[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]





                MENTAL HEALTH: BRIDGING THE GAP BETWEEN
                   CARE AND COMPENSATION FOR VETERANS

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

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 14, 2011

                               __________

                           Serial No. 112-18

                               __________

       Printed for the use of the Committee on Veterans' Affairs














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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy

            Helen W. Tolar, Staff Director and Chief Counsel

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.









                            C O N T E N T S

                               __________

                             June 14, 2011

                                                                   Page
Mental Health: Bridging the Gap Between Care and Compensation for 
  Veterans.......................................................     1

                           OPENING STATEMENTS

Chairman Jeff Miller.............................................     1
    Prepared statement of Chairman Miller........................    59
Hon. Bob Filner, Ranking Democratic Member.......................     3
    Prepared statement of Congressman Filner.....................    60
Hon. John Barrow, prepared statement.............................    61

                               WITNESSES

Advisory Committee on Disability Compensation, Lieutenant General 
  James Terry Scott, USA (Ret.), Chairman........................    26
    Prepared statement of General Scott..........................    72
U.S. Department of Veterans Affairs, Antonette Zeiss, Ph.D., 
  Acting Deputy Patient Care Services Officer for Mental Health, 
  Veterans Health Administration.................................    51
    Prepared statement of Dr. Zeiss..............................    94

                                 ______

American Veterans (AMVETS), Christina M. Roof, National Acting 
  Legislative Director...........................................    48
    Prepared statement of Ms. Roof...............................    86
Hanson, Daniel J., South St. Paul, MN............................     4
    Prepared statement of Mr. Hanson.............................    61
Satel, Sally, M.D., Resident Scholar, American Enterprise 
  Institute......................................................    28
    Prepared statement of Dr. Satel..............................    74
Seal, Karen H., M.D., MPH, Staff Physician, Medical Service, San 
  Francisco Department of Veterans Affairs Medical Center, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs, and Associate Professor in Residence of Medicine and 
  Psychiatry, University of California, San Francisco............    23
    Prepared statement of Dr. Seal...............................    63
Wounded Warrior Project, Ralph Ibson, National Policy Director...    46
    Prepared statement of Mr. Ibson..............................    78

                       SUBMISSIONS FOR THE RECORD

American Association for Marriage and Family Therapy, National 
  Board for Certified Counselors, California Association of 
  Marriage and Family Therapists, American Counseling 
  Association, and American Mental Health Counselors Association, 
  joint statement................................................   102
California Association of Marriage and Family Therapists, 
  statement......................................................   104
Carnahan, Hon. Russ, a Representative in Congress from the State 
  of Missouri....................................................   114
Sawyer, Andrea B., Colonial Heights, VA, statement...............   115

                   MATERIAL SUBMITTED FOR THE RECORD

Pre-Hearing Questions and Responses for the Record:

    Pre-Hearing Questions for the Record, from the House 
      Committee on Veterans' Affairs, Chairman Miller, to the 
      U.S. Department of Veterans Affairs, and VA responses......   123

Post-Hearing Questions and Responses for the Record:

    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to Karen H. Seal, M.D., MPH, Staff 
      Physician, Medical Service, San Francisco Department of 
      Veterans Affairs Medical Center, Veterans Health 
      Administration, U.S. Department of Veterans Affairs, and 
      Dr. Seal's responses.......................................   142
    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to LTG James Terry Scott, USA, (Ret.), 
      Chairman, Advisory Committee on Disability Compensation, 
      letter dated June 23, 2011, and response from LTG Scott, 
      letter dated August 10, 2011...............................   146
    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to Sally Satel, M.D., Resident Scholar, 
      American Enterprise Institute, letter dated June 23, 2011, 
      and Dr. Satel's responses, dated August 5, 2011............   147
    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to Ralph Ibson, National Policy 
      Director, Wounded Warrior Project, letter dated June 23, 
      2011, and Mr. Ibson's responses............................   149
    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to Christina M. Roof, National Acting 
      Legislative Director, AMVETS, letter dated June 23, 2011, 
      and Ms. Roof's responses...................................   152
    Hon. Bob Filner, Ranking Democratic Member, Committee on 
      Veterans' Affairs, to Hon. Eric K. Shinseki, Secretary, 
      U.S. Department of Veterans Affairs, letter dated June 23, 
      2011, and VA's responses...................................   154

 
                    MENTAL HEALTH: BRIDGING THE GAP
                     BETWEEN CARE AND COMPENSATION
                              FOR VETERANS

                              ----------                              


                         TUESDAY, JUNE 14, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                            Washington, DC.
    The Committee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Stearns, Lamborn, 
Bilirakis, Roe, Stutzman, Johnson, Runyan, Benishek, Buerkle, 
Huelskamp, Filner, Michaud, McNerney, Donnelly, Walz, and 
Barrow.

              OPENING STATEMENT OF CHAIRMAN MILLER

    The Chairman. Good morning. Thank you to our witnesses who 
are in attendance. Our hearing this morning is entitled, 
``Mental Health: Bridging the Gap Between Care and Compensation 
for Veterans.''
    On May 10th, the United States Court of Appeals in the 
Ninth Circuit issued a decision that was heavily critical of 
the care and compensation that the U.S. Department of Veterans 
Affairs (VA) provides to veterans with mental illness. The 
Court cited VA's ``unchecked incompetence'' and the 
``unnecessary grief and privation'' that delays in treatment 
and benefits cause veterans and families.
    I am not here this morning to judge the Court's decision, I 
will leave that to others. The heart of the Court's analysis of 
the issue is something with which all of us need to be 
concerned. Namely, is VA's system of care and benefits 
improving the health and wellness of the veterans that are 
suffering from mental illness?
    On behalf of a grateful Nation, we have invested heavily in 
this system over the last decade to improve access and make 
treatment options that experts say are effective more readily 
available, but the question remains, are veterans, especially 
those returning from combat with the invisible wounds of war, 
on a road to recovery and able to live full and productive 
lives?
    Recovery, restoration, and wellness; these should be 
overarching objectives of all of VA's programs, yet when I look 
at trends in disability ratings for veterans with mental 
illness, I see a very confusing picture.
    On one hand we have a medical system that boasts of 
evidence-based therapies, improved access, and high quality of 
care, and on the other hand we have data from VA indicating 
that veterans with mental illness only get progressively worse.
    These confounding facts raise the question, are VA's health 
and disability compensation programs oriented towards VA's 
mission of recovery and of wellness?
    I am not the first who has noted this trend or suggested 
the need for closer integration of VA programs.
    A 2005 report from the VA Office of Inspector General (OIG) 
concluded the following, and I quote, ``Based on our review of 
post-traumatic stress disorder (PTSD) claims files, we observed 
that the rating evaluation level typically increased over time, 
indicating the veteran's PTSD condition had worsened. 
Generally, once a PTSD rating was assigned, it was increased 
over time until the veteran was paid at the 100 percent rate.''
    We also have a 2007 report from the Veterans' Disability 
Benefits Commission (VDBC), and we will hear from the Chair of 
that Commission on our second panel this morning, that 
recommended, quote, ``A new holistic approach to PTSD should be 
considered. This approach should couple PTSD treatment, 
compensation, and vocational assessment.''
    Most recently, we have the Administration raising red 
flags. In its ``Fiscal Year 2010 Performance and Accountability 
Report,'' VA commented on how well its Veterans Benefits 
Administration (VBA) collaborates with the Veterans Health 
Administration (VHA) when providing services to veterans with 
mental illness. The report suggested that with recovery as the 
essential goal to helping veterans with PTSD that perhaps VBA 
and VHA were working at cross purposes.
    Let me quote from that report. ``With the advent of the 
recovery model as central to the treatment of mental health and 
disorders, the current system fails to support and may even 
create disincentives to recovery.''
    Today, we are going to move beyond the numbers that simply 
tell us how many veterans use the system and get into the 
fundamental question of whether they are on the road to leading 
full and productive lives.
    For veterans who don't seek VA care, we need to know why 
they are not seeking that care. We need to know if there are 
inherent disincentives to recovery. We need to know if the 
quality of treatment provided at VA is a reason to seek care 
elsewhere. And, we need to know what is effective and what is 
not effective.
    Quoting from a recent policy paper from the Wounded Warrior 
Project, ``VA's focus on the high percentage of veterans who 
have been treated begs such questions as, how effective was 
that treatment, and how many more need treatment but resist 
seeking it?'' I couldn't agree more.
    It is our duty at this Committee to ask these tough 
questions and the veterans for whom this system was created 
demand it of us.
    We are fortunate to have with us on our first panel Mr. 
Daniel Hanson. Dan served in Iraq, then came home troubled in 
mind, trying to cope with the loss of so many of his fellow 
Marines. His is a story I hope everyone listens to closely 
today as a cautionary tale of where we may be inadvertently 
headed.
    Looking back, Dan has some interesting thoughts of what it 
would have taken to get him into treatment sooner, and just as 
important, he has something to say about how he ultimately 
found help outside of VA's system.
    On our second panel, we have Dr. Sally Satel, Resident 
Scholar at the American Enterprise Institute. Dr. Satel will 
share with us the principles surrounding what she believes 
would be a more effective system of care and compensation for 
veterans seeking mental health treatment.
    As I mentioned, we also have the former Chairman of the 
Veterans' Disability Benefits Commission with us, General Terry 
Scott. We also have a VA clinician, Dr. Karen Seal, who will 
share with us her findings on health care utilization of Iraq 
and Afghanistan veterans.
    And finally, on our third panel, we will hear from the 
Administration, and the views of two important veterans' 
organizations, AMVETS and the Wounded Warrior Project.
    I want to thank everybody for coming, Members and those in 
the audience and those that are going to be testifying, and I 
now yield to the Ranking Member, Mr. Filner.
    [The prepared statement of Chairman Miller appears on p. 
59.]

              OPENING STATEMENT OF HON. BOB FILNER

    Mr. Filner. Thank you, Mr. Chairman, and thank you for 
taking the leadership on this subject.
    Of course we have all raised serious concerns over many 
years about the backlog of claims and there are now a record 
number of servicemembers returning home with scars from the 
War. Now is simply not the time to delay their benefits.
    The report you mentioned that was released last year by the 
VA Office of Inspector General (OIG) focusing on the delay of 
our servicemembers getting an appointment for a medical exam in 
order to process their claim for compensation is just one more 
example of how the VA seems to be failing our veterans.
    That system has many obstacles for our warriors by putting 
them through numerous medical exams for each individual ailment 
for which they are filing a claim.
    The VA could easily streamline this process and allow the 
veteran to receive one complete medical exam to expedite the 
claims process, alleviate the stress on our veterans, and save 
our veterans and taxpayers money.
    You mentioned the recent decision by the Ninth Circuit 
Court of Appeals in Veterans for Common Sense v. Shinseki. That 
decision found that veterans have a property interest conferred 
upon them by the Constitution to both VA benefits and health 
care.
    Ruling for the veteran plaintiffs, the Ninth Circuit went a 
step further to conclude that because there are property 
interests delaying access to health care or the adjudication of 
claims violates veterans due process rates guaranteed by the 
Fifth Amendment.
    Unlike you, I don't want to take a judgment on that ruling. 
I fully support the ruling, and I am disappointed VA has not 
done more and more rapidly to fix the problem.
    We know that every day 18 veterans of this Nation commit 
suicide. We also know that one in five servicemembers of our 
current conflicts will suffer from PTSD, and unfortunately the 
suicide rate for these brave men and women is about one suicide 
every 36 hours.
    Many of them as outlined by the recent Ninth Circuit Court 
ruling will be left undiagnosed, untreated, and uncompensated. 
This is a travesty and an outrage.
    Last year, the VA Inspector General's Office made 
recommendations for the Veterans Health Administration and the 
Veterans Benefit Administration to collaborate more effectively 
and share information on issues affecting a timely delivery of 
exams.
    I am disappointed, as you are, Mr. Chairman, that we are 
still discussing this issue 15 months after those findings and 
recommendations.
    The VA is simply not committing sufficient resources to 
meet the demands of our warriors when they return home. I hope 
the VA will address these shortfalls and I expect them to come 
to the table with a plan to fix the problem.
    Mr. Chairman, I look forward to this testimony.
    [The prepared statement of Congressman Filner appears on 
p. 60.]
    The Chairman. Thank you very much. I would like to call to 
the witness table Dan Hanson, if you will. He is joined by his 
wife Heather. Dan and Heather are from St. Paul, Minnesota. Dan 
joined the Marines in 2003.
    We appreciate you being here to share your story. Thank you 
for your service to our country. You are recognized for your 
statement.

