of our panelists who were here today. I 
want to thank all of our staff, my staff members who spent an 
incredible amount of time putting this together as well as our 
staff from the Veterans' Affairs Committee who have been here 
today. To the veterans again, I have a number of staff members 
here. There are a number of professionals here.
    If you are here with an issue that you are trying to work 
your way through and need help, we have a lot of people around 
the room that are willing to help you from all of the different 
agencies as well as my staff, and I want to thank everybody who 
has come today to be a part of this and to voice your issues as 
well. We do have comment piece for any of you who did not have 
a chance obviously to speak out today, but again, thank you 
very, very much for your input and we will take that back to 
Washington, DC, to all of my colleagues.
    This now ends this session.
    [Whereupon at 1:45 p.m., the Committee adjourned.)