 STATEMENT OF DANIEL J. HANSON, SOUTH ST. PAUL, MN (OPERATION 
                  IRAQI FREEDOM (OIF) VETERAN)

    Mr. Hanson. Thank you, Mr. Chairman. I appreciate the 
opportunity to speak in front of the men and women that change 
our country, so thank you. I will get into why I am here with a 
brief testimony.
    I grew up in South St. Paul, Minnesota, came from a large 
family, went through high school, eventually joined the Marine 
Corps after two of my brothers did before me. I actually 
thought about joining the Air Force, but they said they would 
break my arm, so I joined the Marine Corps in 2003 and shortly 
after I was deployed to Ar-Ramadi Iraq in 2004, and it was a 
deployment that started with one of our Marines shooting 
himself in the head.
    I just kind of brushed that under the table, And then 34 
Marines we lost throughout the deployment, had about 400, 450 
Marines injured, came back and went on leave and that was that.
    I started drinking pretty heavy, dealing with nightmares, 
dealing with things that I wasn't really prepared to deal with 
I would say, and I think one of the biggest reasons that I 
dealt with it myself was just because, I mean, I was in a 
battalion of 1,000 Marines and I don't think people wanted to 
hear, you know, my whining and complaining.
    So then, shortly after we went on another deployment, non-
combat, which just kept on drinking, kept on masking my issues 
with whatever would take away any of the pain.
    I came back and then about 6 months later, my unit was 
deployed again to Iraq, this time I was in the remain behind 
element so I was kind of able to see the other side of things 
when we would get the casualty reports, we would get the KIAs 
(killed in actions) in and have to notify and take, you know, 
be on that end of things as well.
    I decided that I was going to get out of the Marine Corps, 
but I was persuaded by a good friend, Sergeant Major Ellis, to 
stay in, but on that deployment he ended up getting killed, and 
I went to his funeral over in Arlington National Cemetery.
    Then about 2 weeks after that, a friend also in Second 
Battalion 4th Marines, John Shulzy, hung himself in the 
basement of his home and that kind of got me twirling out of 
control just before I was going to get out of the Marine Corps.
    And then finally I got discharged in February 2007 and then 
on March 23rd, 2007, my brother, who was also in the Marine 
Corps, he hung himself in the basement of his home, and at that 
point I think I decided I was going to do everything to avoid 
pain, that I was going to do everything to deal with it myself 
as I had been doing for the last 3 or 4 years, and I got into 
drugs, I got into alcohol, I got into whatever it was that 
would mask the pain that day. Eventually I attempted to kill 
myself. I ended up in the St. Cloud VA Medical Center for about 
48 hours in lock up and then I was released and off to do 
whatever it is that I wanted to do, which was go back to work, 
because that seemed like the normal thing to do after something 
like that.
    And eventually I found myself in and out of jail. And I was 
getting treated on an outpatient basis for a while at the VA 
Medical Center, but when you were as messed up as I was it 
takes a lot more than one or two sessions a week to get through 
my issues, and so I eventually found my way into the Dual 
Diagnosis Program to get help. It was mostly to avoid a longer 
stint in jail for my DUIs (driving under the influence).
    Eventually I got out after about 30 days. I think I started 
drinking the next day. About a year later I found myself in 
jail for I don't know the sixth or seventh time, and I decided 
for myself that I was done hurting myself, I was done hurting 
my family, I was done hurting my children, and I checked into a 
13 to 15-month faith-based program. That was what changed my 
life.
    About a week after jail I stopped going to work, stopped 
going to school, and I decided that I wasn't going to be very 
productive unless I got help, and that is what I did at 
Minnesota Teen Challenge. It was more of a holistic approach. I 
went to the VA once a week to get help on the combat and the 
military specific issues, and then I would stay there 7 days a 
week.
    I wasn't able to get any funding through the VA because it 
was not a VA funded program, therefore, I got backed up on 
bills, I wasn't able to pay things, and eventually filed for 
bankruptcy.
    So in my dealings with the VA Medical Center, I always felt 
like I was in control, I was running my own rehabilitation, 
although I couldn't even put my shoes and socks on correctly 
most days, I felt like it was whatever I wanted to do, Mr. 
Hanson, whatever I wanted to do that I thought was best for me.
    Well, I thought what was best for me was to go and get 
drunk and get high and forget about all of my troubles and 
forget about all of my nightmares and pass out with a bottle in 
my hand, that way I didn't have to deal with any of those 
issues that were affecting my life.
    It was something I believe that could have been ended a lot 
shorter if I would have been able to be forced or somehow 
just--you know, I felt like the VA's role in my treatment over 
the last several years was more of a friend relationship 
instead of a parent relationship. Where it wasn't hey, you need 
to do this or else, it was, hey, you know, if something is 
wrong we have things that can help you, you seem like, you 
know, you have been through some things, so what can we do to 
help you?
    So I appreciate the time and the honor to speak in front of 
you. Thank you, Mr. Chairman.
    [The prepared statement of Mr. Hanson appears on p. 61.]
    The Chairman. Thank you very much for your eloquence. You 
had a written statement and you didn't even look down at it. 
What you said obviously came from experience and from the 
heart.
    Thank you for your service to our country and thank you for 
your service and your continued desire to not only seek help 
for yourself but your fellow veterans who are out there.
    And I am interested in your written statement. You said, 
``I know that when I was discharged from the Marine Corps I was 
not a healthy individual, but I certainly would not have let 
anyone know that.'' Why do you think it was so hard for you to 
speak up about needing help, what can we do as Members of 
Congress to help improve the system? Is there a way to 
encourage people to seek the help that they need?
    Mr. Hanson. Yes, Mr. Chairman. I knew I was very messed up 
when I got out of the Marine Corps, it was apparent, people 
told me you are not the same person, you are angry, and I was 
drinking and I was depressed, and it was apparent to me--and to 
go back a little bit in the Marine Corps my primary military 
occupational specialty was an 0151, which is administrative in 
nature, so I was attached to 2nd Battalion 4th Marines, a grunt 
unit sent to Iraq, so I immediately felt like I didn't deserve 
to get help because I wasn't 03, wasn't infantry by trade, so 
therefore, the things that I saw were things that are natural 
and therefore, you know, I just kind of need to suck it up.
    So when I got out of the Marine Corps I started seeking 
treatment at the VA, and I just, I felt like I didn't get help 
because if I admitted that there was something wrong with me 
there was something wrong with me, and the VA though they were 
there and they were supportive they never really said, this is 
what is going to happen if you continue and you don't get help, 
you need to get help. Or if you don't get help, you are not 
going to get this disability check that, you know, you go and 
spend on the booze and strip clubs, to be very frank, and that 
is what I did.
    And so I think the biggest reason I didn't get help is 
because I felt ashamed, I felt like I didn't--there was another 
bed for someone more deserving than myself, so that was the 
main reason, Mr. Chairman.
    The Chairman. You raised two important issues in your 
testimony. First, you said that although you needed to get help 
you chose not to get it because, and these were your words,'' I 
was able to afford not to.'' And I think it would be important 
for you to explain what you meant by that.
    Also, how common do you think it is for individuals not to 
seek help because they have other avenues in which they could 
go?
    How many out there who need help don't get it because they 
can ``afford not to?'' Do you think it is a large group?
    Mr. Hanson. I do, Mr. Chairman, I obviously don't have an 
exact number, but I have plenty of friends that I feel, you 
know, you get the disability check and they are comfortable 
with it. They get it for whether it is a mental illness or a 
physical illness and a lot of the goal is to get it bumped up, 
and that way you don't have to--you know, it is $800, $1,000 
that you don't necessarily have to--I shouldn't say work for, 
but it makes life easier.
    And for me, as you said, I could afford not to because it 
was kind of supporting my alcohol problems, and I am not 
saying--I mean it has helped me tremendously, but when I was in 
my mix when I was unhealthy and making poor decisions, it was 
just a way for me to support my addiction essentially, and I 
know plenty of people that I was friends with and that I served 
with that, you know, it is kind of the same thing where it is a 
convenience thing, and it pays certain bills and it does 
certain things so why get help when that will take away from 
the money you are making every month essentially, money that 
goes in the bank.
    The Chairman. Mr. Filner?
    Mr. Filner. Thank you, Mr. Hanson, I know it is not easy to 
talk about your own life here, but in your written testimony 
you do mention certain things you think the VA could do to 
serve you and your comrades better. Do you want to go over 
those ideas a little besides the one you just mentioned to the 
Chairman?
    Mr. Hanson. Yes, sir. I felt that very often it was just 
kind of like I was another number in a revolving door, I never 
felt there was much of an actual care, whereas when I 
eventually did go to Minnesota Teen Challenge, I felt there was 
an actual effort for me to get help, to get better, not because 
it was their job, because it was something they were passionate 
about, and that was a big part of it for me.
    And another big part of it for me was I was able to go to 
the VA Medical Center to get help once a week, but then I was 
removed. I didn't have to be the Marine, the combat veteran 
every time I went back to get help. I wasn't around a lot of 
veterans and I can understand that there is a certainly benefit 
to it, but there is also a benefit to not being with all the 
people that know what I went through. There was a certain part 
of it that being around people that didn't know what I went 
through was beneficial. I didn't have to put on this, you know, 
macho man, yeah, you know, I am this tough guy, which I am not, 
so it was a lot easier not to act most of the time, and I think 
that was a big part of it. A big part of it for me was being 
removed from a lot of the people that had been through the same 
things as I did myself.
    And there is also certain other parts about the VA where I 
just don't feel they have any--at least for me I was able to go 
to a Dual Diagnosis Program, which is in St. Cloud VA Medical 
Center, which is 30 to 90 days. I mean after years and years of 
abuse and years and years of just masking my problems, I needed 
more than 30 to 90 days. I needed 13 to 15 months and that is 
what did it, and although it was painful at times and I hated 
it most of the time, there was a reason I did that. I wasn't 
able to get comfortable, I wasn't able to just pretend that 
everything was all right, because eventually things are going 
to come out and sometimes it takes time and that is what I 
needed.
    The Chairman. Dr. Roe?
    Mr. Roe. Thank you, Mr. Chairman, and thank you Mr. Hanson 
for being here today and giving some I think very tough 
testimony for what you have done. And how are things going now 
for you?
    Mr. Hanson. Things are going great, sir. I am going to 
school full-time working on another Bachelor's degree. I am 
married, I have children. I serve people instead of taking 
away. I live a life to, you know, volunteer for veterans. I am 
a Veterans Affairs Liaison at Minnesota Teen Challenge. I am 
able to affect people in a positive way, and for all the years 
I took away give back, so I am very, very, very happy for the 
turn around in my life and so is my family.
    Mr. Roe. It is great to hear that, and I know it is tough 
to lose friends, I certainly understand that as a veteran and 
having done the same thing myself it is very hard to talk about 
and you deal with it every day. I am sure you think about these 
men that you lost, friends that you knew every day. Do you feel 
any guilt for surviving and they didn't? Is that an issue with 
you, do you feel that?
    Mr. Hanson. There was a particular incident in which yeah, 
there was a lot of survivor's guilt that I dealt with when I 
was supposed to go and inspected a VBIAD (Vehicle Born 
Improvised Explosive Device) and we got called off. Another 
unit came and they ended up losing seven Marines and I was the 
lead vehicle, and then as we pulled away, we got swore at and 
told that we should be the ones. And I don't want to bring 
stuff like that up, but yeah, there was a lot of survivor's 
guilt that I dealt with and that was, you know, what drove at 
times my drinking quit, you know, considerably.
    Mr. Roe. I think that probably had something to do with a 
lot of folks.
    I want to hear a little bit more about how you are faith 
based, how the program you felt was successful for you. I think 
that is really important, because obviously everybody is 
different, but this clearly worked with you and I think you had 
made your mind up too that you were going to change your life, 
I think it had a lot to do with you also.
    Mr. Hanson. Yes, sir. I mean, I was at the point where it 
was either--I mean, I was on my knees in my jail cell praying, 
I said, you know, God, either use me or kill me, and I 
eventually went to Teen Challenge, and the reason I feel that 
was so effective was it was more of a holistic--I mean, I was 
such an immoral, I used to say social parasite, where I was a 
liar I was an alcoholic, I was a deadbeat dad essentially, and 
when I went into Minnesota Teen Challenge, I was able to deal 
with the moral and the--and not just the things that happened 
in combat, but going all the way back to childhood, you know, 
some of those issues and get to the heart. And for 13 to 15 
months, you know, you are going to get through a lot of the 
issues.
    I still have issues, but they are considerably less, and I 
mean it was physical healing, emotional healing, spiritual 
healing. It was, you know, a mental healing, and it was like I 
said more of a holistic approach of getting help for not just 
what happened when I was in the Marine Corps, but before and 
after and the damage I had done and the survivor's guilt and 
knowing that what happened happened. But I have a future and I 
have the chance to make the best out of it and that is what I 
intend on doing now.
    Mr. Roe. Well, you have obviously done a great job with 
that, and a real asset not only as a soldier and a Marine, but 
as just a citizen of the country and as a father.
    And again to the Chairman and Mr. Filner's question, how do 
you think the VA could have used some of the experiences you 
have had to make it better for other Marines or soldiers or 
airmen that have experienced the same thing?
    Mr. Hanson. Well, I definitely feel that at times if I 
would have gotten the kick in the butt I needed to get into 
true rehab where the VA would have said look, either you go to 
rehab, you get better, or you know, you are not welcomed here. 
Basically, you know, if you don't want to use what we have set 
up for us then maybe you should use somewhere else.
    Because if there are people that really want to get help, 
this place needs to be open for those individuals, and for 
years I had great opportunities to get help, but I didn't 
because I didn't want to.
    And I think if the VA, you know, instead of a friendship 
role took that parent role where I know there are plenty of 
times when my dad made choices where I, you know, I hated him 
for it at the beginning, but I saw the absolute, you know, 
necessity of it, you know, years down the road, I appreciated 
it much more. Obviously instead of, you know, him not parenting 
me--and I am not--that is a weird analogy to use the VA as our 
parent, but I just think if the VA would be possibly more 
assertive in their treatment in saying, look you are obviously 
messed up, you have been through this, you have been through 
this, you have this police record, it is time to either get 
help or, you know, find somewhere else to try to get help.
    Mr. Roe. Tough love.
    Mr. Hanson. Tough love.
    Mr. Roe. Again, thank you so much for your service to our 
country.
    Mr. Hanson. Thank you, sir.
    The Chairman. Mr. Michaud, you are recognized for 5 
minutes.
    Mr. Michaud. Thank you very much, Mr. Chairman, and I want 
to thank you, Mr. Hanson, for your service to this great Nation 
of ours and for coming here today, because I know as the others 
mentioned it cannot be easy for you to do that.
    I have a couple of questions. First of all how did you find 
out about the Minnesota Teen Challenge program?
    Mr. Hanson. I was actually in jail. I had gotten my 700th 
DUI it seemed like, and I made a phone call to tell my sister 
to pick up my son for a trip to Wisconsin Dells. I saw an 
advertisement on the wall, and then my brothers picked me up 
from jail and I heard an advertisement on the radio for 
Minnesota Teen Challenge, and said, okay, well, I think that is 
the sign. A week later I told work I got to go get better and I 
will be gone for a year. So that was how I heard about it.
    My family had known about it because it is a faith-based 
program and my mom is a very religious person, and so she had 
mentioned it actually, previously, but I said, come on it is 
for 13 to 15 months and I have things to do, let us go here.
    Mr. Michaud. Thank you.
    Do you think that it would be more beneficial for those who 
are serving in the military today if actually before they are 
discharged that they actually are aware of different programs 
out there in trying to get some of those services while you are 
actually in the service versus once you are discharged from the 
military?
    Mr. Hanson. Yes, sir, absolutely, 100 percent. I know when 
I was back from Iraq and I still had a couple years left in the 
Marine Corps and I had really no idea, you know, I could have 
spoken to the chaplain or went to the battalion aid station or 
something like that, but other than that, I really had no idea 
what I would do if I really wanted to get help.
    So I wasn't really in the mindset of getting help. But I 
think if I would have been more aware and I would have been 
under the understanding that a lot of people did it, and I 
wouldn't have been the only one and that it wasn't weird or 
weak for me to that do that, I would have been much more apt to 
do it and get the help before I got discharged, and saved a lot 
of pain and suffering for my family, my children and my wife.
    Mr. Michaud. And how do you think those services would be 
more beneficial?
    For instance, I have been to Iraq and Afghanistan several 
times and every trip that I have been to Iraq and Afghanistan 
when I talk to the generals and ask them if they need help 
particularly with those who have traumatic brain injury (TBI) 
or severe post-traumatic stress disorder (PTSD) what do they 
need we get the same answer, well, they have the resources they 
need to take care of them, but the interesting thing is on one 
of those trips, I had someone with much lesser rank approach 
me, pulled me aside and said they need a lot more help, and one 
of the suggestions that they actually made was that I talk to 
the clergy.
    And so since that trip to Iraq, every trip I have taken 
since then I did talk to the clergy, and the interesting thing 
is they were telling me that more and more of the soldiers are 
going to them because they are afraid to seek help from a 
doctor because they are afraid what other soldiers would say.
    Do you find that true as well that they might be afraid to 
actually seek help while they are in the service because they 
might not get the promotion that they are looking for?
    Mr. Hanson. Yes, sir, absolutely. I feel like it needs to 
start probably from the top on down, because when you were in a 
unit like that and you take the risk of asking for help--I mean 
you might be considered a broken Marine or you might be 
considered someone that isn't ready for the next promotion or 
isn't ready to lead Marines or be put in that billet in which 
you have a lot more responsibility-- from then on out, I think 
if you were to do that I feel like, yeah, you would be putting 
yourself at risk because you are basically looked as possibly 
like someone that is broken and that is no good to them or be 
given a job, you know, like cleaning toilets or something like 
that.
    And that is probably not the case in every unit, but I know 
definitely in my unit, I would probably have been terrified to 
actually ask somebody for help and say, hey, I am having 
nightmares or I am having issues like that because I would have 
felt like that could have been the start of a domino effect of 
discussions about where I am headed, my next rank and my 
cutting score, and things like that, sir.
    So, I definitely feel like there probably needs to be an 
atmosphere of, that is all right. But then, where do you draw 
the line? Is everyone going to be raising their hands? I am 
sure that is going to be the next question asked, but I think 
that definitely is where it starts is the top on down because I 
worked pretty closely with your RP and our chaplain and they 
had someone in there every single day. If you would have 
possibly asked a sergeant major or somebody else, they probably 
would have had no idea.
    Mr. Michaud. My last question and everyone is different. 
You mentioned when you went to the VA that it was more of a 
friendship type of situation versus being a parent-type 
situation. And what is best when you are dealing with traumatic 
brain injury or post-traumatic stress, I think individuals 
react differently.
    My next question is, and last question is, actually there 
was a report the Inspector General had done actually of a 
Marine that they investigated whether or not the VA provided 
this particular Marine the health care that he deserved, and 
actually it came out that in fact that was not the case, and 
primarily it probably was a different situation than yours 
where the VA actually was going to cut the disability benefits 
from this Marine, and it pretty much, I think, put the Marine 
over the edge as far as he has lost his benefits versus, you 
know, how can we better serve, you know, this particular 
individual.
    So in your comments about you need that tough love, so to 
speak, do you think that would be the case in every situation 
or should the VA look more at the individual and more or less 
take down the silos between the benefits versus the VHA and the 
health care side? Do you think they should look differently at 
different situations versus saying, well, you have to show that 
tough love in all cases?
    Mr. Hanson. Yes, sir, I definitely agree it is on a case to 
case basis, and for me I was financially secure enough where if 
they would have shown the tough love and said we are going to 
cut you off, I mean, I would have been able to survive and it 
would have angered me and I probably would have had some harsh 
words to say, but I would have been able to--I am sure it would 
have forced me into some sort of rehab and I think that would 
have helped.
    But I definitely agree with you where there are some 
circumstances where people are not abusing that compensation 
and they do still need help, but I am sure there are other way 
to go about it than just cut compensation. But I think for some 
people like myself, it would have been beneficial to do so. But 
for some people, I agree that it is not the best route to go.
    Mr. Michaud. Thank you. Thank you very much, Mr. Chairman.
    The Chairman. Mr. Stutzman.
    Mr. Stutzman. Thank you, Mr. Chairman, and thank you Mr. 
Hanson for being here, your testimony has just been--it is an 
amazing story and it is so good to see you here and taking the 
opportunity to share with us your experiences and what you have 
experienced not only in the military but also after the 
military and how you are a fighting success.
    Also to your wife, I know she has been through a lot as 
well, I can tell she is very proud of you sitting back there.
    My question is, is after you left the military, did the VA 
ever give you any direction on programs?
    You mentioned that you heard about Teen Challenge on the 
radio and on an ad, and I am familiar with Teen Challenge, in 
fact a good friend of mine growing up, hit, you know, the 
bottom in his life and actually found a lot of success at Teen 
Challenge, so it is really encouraging to hear this.
    But did they give you any direction of different programs, 
any ideas on where to find help, anything like that?
    Mr. Hanson. When I did finally decide that I needed to get 
help, and you know, they were supportive in saying yeah, you 
should find a place, they offered VA treatments, which was the 
Dual Diagnosis Program in St. Cloud VA Medical Center that was 
30 to 90 days. Then they offered an outpatient one at the 
Minneapolis VA Medical Center that was, I believe, it was 6 
weeks. It was Monday through Friday something like 8 a.m. to 4 
p.m..
    But also at the Dual Diagnosis Program, I was able to leave 
on the weekends, so you know, I am there Monday through Friday, 
inpatient the whole week, but then on the weekend, I am able to 
get out and do whatever I really want to do.
    So I think that was also a part of the reason I didn't gain 
as much success from that program, as well, because I was given 
that freedom. It is what I wanted, but freedom wasn't what I 
needed at the time. I needed a swift kick in the butt and some 
serious help.
    So those were the two programs that they offered to me, 
they were both VA funded and through the VA.
    Mr. Stutzman. And then so at Teen Challenge you were there 
24/7 committed for about a year.
    Mr. Hanson. Yes, sir, I lived there. There was special 
occasions where, you know, you can get a couple days where you 
go on a pass or something like that, but for the most part, you 
are there 24/7. You wake up, you get breakfast, I worked out 
and go to chapel. Then for the second half you are doing 
chores, you are doing all those things, but you are there every 
single day.
    And like I said, it was nice because I was there. I was 
able to go to the VA for treatment and then come back to a safe 
place, a safe environment where I could be my own self, which 
wasn't, you know, Dan Hanson, Marine, combat veteran. I was 
just Dan, and I think that was a big part of it for me.
    Mr. Stutzman. You mention in your testimony one of the 
biggest struggles that you dealt with was not having the funds 
to complete the program. What kind of cost did it take to 
attend the program for 1 year?
    Mr. Hanson. For a full year it was about $850 to $860 a 
month, and so I had other priorities at the time that I was 
trying to pay for and yeah, there were times I was behind in my 
payment to Minnesota Teen Challenge and I asked them several 
times to try to fund the program. They said that was not 
possible because that was a program that didn't fund. And then, 
I tried to do some other things, and eventually they bumped by 
service-connection after I was done with the program, but by 
that time. I was behind on all sorts of bills, and you know, it 
was a little bit of a disaster financially.
    Mr. Stutzman. Did you meet any other veterans in the 
program by chance?
    Mr. Hanson. Yes, I met some Vietnam veterans who were 
really struggling, that had been struggling for 30 years, I met 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) 
veterans. Granted there wasn't a lot of them, but, there was a 
handful of them, and that is why I still do work with Teen 
Challenge to get veterans in there. I know that for the 
veterans that were in there and went through the program, it is 
a little bit easier because the structure is almost, you know, 
like the military where you wake up, you go to bed when they 
tell you, and there are strict rules. If you want to get in a 
fight, you are gone. There is nothing to talk about. And it was 
somewhere that I fit into very well because of the structure, 
and was able to excel.
    Mr. Stutzman. Very good. So about $10,000 a year then for 
the program.
    Mr. Hanson. Yes, sir.
    Mr. Stutzman. Okay. All right. Thank you, Mr. Chair, and I 
will yield back.
    The Chairman. Sergeant Major, Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman, and Mr. Hanson thank you 
as a fellow Minnesotan. Did you go to South St. Paul High?
    Mr. Hanson. Yes, sir, I did.
    Mr. Walz. I coached football there many times for Mankato 
West, so we probably played against you at some point.
    Mr. Hanson. Yeah, I believe we won most of the time.
    Mr. Walz. Yeah, I think so too. Thank you for adding that.
    But again, thank you for your service and again, there are 
not words that we are going to share with you that are going to 
ease that pain other than for you to recognize that we take our 
responsibility very seriously here, so your coming here and 
your family, your wife coming is hugely important, and I am 
certainly not going to tell you that in 2003 and in the early 
stages of this current conflict we were ill prepared for the 
influx of veterans, we did not have that.
    What I would say is, is this issue that I think we are 
getting at and I think it is very important, and with the next 
panel I will discuss some issues on the case for coercion 
versus autonomous care, but for you on this it obviously worked 
and that is what we want. One veteran that succeeds is what we 
are after.
    My approach to this, and I see this and I take it very 
seriously as a senior non-commissioned officer (NCO), you are 
right, this culture of how you seek care and how you get your 
soldiers into that. This is--I think we need to keep in mind--
this is a broader issue and Minnesota has a long legacy in this 
with former Senator or late Senator Wellstone and former 
Congressman Jim Ramstad on this idea of mental health parity, 
something we fought for hard that this idea that you should be 
treated for mental health issues just as if you had lost a leg 
and those care.
    And we are trying to get this right, we are trying to, and 
I think what is coming up and Mr. Michaud brought up, I think 
Mr. Stutzman talked a little bit about this individualized 
care, how do we get that right.
    One of the things we have to be concerned with is evidence-
based policy and those types of things.
    Since you first testified over in the Senate side, have you 
used the VA for anything?
    Mr. Hanson. Yes, sir, when I was in Minnesota Teen 
Challenge--oh, I apologize that was after--I have, very 
recently I met with a psychiatrist, Dr. Brown, who has seen me 
since I got out in 2007 and I have met with him and just kind 
of talked about things and then I have done physical therapy 
for my back and neck. But as far as mental health goes, I have 
pretty much done no follow up as far as that goes whatsoever.
    Mr. Walz. And I want to assure you and make sure you know 
as Minnesota's only Member of the delegation that is on this VA 
Committee, I spend a lot of time at those and 3 weeks ago, I 
was up at St. Cloud, I was in the in-treatment facility there 
and met with Dr. Ball and the administrator and talked a lot. I 
want you to know that I take the job very seriously of seeing 
what is working there and I think it is important to know that 
we are having successes there, which you have friends that have 
probably gone through there and we are having that.
    I also want you to know any time there is a failure in any 
way, my job is to get to the end of it. And with Jonathan 
Shulzy I have spent, and my staff has spent, countless times 
understanding what happened there, where things went wrong, 
where we could have done better, what the outcome was. You need 
to know that you coming here and testifying gives us the 
motivation, if you will, makes it very clear to us what our job 
is to try and deliver.
    And what we are trying to figure out is how do we best 
treat and care for folks like yourself? How do we do it in a 
way that respects your personal freedoms and your rights, but 
how do we make sure that you were given the opportunities to 
enter back into society?
    And I think you keep bringing up a very good point, and I 
hope the Committee does, this holistic approach. I am very 
concerned with the employment issue. You know, this as well as 
anybody a good job is a good way to start getting better if you 
can get that and hold onto it in conjunction with therapy in 
conjunction with a family that is committed.
    One of the problems we have is we have let some of those 
programs for hiring veterans lapse and we need to bring them 
back again. But you are working now, right?
    Mr. Hanson. No, sir. Well, I do do some work, it is 
volunteering. Minnesota Teen Challenge has a Veterans Affairs 
Liaison, but I do go to school full-time at North Western 
College.
    Mr. Walz. Great. Using the GI Bill?
    Mr. Hanson. Using the Post-9/11 GI Bill.
    Mr. Walz. It is working for you?
    Mr. Hanson. It is working great for me, sir.
    Mr. Walz. So those benefits get you by, you are able to 
provide your wife and family, by the way of getting your 
education, provide your housing, food, and things like that.
    Mr. Hanson. Yes, sir. I am sure I would have no problem 
getting a job right now, it is just I want to use the Post-911 
GI Bill.
    Mr. Walz. What if those benefits were held back until you 
got treatment?
    Mr. Hanson. That is a very good point, because all the way 
up until I went into Minnesota Teen Challenge, I was utilizing 
those. I was going to school full-time, and the biggest reason 
was that I did want more money and I was getting disability, 
but I was also, hey, I can go to school full-time and get this 
money. But if that was held back, I think that would have 
really done a good job of pointing me in the right direction 
saying, okay, they are serious now.
    Mr. Walz. So for you the holding it back would have 
motivated you to it?
    Mr. Hanson. Absolutely. If they would have said you can't 
go to school and we are going to pay for it until you get help 
because you are clearly, if we look back in your history and in 
your doctor's appointments, you need help and here is your 
incentive, you want to go to school, go get help.
    Mr. Walz. So this is an issue I am very interested in and I 
have been spending a lot of time reading the literature on this 
to try and see overall how many times that works or what it 
does, so that is helpful to me.
    Again, thank you for your service. I appreciate your 
courage in coming forward talking about these issues, and I 
assure you, I think we have learned during this conflict, at 
least I would like to believe this, I think especially as 
senior NCOs, we are getting better at seeing this issue of 
mental health parity and early treatment when the wounds are 
fresh is the best way to go instead of just sending you back to 
fend for yourself. So that is not the right way to do it.
    So thank you for that and thanks to your family. I yield 
back.
    Mr. Hanson. Thank you, sir.
    The Chairman. Dr. Benishek, you are recognized.
    Mr. Benishek. Thank you, Mr. Chairman.
    Mr. Hanson, thank you so much. I want to commend you on 
your courage for being here today and providing us with that 
testimony, because I can tell it wouldn't be easy for me to 
give that story if it was me, so I really commend you and your 
wife for being here today and I appreciate the education.
    I just have a couple simple questions. When you were 
discharged from the Marines, was there any sort of a mental 
health evaluation upon discharge or would you have been willing 
to, you know, talk about your problems upon discharge so you 
could get help?
    I mean, I was curious about how you were reluctant to seek 
attention because you felt embarrassed about it. Tell me more 
about that discharge process.
    Mr. Hanson. Yes, sir. There is the final physical in which 
you go through to make sure when you are discharged that you 
are 100 percent, you know, as when you joined the Marine Corps, 
and then if you are not, then you get hooked up with the VA.
    But for me, I passed my final physical and they--you know, 
it was easy for me to say, yeah, I don't have nightmares, I 
don't have this, and that is what I did. You fill out a form 
and they ask are you going through any of these things, and you 
just circle no, and that is just really that, as far as that 
goes.
    And then they have the Temp and TAP Program, which is 
about, I think, 4 days and that is about integrating back into 
society with civilians.
    But for the final physical and Temp and TAP, it is really--
you go through the physical part of it and then for the mental 
stuff, you fill out some paperwork. For me, I just pretty much 
X'd no on everything, and that was that. They didn't really ask 
me any follow-up questions. They didn't go any deeper into it, 
they just said, okay, it looks on the paper like you are doing 
pretty good.
    Mr. Benishek. So you just basically didn't tell the truth 
in that.
    Mr. Hanson. Yes, sir.
    Mr. Benishek. Okay. And then no one really questioned you 
about it or you didn't have an evaluation with someone sitting 
down and talking about them.
    Mr. Hanson. No, sir, they just basically had me fill out 
the paperwork and said, looks like you are doing well, and I 
said, yes, let's get out of the Marine Corps now.
    Mr. Benishek. All right.
    Another question I have is, tell me more about what you are 
doing with this group, this Teen Challenge group. What exactly 
are you doing for other Marines?
    Mr. Hanson. With Teen Challenge basically I go to 
different--whether it is like VA, like the stand down, the VA 
stand down or I will go to any sort of veterans' event and I 
will have a table and I will just try to get the word out that, 
hey, this is a great place for veterans. It is a good option, 
it worked for me, here is my story. I would like to see more 
people going through that. So anywhere I can.
    Like I am testifying at a court case on Friday about trying 
to get someone sent there instead of prison essentially. He is 
a combat veteran struggling with PTSD, and they want to send 
him to prison.
    So any time I can speak about things like that, get a hold 
of someone that is a combat veteran or just a veteran--not just 
a veteran, but a veteran--and try to steer them into this long-
term care, because I feel the key is, is the long-term care. 
For me, I put it off for as long as I could, but I know I would 
not be where I am today unless it was a year-long program, in 
which it was.
    So that is essentially what I do for Teen Challenge. Just 
go to events, recruit any way I can, network and try to get a 
hold of veterans that are hurting and get them into the 
program.
    Mr. Benishek. Thank you very much for your testimony, and I 
will yield back the remainder of my time.
    Mr. Hanson. Thank you.
    The Chairman. Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Daniel, I want to thank you like every Member of this panel 
for serving our country and for sharing your insights, and you 
are sharing stuff with us that I haven't really heard before so 
it is useful.
    I just want to talk a little bit about the Teen Challenge. 
It is obviously not aimed at veterans; is that correct?
    Mr. Hanson. It is not, sir, it is for just normal non-
veterans.
    Mr. McNerney. I am a little unclear about the relationship 
between the VA and the Teen Challenge. Were those two 
organizations able to work to make the program work for you or 
was it just something you had to fight through?
    Mr. Hanson. It was more Minnesota Teen Challenge, working 
with the VA. The VA was open for me to do a program while I was 
in Teen Challenge, so essentially, I had to get it approved by 
Minnesota Teen Challenge because they have their rules and they 
have their Monday through Friday, everything planned out. But I 
was able to ask them, can I go to this, it was cognitive 
processing therapy, it was about 3 months, so 3 months out of 
the year that I was there, I was able to go to the VA, go meet 
with my psychologist, then I would go to a group meeting with 
some other veterans and then I would be sent back to the 
program.
    So it wasn't really much of a working relationship, I would 
say it was Teen Challenge saying, yes, if you want to go there 
one day a week you can do that, and then the VA setting up a 
program for that.
    Mr. McNerney. So there could be better cooperation between 
the VA and some of those community-based operations.
    Mr. Hanson. Yes, sir, absolutely, and that was something I 
struggled with and something I continue to try to help with 
when I graduated. The program was being more open to a program 
like this, because every time I try to talk to people, you 
know, someone at the VA about hey, this is a great program will 
you fund this, or you know, can I put up a sign for people. It 
was just they didn't want anything to do with it because it is 
not a government-funded program and that is understandable, but 
I feel it is a great program and hopefully some day there can 
be a better relationship there.
    Mr. McNerney. Well, I am sure my office would love to work 
with you on developing an idea on how to make that happen or 
anyone on this panel would I can guarantee you, so if you feel 
like you want to do that, any of our offices would be open, my 
office would specifically.
    Now about Teen Challenge, were you compelled to stay there, 
did you have to stay there?
    Mr. Hanson. No, sir, I did not have to stay there. I could 
have left. There are certain people that are, as I said to Dr. 
Benishek, that are required--they are court ordered there. But 
for myself, I checked myself in, therefore, I could leave at 
any time and there were plenty of times I thought I was going 
to leave, but I stuck through it and, you know, pushed through 
a lot of the pain.
    Mr. McNerney. So the interesting thinking is that you had 
decided that you wanted to go through the program, that you 
needed help, that you had reached rock bottom or whatever 
decision had come to you that you wanted to do this program.
    Would there be any way to compel folks that didn't want to 
go through that program that needed help as you did to go 
through the program?
    Mr. Hanson. Yes, sir, I believe so. There is a program that 
is part of Minnesota Teen Challenge, it is called Extended Care 
Program, that is a 30- to 90-day program. Then, if you feel 
like you are not where you need to be, then you can transition 
right over into the year-long program where those 90 days that 
you were already there count towards your year-long stay.
    So you can get basically a small part of what the program 
is about through the 30- to 90-day program, see if it is a good 
fit for you. If it is not you, complete the shorter-term 
program and you can leave. But if you feel like this is what I 
need, I am getting the help I need here, then you just 
transition right over into the long-term program.
    Mr. McNerney. Well, I am really glad to hear about this. We 
just had a tragic case where a young man went through a program 
and he left and he walked in front of a train that afternoon a 
few hours after he was released, so clearly that wasn't giving 
him what he needed. He had been through several 2-week 
programs, it didn't help, so now I see the value of that.
    So thank you for your testimony today.
    Mr. Hanson. Thank you, sir.
    The Chairman. Mr. Runyan.
    Mr. Runyan. Thank you, Mr. Chairman, and thank you, Mr. 
Hanson, for your service to this country. I think many people a 
lot of times fail to recognize the sacrifice is lifelong and I 
think you are a prime example of that in dealing with this.
    Another thing you touched on earlier and going back to the 
VA stuff, the lack of being a parent. I think sometimes here on 
the Hill we have the lack of ability to have adult 
conversations a lot of times, and I think you see that 
trickling down into the Administration throughout. You know, we 
are treating veterans, but we are not treating veterans. You 
know what I am saying?
    Mr. Hanson. Yes, sir.
    Mr. Runyan. We are not solving the problem.
    Specifically to your situation as you said, you were in the 
program, and you were allowed to go home on the weekends. 
Obviously, we know the mental issues are underlying, but there 
is also a substance issue that was there also. Was that being 
addressed at all on say when you came in on a Monday morning, 
was that being addressed or were they just kind of saying, oh, 
whatever happened on the weekend happened?
    Mr. Hanson. No, they would do urine tests when we would 
come back from the weekend and certain things like that--and we 
did, they had AA meetings at the program and things like that 
as well. But kind of like you said, I feel like it was a set up 
program, and while I was there it wasn't very structured to my 
individual needs.
    You know, I agree with you there is an addiction problem 
100 percent, but for me, I think it was much more emotional. I 
was a sensitive guy and I needed something to address that much 
more than I did my alcohol, and that I felt like solely it was 
either about the alcohol or it was either about the combat. It 
wasn't about some of the other issues like the guilt.
    Sure that ties in with it, but specifically the guilt and 
the shame and the hate I had for myself, it was never really 
addressed whatsoever.
    Mr. Runyan. And I know what you are saying, but sometimes I 
think most people agree with me. It is hard to get to the root 
of those issues until we get the chemicals out of the way.
    Mr. Hanson. Absolutely.
    Mr. Runyan. You know, there needs to be, as you say, 
specifically tailored to your issue. Obviously your issue kept 
ballooning and ballooning on the substance issue, we can't 
treat the mental issue until we get the drugs and the alcohol 
out of the way, and I think it was a shortcoming on the VA's 
program within itself there.
    Mr. Hanson. Yes, sir. And going back to your question 
actually, you know, we would be released on Friday afternoon. 
Well, you can drink Friday night and Saturday night as long as 
you stay off the bottle on Sunday so when you come in, you will 
have a clear urinalysis test.
    So absolutely, I agree with you where, you know, we are in 
there for a chemical addiction. Yet, we have an opportunity to 
drink for a couple of days, go back, look like it is all clear, 
not talk about it, pass the urinalysis test, and keep on going.
    Mr. Runyan. I think that says it all, and with that I yield 
back, Mr. Chairman.
    The Chairman. Mr. Barrow. I thought you were leaning back, 
couldn't see you behind the sergeant major there, sir.
    Mr. Barrow. I thank the Chairman, and with my thanks to the 
witness and all those that he represents I will defer to my 
colleagues.
    The Chairman. Thank you.
    Mr. Huelskamp.
    Mr. Huelskamp. Thank you, Mr. Chairman, I additionally want 
to thank Mr. Hanson for his courage of being here and sharing 
his testimony. I think part of this is a faith testimony and I 
appreciate that. I come from a very rural district in western 
Kansas and this is a story that I have heard from a number of 
my constituents, as well as family members, so I believe your 
presence here today, I hope, will save lives and hopefully 
changes for the better at the VA.
    And with that I yield back my time, Mr. Chairman.
    The Chairman. Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman, thank you for your 
service, sir. I appreciate it very much, and thank you for your 
testimony.
    Just a couple quick questions. What is the greatest barrier 
you saw in getting treatment?
    Mr. Hanson. Really just getting past myself. I knew the 
options were there, but I was working full-time, I was going to 
school full-time, I had a life. I wanted to party so it was 
getting past the inconvenience of having to get help, whether 
it be outpatient or inpatient, most certainly inpatient was out 
of the question. So that is why for some time I did outpatient 
care because there were times I felt like I would walk out of 
there feeling better. Certainly the biggest barrier was myself, 
getting past being able to control whether I get help or not 
was the biggest thing, because I didn't want to be 
inconvenienced, because I knew what was right for me at the 
time.
    Mr. Bilirakis. What can the VA do to further encourage 
treatment?
    Mr. Hanson. Well, I think as I touched on a little bit 
earlier, I think just maybe being a little bit more forceful in 
their approach saying--not just saying we have these rehab 
programs, you are definitely a good candidate for them. But 
instead saying, we have these rehab programs and you need to 
get help, and you know, if you don't get help, there is going 
to be some sort of a consequence. I guess I don't know if it 
should be financial or you can't get help there, but I just 
feel like once a person--it is clear that they need help, 
possibly somehow it should be not just a good idea between 
myself and the psychiatrist or the psychologist I am talking 
to, it should be something where it is more assertive, more 
take charge, kind of you are messed up, we are going to get you 
into treatment one way or another. Not just giving me options 
as you are good candidate for help, you need help.
    Mr. Bilirakis. Okay, thank you very much, appreciate it.
    Mr. Hanson. Thank you, sir.
    Mr. Bilirakis. I yield back.
    The Chairman. Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman, and thank you for 
holding this hearing.
    Let me again reiterate what my colleagues said, Mr. Hanson, 
we appreciate your service and your willingness to come here 
and to really be honest and candid with us.
    When I read through your opening statement, you indicated 
that when you were discharged from the Marine Corps you knew 
you were not a healthy individual, but at the same time you did 
not tell anybody, and there was a feeling I guess in your own 
mind, mentioned in your opening statement, that you felt 
indestructible because you were in the Marine Corps and you had 
served, yet you were struggling.
    You suggested that perhaps everyone should realize that 
they should get some help and perhaps as an incentive to have 
compensation withheld.
    Let me ask you this, do you think if you, not talking about 
the VA, but about the military services, do you think the 
Marine Corps itself should have briefed you before you were 
discharged to say look, it is not being less of a Marine if you 
realize you need help and that somehow this feeling--not just 
in the Marine Corps, but all the military--that you are weak if 
you say I need help?
    So, and I have been to these hearings before and generally 
I find that persons like yourself are courageous and are 
willing to give your life for your country, and so when it 
comes to signing on the dotted line that I am weak and I need 
help, people won't do it because they say it is a sign of 
weakness in America.
    So had you ever thought, I know you suggested that as an 
incentive to withhold compensation, but is there a way through 
education perhaps that we could have you in the very beginning, 
either through the Marine Corps or the VA, through education?
    Mr. Hanson. Yes, sir, I do believe so.
    Like I said, when I got back from Iraq and was in the 
Marine Corps for a few years after, I was really not aware of 
any sort of program that I could do while I was a Marine. I 
really had no idea as far as that would look any ways, and 
there is definitely a certain amount of pride that goes along 
with admitting that you do have that problem.
    So when you are coming to work every day with 1,000 other 
Marines, it is kind of like does he know, does he know? You 
know, you don't want to feel like the odd man out.
    So, if there was much more openness at least when I was in 
the Marine Corps to get help, and to least talk about it or 
take the initial steps into at least realizing that there is 
help, you have a problem, and it is okay to get it, then just 
maybe having some sort of a more open communicationline between 
the top heavies and on down the chain to the the privates, 
PFCs, whatever, that it is okay to get help, and here is the 
way to do it, and you are not going to be looked down on if you 
do, we encourage it, it happens.
    And I think it is pretty safe to say that if anybody goes 
to combat, they are changed for the rest of their life. So just 
sometimes there are more cases like myself that aren't quite 
able to take it as well.
    So, it is definitely, based on the person. But I know if 
there were probably more of an open communicationline between 
myself and the higher ups, I would have been apt to get help 
sooner.
    Mr. Stearns. You indicated that everybody has changed in 
the military service, that is true, but it is also dependent 
upon the amount of stress and combat and what you see, and 
judging from what your opening statement, is you saw a lot, and 
all that impacted you in ways you didn't know until it was 
almost too late.
    So in a way the VA has a responsibility, but in a way I 
think you are saying the Marine Corps, the Navy, the Air Force, 
the Merchant Marines, all have the responsibility to at least 
let the people in combat know that it is not a sign of weakness 
if you feel you are struggling.
    Mr. Hanson. Yes, sir, absolutely.
    Mr. Stearns. And that before you discharge, this kind of 
message should be presented to the soldier so he or she knows 
it is not a sign of weakness, just realize that you have this 
option and so that everyone doesn't think it is a liability on 
your part.
    Mr. Hanson. Absolutely, yes, sir.
    And I feel like it would be just as important to get that 
communicated with the families of veterans of Marines coming 
back.
    I mean, if I am not willing to get help, then the pressure 
from my family, once they know from the chain of command that 
there is an open forum, if they are having these issues, 
nightmares, if they are drinking a lot, talk to us and it is 
okay that they are all right, we are not going to look down 
upon them, we are not going to withhold a promotion. Talk to 
us, it is okay. He is a Marine, he has done this. But keeping 
that open line of communication between the military member and 
then their family as well--because if that person is not apt to 
go, their family is going to be the biggest reason that forces 
them into it. Because, oftentimes, I believe it is the family 
that gets them in and not the actual individual servicemember.
    Mr. Stearns. Thank you, Mr. Chairman.
    The Chairman. Ms. Buerkle.
    Ms. Buerkle. Thank you, Mr. Chairman, and thank you, Mr. 
Hanson. Thanks for your service to this Nation and for your 
courage to be here this morning.
    I just have one question. You mention that the biggest 
obstacle that you had was getting past yourself and 
understanding and realizing that there is a need there for 
help.
    Mr. Hanson. Yes, ma'am.
    Ms. Buerkle. Now something in Teen Challenge versus the VA 
system, there was a difference in those two programs. What was 
it with the Teen Challenge that let you get past yourself that 
was missing in the VA's approach to mental health?
    Mr. Hanson. Well, ma'am, I believe it was really just--it 
was a couple things. One, the environment was where--which I 
mentioned earlier, it wasn't a bunch of combat veterans, it was 
people that are from all over the State and that had different 
experiences--but all had problems and we could talk about our 
issues and they were very different, but yet they were the 
same.
    So there was yeah, a sense of--it was a lot easier for me, 
I feel, to let go and talk about my issues with people that 
didn't know exactly what I went through.
    And I think also in my time at Minnesota Teen Challenge, I 
felt that it was much more--I wasn't just a number going 
through a revolving door. I felt like I was a person that they 
loved and that they cared about and they wanted regardless of 
what they got paid, regardless of what--they wanted to see me 
better and they wanted to see me better for my family, for my 
kids, and it was the faith-based part of it.
    Once I was getting better, you know, ultimately hanging 
onto that religion, hanging onto God is--has a plan for me. God 
has a reason for me to live. Although I went through some of 
the things I went through, there is a reason for it, and I can 
be used and I can be loved and that was a big part of it as 
well, was the faith-based aspect that really led me to believe 
that you know what, even though everything that happened 
happened, I am loved and I have a future and there is a plan 
for me.
    Ms. Buerkle. Thank you very much, and I yield back, Mr. 
Chairman.
    The Chairman. Mr. Lamborn, any questions?
    Mr. Lamborn. My questions have basically already been asked 
and answered. I thank you for your service.
    Mr. Hanson. Thank you, sir.
    The Chairman. You said that Teen Challenge wanted you to be 
better.
    Mr. Hanson. Yes, Mr. Chairman.
    The Chairman. Do you think the VA wanted you to be better?
    Mr. Hanson. I do absolutely, Mr. Chairman, I just feel that 
it was--I don't know if I want to say a generic sort of feeling 
better, if that even makes sense, but I feel like it was much 
more at Minnesota Teen Challenge it was much more----
    The Chairman. Personal?
    Mr. Hanson. Yes. Thank you. It was much more personal, yes, 
Mr. Chairman.
    The Chairman. You said that even though VA screened you 
positive for PTSD, they never mentioned any option for 
immediate care and there was no immediate action on their part.
    Mr. Hanson. No, Mr. Chairman, I actually was screened the 
first time and they said that I was fine. Then in a follow-up 
appointment, they just gave me a random survey in which I 
answered positively to on several questions on a scale of one 
to ten. Then they sent me a follow-up letter that said, you 
seem like you might have some PTSD issues so we would like to 
do a follow up.
    Then I did a follow up and they suggested some outpatient 
things, but they didn't suggest anything really on a larger 
scale.
    The Chairman. So again, we all have voiced our opinion. We 
thank you for your service to our country and your courage to 
testify before both the Senate and the House. We appreciate 
what you are doing. You are making a difference, and with that, 
we thank you for being with us today.
    Mr. Hanson. Thank you. Thank you, Mr. Chairman. Thank you 
very much.
    The Chairman. Now I ask the second panel if they want to 
begin making their way to the table. Dr. Karen Seal, a 
Clinician and Researcher at the San Francisco Department of 
Veterans Affairs Medical Center (VAMC); General Terry Scott, 
Former Chairman of the Veterans Disability Benefits Commission; 
and Dr. Sally Satel, Resident Scholar at the American 
Enterprise Institute. We thank you all for being here with us 
today.
    Let us begin with Dr. Seal, you are recognized.

   STATEMENTS OF KAREN H. SEAL, M.D., MPH, STAFF PHYSICIAN, 
 MEDICAL SERVICE, SAN FRANCISCO DEPARTMENT OF VETERANS AFFAIRS 
MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT 
 OF VETERANS AFFAIRS, AND ASSOCIATE PROFESSOR IN RESIDENCE OF 
    MEDICINE AND PSYCHIATRY, UNIVERSITY OF CALIFORNIA, SAN 
 FRANCISCO; LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.), 
 CHAIRMAN, ADVISORY COMMITTEE ON DISABILITY COMPENSATION; AND 
   SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE 
                           INSTITUTE

             STATEMENT OF KAREN H. SEAL, M.D., MPH

    Dr. Seal. First I just want to recognize Mr. Hanson for his 
bravery and courage coming forward to tell his story which, you 
know, as a clinician at the VA I hear weekly, and it motivates 
me to do the job that I do, it also motivates us at VA to 
figure out how we can better individualize treatment, so I just 
wanted to acknowledge that and thank him very much.
    Good morning, Chairman Miller, Ranking Member Filner, and 
Members of the Committee, thank you for giving me this 
opportunity to testify today.
    I will begin by placing my comments in context. I am a 
primary care internist based at one VA facility, the San 
Francisco VA Medical Center. In this capacity, I direct the 
integrated care clinic OEF/OIF veterans.
    The clinic at the San Francisco VA Medical Center is novel 
in that it offers all new OEF/OIF veterans a one stop three-
part initial visit with a primary care provider, a mental 
health clinician, and a social worker.
    The integrated care clinic providers are all integrated and 
co-located within the primary care clinic and are trained to 
address post-deployment health concerns.
    I am also an Associate Professor of Medicine and Psychiatry 
at the University of California, San Francisco and in this 
capacity, conduct clinical research that is focused on gaining 
a better understanding of the burden of mental illness in OEF/
OIF veterans who use VA health care.
    Based on my experience as a clinician and researcher, I 
offer my prospective first on the mental health problems of 
OEF/OIF veterans who use VA health care, second on utilization 
and barriers to VA mental health services, and third, current 
efforts by VA to overcome barriers to mental health care for 
OEF/OIF veterans.
    I conclude with some thoughts about how VA might further 
meet the mental health needs of the several hundred thousand 
men and women who have served this country and deserve the best 
care possible.
    Rates of mental illness, particularly rates of PTSD among 
OEF/OIF veterans enrolled in VA health care, have increased 
steadily since the conflicts began in 2001, closely followed by 
increasing rates of depression.
    According to the most recent data released by VA in January 
2011, over 300,000 OEF/OIF veterans, or 51 percent, or one in 
two veterans, has received one or more mental health diagnoses, 
and 27 percent, more than one in four veterans has received 
diagnoses of PTSD.
    Our research indicates that not all veterans have been 
affected by war in the same way. Younger, active-duty veterans 
are at particularly high risk for PTSD and drug and alcohol 
abuse, whereas older National Guard Reserve veterans are at 
higher risk for PTSD and depression.
    Rates of depression, anxiety, and even eating disorders are 
higher in women than in men. Female veterans who have 
experienced military sexual trauma are at four times the risk 
for developing PTSD as women who have not experienced military 
sexual trauma.
    Appreciating these subgroup differences in OEF/OIF veterans 
seeking VA health care will help VA better implement more 
targeted interventions and treatments, as well as guide future 
research.
    In 2007, the Institute of Medicine determined that only two 
therapies for PTSD Prolonged Exposure and Cognitive Processing 
Therapy, had sufficient evidence for the effective treatment of 
PTSD. Both therapies have been endorsed by VA and many VA 
mental health specialists have been trained to deliver these 
therapies to their patients in mental health clinics. These 
therapies require a minimum of nine or more sessions, ideally 
spaced at weekly intervals.
    Our research showed that 80 percent of OEF/OIF veterans 
with new PTSD diagnoses attended at least one VA mental health 
follow-up visit in the first year of their PTSD diagnosis; 
however, unfortunately less than 10 percent of veterans with 
new PTSD diagnoses attended a minimum number of sessions within 
the time frame required for evidence-based PTSD treatment.
    We found that being young, less than age 25, and male, 
having received a mental health diagnosis from a non-mental 
health clinic, such as primary care, and living far from a VA 
facility, greater than 25 miles away, were all associated with 
failing to receive adequate PTSD treatment.
    Because adequate, evidence-based PTSD treatment may prevent 
chronic PTSD, VA needs to focus on developing interventions 
designed not only to improve initial engagement in mental 
health treatment, but also retention in care.
    Patient barriers to mental health care among OEF/OIF 
veterans include stigma, logistical barriers, and even the 
symptoms of the mental health disorders themselves, as you 
heard today. Avoidance in PTSD, apathy and depression, and 
denial and self-medication with drugs and alcohol may prevent 
veterans from seeking care.
    The persistence of ``Battle Mind'' mentality, in other 
words continuing to think that symptoms like hypervigilance are 
as adaptive rather than problematic after returning home, has 
also prevented many veterans from seeking the care they need.
    From a system standpoint, VA has not always been able to 
keep pace with the growing demand for specialty mental health 
services. System barriers include shortages of mental health 
personnel trained in these evidence-based mental health 
treatments. There is a lack of universal access to video 
teleconferencing, known as telemental health in which rural 
veterans can receive specialty mental health services at VA 
community-based clinics delivered by specialists based at VA 
medical centers.
    In addition to the barriers we hear about frequently from 
veterans, difficulties navigating the VA system to make 
appointments, lack of extended hours, and drop in appointments, 
and lack of services for families and children, which tends to 
differentially impact women, there are some other potentially 
challenging barriers to mental health care.
    For instance, while IT security is clearly important, 
excessive security concerns may be limiting the development and 
more novel Internet and telephone-based mental health treatment 
options that would expand access to VA mental health services 
and appeal to this younger generation of veterans.
    In addition, privacy concerns about the Department of 
Defense's access to veterans' electronic medical records have 
discouraged some veterans from coming forward and disclosing 
more sensitive mental health symptoms, such as substance abuse 
and domestic violence.
    In fact, in contrast to the under-utilization of mental 
health services, OEF/OIF veterans with mental health disorders 
disproportionately use VA primary care medical services. 
Capitalizing on this trend, VA might consider a further 
restructuring of VA services such that more specialty mental 
health providers trained in evidence-based mental health 
treatments are embedded within VA primary care. This may even 
involve infrastructure changes to existing medical clinics to 
accommodate the co-location of more specialty mental health 
providers in primary care. These structural changes could 
literally break down the walls that exist between medical and 
mental health services, overcome stigma, and narrow the gap 
between primary care and mental health.
    For instance, pre-scheduling mental health visits to occur 
at the same time as a veteran's primary care visit, as we do in 
our one-stop integrated care clinic at the San Francisco VA 
Medical Center, could make it more likely that patients will 
attend and be retained in mental health care.
    In addition, new clinical resources available through the 
VA Medical Home Patient Aligned Care Teams (PACT) in VA primary 
care, such as nurse care managers, could be leveraged to 
facilitate engagement of veterans in mental health treatment. 
For instance, PACT nurses could act as ``motivational coaches'' 
to remind or encourage veterans to attend mental health 
appointments while at the same time working with veterans on 
behavioral concerns or physical complaints that often accompany 
the mental health problems.
    PACT nurses could also provide veterans access to new 
technologies such as the VA Internet site My HealtheVet or 
smart phone applications, such as PTSD Coach, to enhance access 
to online mental health treatment or treatment adjuncts. 
Finally, there is a need for more research to develop and test 
modified evidence-based treatments for PTSD that are better 
suited to primary care settings.
    In summary, OEF/OIF veterans have extremely high rates of 
accruing combat-related mental health problems. Despite this 
large burden of mental illness, many OEF/OIF veterans do not 
access of receive an adequate course of mental health 
treatment. Veterans with mental health problems 
disproportionately use VA primary care medical services. The VA 
has already made advances through the VA primary care mental 
health integration initiative, and more recently the VA Medical 
Home Patient Aligned Care Team model. Thus, VA is now well-
positioned to take the next step to address many of the 
remaining barriers to mental health care by incorporating more 
specialty mental health services within VA primary care 
settings. In this way, VA can continue to work to meet the 
growing mental health needs of this current generation of men 
and women returning from war.
    Thank you.
    [The prepared statement of Dr. Seal appears on p. 63.]
    The Chairman. Thank you, Doctor.
    General, it is good to see you again, and you are 
recognized.

 STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.)

    General Scott. Well, thank you Chairman Miller and Members 
of the Committee, it is a pleasure to be with you today.
    My oral remarks will be brief. I hope that my complete 
written statement can be included in the record of the hearing.
    The Chairman. Without objection.
    General Scott. I am presently the Chair of the Advisory 
Committee on Disability Compensation chartered by the Secretary 
and in compliance with the Public Law 110-389, and this 
Committee has forwarded reports to the Secretary that has 
addressed our efforts.
    Our focus has been on disability compensation on the 
revision of the VA Schedule for Rating Disabilities (VASRD), on 
procedures for servicemembers transitioning to veteran status 
with special emphasis on the seriously ill or wounded, and on 
disability compensation for non-economic loss, sometimes 
referred to as quality of life.
    Recently we have added a review of individual unemployment, 
a review of the methodology for determining presumptions, and a 
review of the appeals process and its effect on disability 
compensation.
    My discussions with your Committee staff included a request 
that I review the pertinent findings and recommendations of the 
Veterans Disability Benefits Commission that met from 2004 to 
2007 and made 113 recommendations covering a wide range of 
veterans disability issues.
    Specifically, I was asked to discuss the VDBC 
recommendation to integrate compensation, treatment, vocational 
assessment or training, and follow-up examination for veterans 
suffering from mental disability to include PTSD.
    The VDBC invested significant time and effort in analyzing 
the then current methods of diagnosing, evaluating, and 
adjudicating the claims of veterans suffering from mental 
illness, including PTSD.
    The principal source documents that we used in the analysis 
were those you mentioned, Mr. Chairman, at the outset of the 
hearing, a 2005 report by the VA Office of the Inspector 
General and an Institute of Medicine study completed in 2006 
entitled, ``Post-Traumatic Stress Disorder Diagnosis and 
Assessment.''
    These studies, and the testimony of veterans, family 
members, medical professionals, and VA subject experts provided 
the basis for such recommendations that the VDBC offered. The 
complete recommendations and accompanying explanations are in 
my written statement.
    The key recommendation of the VDBC was to change the VA 
approach to diagnosing, evaluating, adjudicating, and treating 
mental disability by establishing linkage among compensation, 
treatment, vocational assessment and rehabilitation, and 
follow-up examinations.
    The purpose of the follow-up examination would be to 
determine the efficacy of the treatment that is being 
undergone.
    The benefits of linking these factors might very well 
enable us to reduce homelessness, suicide, and substance abuse, 
as well as to evaluate the effectiveness of various treatment 
programs.
    Most importantly, it greatly improves the opportunity for a 
veteran suffering from a mental disability to maximize his or 
her future contributions to society, which is what we should 
all be about.
    Now, I understand that this recommendation is somewhat 
controversial in many circles. For one thing, it dramatically 
changes the role of the Department in evaluating and treating 
mental disability.
    The principal arguments against the linkage are that it 
will be viewed by some stakeholders as a mechanism to reduce 
disability payments and that it differs from how the Department 
addresses physical disabilities, vis-a-vis, mental 
disabilities. Both of these arguments can be addressed with 
carefully written and explained regulations and policy 
directives.
    The VDBC offered a recommendation that offered an approach 
to compensation that recognizes the relapsing and remitting 
nature of these illnesses.
    Regarding the differences in approach, the physical versus 
mental disabilities, there is significant evidence that 
individuals with mental disabilities are less likely to seek 
and maintain a treatment regimen than those with physical 
disabilities.
    There is of course a resource bill that accompanies an 
expanded treatment mandate and the Committee was aware of that 
and as I am sure most of you are; however, the VDBC 
recommendation to link compensation, treatment, vocational 
assessment and training, and periodic reevaluation offering an 
opportunity to reduce homelessness, suicide, and substance 
abuse among the veterans. Such an approach should offer some 
long-term help for mentally disabled veterans and improve their 
chances for integration into society.
    I would like to thank you, Mr. Chairman, and Members of the 
Committee for the opportunity to present to you today. I will 
be happy to respond to any questions you may have now or as the 
hearing goes forward.
    Thank you.
    [The prepared statement of General Scott appears on p. 72.]
    The Chairman. Thank you very much, General.
    Dr. Satel.

                 STATEMENT OF SALLY SATEL, M.D.

    Dr. Satel. Thank you, Mr. Chairman and Committee for the 
invitation to be here.
    My name is Sally Satel, I am a psychiatrist who formerly 
worked at VA in West Haven Connecticut and now I am a Resident 
Scholar at the American Enterprise Institute.
    In the current system as we have seen and as we have been 
discussing, a veteran can receive disability compensation for a 
psychiatric condition that has never been treated.
    A straightforward approach to bridging this gap, and the 
kind that General Scott has been focusing on, is an urge of 
course to integrate VBA and VHA so that claimants are referred 
for treatment. I am certainty not the first to suggest this.
    But integrating compensation and care while a definite 
advantage over current practice, does not address the timing 
issue. That is whether veterans necessarily benefit when the 
disability claims process can proceed care and that is what I 
want to focus on now.
    We have to consider the fact that compensation before care, 
that kind of a sequence of granting disability claims before a 
veteran has been treated, can sometimes have significant draw 
backs.
    For one thing, it is very difficult for a compensation 
manager to make an accurate assessment of a veterans future 
function, that is whether or not he or she will continue to be 
disabled in a way that impairs employability before treatment 
and rehabilitation has taken place.
    As clinicians know, not everyone in pain with symptoms or a 
diagnosable mental health disorder is going to be disabled, 
that is impaired in terms of future workplace function.
    Beyond the matter of accurately judging functional 
impairment, which I have been saying is kind of hard to do as a 
compensation and pension (C&P) manager without the person being 
in treatment and rehabilitation first, there is the possibility 
that with our current sequence of being allowed to receive and 
file disability claims before treatment, that despite the best 
intentions of this system awarding disability status 
prematurely, especially at levels that indicate unemployability 
can actually complicate the veterans path to recovery.
    Now consider the example below based on an actual case. 
This is a young soldier, we will call him Joe, who was wounded 
in Afghanistan. He has classic PTSD, noises make him jump out 
of his skin, he is flooded with bloody memories and nightmares, 
he can barely concentrate, and he feels emotionally detached 
from everything and everybody. He is 23 years old, about to be 
discharged from the military. He is afraid he will never hold a 
job, he will never integrate fully and function fully in 
society, and he applies for total disability compensation from 
the VA.
    And on its face, this seems quite logical and granting 
those benefits seem quite humane. But in reality, this is 
probably the last thing that this young soldier turning veteran 
needs. And what I mean by that is that compensation at a high 
level can confirm the fears that in fact he will remain deeply 
impaired for years, if not for life.
    Now that is a sad verdict for anyone, but it is especially 
tragic for someone who is only 23.
    You know, imagine telling someone with a spinal injury they 
will never walk again before he has even had surgery or 
physical therapy.
    Now a rush to judgment as well meaning as it is about the 
prognosis of psychic injuries can carry significant long-term 
consequences insofar as a veteran who is unwittingly encouraged 
to see himself as seriously and chronically disabled, risks 
fulfilling that prophesy. Why should he even bother with 
treatment he might think, which of course is a terrible 
mistake, because this period soon after separation as a veteran 
as quite as young is when mental wounds are most fresh and when 
they are most responsive to therapeutic intervention.
    But Joe is told he is disabled and he and his family may 
assume, typically incorrectly, that he will never be able to 
work, he will no longer be able to work. This becomes a self-
fulfilling prophesy in many cases and ending up depriving the 
veteran of work itself, which has enormous therapeutic value. 
It is also quite demoralizing, and once a patient is caught in 
a downward spiral of invalidism, it can be very hard to 
throttle back out.
    For example, even if he wants to work very much he 
understandably fears losing that financial safety net if he 
were to get off the disability roles.
    Now of course this suggests, everything I have just said so 
far suggests, a sequence that would begin with treatment and 
move to rehabilitation. And then if necessary, the veteran 
would go on to become assessed for disability, if he was not 
improving, but this can't be all.
    Any person who is too fragile for employment while he is in 
treatment will need to receive a living stipend. A treatment 
first approach could not work without some sort of living 
stipend for the veteran and his family.
    Now in closing, however, this gap between care and 
compensation is to be closed, there are at least four important 
things to remember.
    First, there has to be sufficient information for the C&P 
examiner. He needs to make a good determination about ongoing 
employability, and without a course of quality treatment and 
rehab, there is often not enough information to make judgments 
about disability.
    Two, except for total and permanent disability and 
Individual Unemployability (IU) status, reevaluations every 2 
to 5 years are vital and also communicate the expectation of 
improvement.
    Three, while a veteran is getting care neither he, she, nor 
the family should suffer economically.
    And four, we should try as best as we can to avoid 
premature labeling of disability that down plays the recovery 
prospects.
    It is reasonable and important to instill the expectation 
that most veterans will get better, they are changed by their 
wartime experience naturally, but that they will find a 
comfortable and productive place in the community and their 
family.
    Finally, conferring a high-level disability status upon a 
veteran and the chronicity of dysfunction that that implies 
before his prospects for recovery are known, can make the long 
journey home even harder than it is.
    Thank you very much.
    [The prepared statement of Dr. Satel appears on p. 74.]
    The Chairman. Thank you very much.
    Dr. Satel, you raised the issue of prematurely granting 
disability compensation and caution against the perverse 
incentives that such a designation may have.
    How can we balance the need to encourage early and 
effective treatment with the financial reality that many young 
servicemembers have when they return from combat and are 
experiencing mental health problems?
    I think you may have addressed it from the fact that you 
said a treatment with some type of a stipend, but could you 
elaborate a little further?
    Dr. Satel. Well, that is the basic idea, that there would 
have to be some sort of living stipend. The important thing in 
my view is to not call it disability. It could be as generous, 
it could be more generous even than his disability rank might 
have been if he were assessed for a claim right out of, you 
know, right off the bat without first getting treatment. That 
is not my concern.
    My concern is that the family and he not worry about their 
support, that will impair his ability to get better, of course 
just that financial security is so anxiety provoking I don't 
see how anyone could get better, and the family shouldn't 
suffer at all either, but call it a wellness stipend, call it a 
treatment scholarship, call it something. But I personally 
prefer not--the word disability has so frayed it now frankly in 
the--well, I work in a clinic because I have seen this in 
Social Security and also in the VA, that I feel the language 
here is important as well.
    The Chairman. General, your Commission recommended periodic 
reevaluation of PTSD every 2 to 3 years to gauge the treatment 
and effectiveness and to encourage wellness. Did the 
recommendation extend to veterans of all eras?
    General Scott. Yes, sir, I would say that it does. I would 
say that we have an opportunity here with this young group of 
veterans to start the process that we have not chosen to begin 
in the past, but I would say that it probably should apply to 
all.
    You know, I would be the first to say and I am certainly 
not a clinician or a medical doctor, that every case is 
different, and the clinician should be the person who decides 
it every 2 years, 3 years, 5 years, or whatever.
    So it is probably not a cookie cutter approach, but it is 
something that I believe could be decided inside the treatment 
part of VHA.
    The Chairman. And Dr. Seal, in your testimony you said 
despite the initial use of VA mental health services among OEF/
OIF veterans retention in VA mental health services appears 
less robust. You also noted that compared to studies of 
civilians retention in VA mental health treatment appears 
inferior. How do we improve it?
    Dr. Seal. Well, I think I laid out in my oral testimony 
some ideas for how to improve it. We know that OEF/OIF veterans 
are coming into primary care. They are coming into primary care 
for physical complaints. Often pain and other physical 
complains do keep company with PTSD and depression, so they 
come to primary care. We are trying to meet veterans where they 
are, at least in our clinic.
    I think we run into difficulties when we separate mental 
health from primary care and we don't adopt a more holistic 
approach.
    It is very difficult sometimes for veterans to come into 
primary care, seek care for their physical complaints, then 
have a separate appointment at a separate time in a separate 
building for their mental health complaints.
    I think if we can bring the two together more holistically 
I think veterans would be more likely to stay in care.
    I also think that sometimes it is difficult to come to the 
VA at all. People have jobs, they go to school, and I think we 
really have to be open to more innovative approaches to deliver 
specialty mental health care, and that is why I brought up the 
use of the Internet, the use of the telephone, and even iPhone 
applications that can serve as mental health treatment 
adjuncts.
    I think we need to broaden the way in which we deliver 
specialty medical health care.
    The Chairman. Thank you.
    Mr. Filner.
    Mr. Filner. Thank you for your testimony.
    Dr. Seal, I appreciate your specific recommendations from 
my own experience and I think they have a lot of merit.
    There is so much of the testimony that we get from people 
who have had problems. Mr. Hanson, who was on the panel before 
you was turned away by the VA. I don't know if you saw his 
written testimony. Each of the suicide cases that occurred in 
the United States was preceded by attempts to go to the VA for 
help. Mr. Hanson used the phrase turned away. Our veterans have 
to almost fight to get care.
    I just had a constituent who was fighting for months for VA 
to take him seriously, and nothing occurred, he then committed 
suicide.
    So once you get in, your reforms make sense. What is going 
on with the testimony that we get from our veterans? Is it 
subjective or is it their impression? If it is their 
perception, it is obviously meaningful. Why do so many veterans 
feel they can't get the help that they need when they go to the 
VA? It seems that all of the cases that we hear about involve 
that in some way.
    Dr. Seal. Well, I think you raise a very, very important 
concern.
    I do meet veterans who come into my clinic who say that it 
was hard for them to figure out how to come into our clinic, 
and yet there are other veterans who walk into the building, go 
to the combat case manager, are literally escorted upstairs, an 
appointment is made, and in many cases, they are seen the same 
day.
    So I think there is a wide variation of experience, which 
isn't to say that it isn't tragic when one person is not able 
to get services and commits suicide, obviously that----
    Mr. Filner. By the way, why is there such variation in the 
national system that we have? That is, don't we have common 
policies and supposedly common sense training?
    Dr. Seal. I think there are common policies and I think 
there are common standards, but I think there really are 
regional differences.
    We have VA medical centers, we have VA community-based 
outpatient clinics (CBOC), and we have other types of VA 
facilities that don't even fall under that description, and I 
think some VA facilities are not sufficiently resourced with 
outreach workers, and with administrative staff to handle the 
influx of veterans that are coming in. I actually think we 
could use more combat case managers.
    In fact, at our VA Medical Center, I just learned that they 
are no longer called OEF/OIF combat case managers, they are now 
in some more generic social service role, and I think that it 
is exceedingly important that we maintain that particular 
position at all VA facilities, so that we have VA outreach to 
communities, and when veterans come into VA, they are met with 
somebody that knows exactly what they need and can literally 
escort them through the process of enrolling in VA through 
member services in order to receive care.
    Mr. Filner. You might supplement your written 
recommendations with looking at that aspect too for us, that 
would be great.
    We have had hearings in this room recently and we will have 
more on employment and on PTSD. You know, we have 20, 25 
percent unemployment with OEF/OIF veterans, surely they could 
help our veterans. We ought to be hiring them. They could get 
training in this area. And help brothers and sisters who are 
coming in and they could help guide them.
    Do you think there is a bigger role for our veterans and 
that you could work with them and get them at least some of the 
training they might need----
    Dr. Seal. I think that is an excellent idea.
    Mr. Filner. I think we each have a responsibility to these 
kids to do that.
    Dr. Seal. But I think again we have to look at resources, 
and at our VA there is a hiring freeze, so I don't know--I am 
not exactly----
    Mr. Filner. I don't mean to interrupt you. Mr. Chairman, I 
have heard this in several places that there is a hiring 
freeze.
    We have the biggest problem we have ever had, we have given 
the VA more money than they have ever had and we keep hearing 
about a hiring freeze. What is going on here? We are under 
resourced, you say?
    We have increased the VA budget every year, as long as we 
have been here it is 60, 70 percent higher than it was just 5 
years ago. What is going on? Do you have any sense of that from 
where you are?
    Dr. Seal. Well, I mean, I think it is important to look at 
where I am. I am a primary care clinician and I am a 
researcher, so I don't know that I can answer for VA.
    Mr. Filner. I keep hearing this and yet from our 
perspective we keep pouring in money and then we hear there is 
a hiring freeze.
    Dr. Seal. Well, it depends where you want to spend the 
money. The money has been spent to greatly expand the capacity 
of mental health services.
    So we are hiring psychologists, we are hiring 
psychiatrists, but what you were talking about is different, 
you were talking about an outreach worker which is----
    Mr. Filner. I wasn't talking about the hiring freeze but 
you brought it up. You said you have a hiring freeze, so for 
what jobs do you have a hiring freeze?
    Dr. Seal. Well, I don't know if there is a hiring freeze on 
everybody at the San Francisco VA. I know for clinicians there 
is right now because we have greatly expanded our mental health 
services capacity. That may not apply to outreach workers, I 
actually don't know.
    Mr. Filner. By the way, you have joint employment with the 
university and with the----
    Dr. Seal. Yes.
    Mr. Filner. What percentage do you have with each?
    Dr. Seal. I am five-eighths VA and three-eighths university 
employment.
    Mr. Filner. I know hospitals where the employees are one-
eighth VA, seven-eighths university, and yet we say we have 
eight psychiatrists on staff when there is only one. I never 
underrate the importance of research and you know the daily 
needs, and also your own integrated life, but with all the 
clinical needs it seems that we shouldn't be putting people on 
seven-eighth time. If they want to do research let them do it, 
but let us get full-time clinicians in there.
    Dr. Seal. So just to clarify I am based 100 percent at the 
VA, so I am partially supported by the university through my 
own grant funding, but I am based 100-percent of the time at 
the VA.
    Mr. Filner. Okay.
    Dr. Seal. And interestingly, all of my research involves 
access to mental health care for OEF/OIF veterans.
    Mr. Filner. I understand. I know universities where it is 
the other way around, they are mainly at the University.
    Mr. Chairman, it seems that we have the heart of the 
problem where we keep thinking we are giving the resources, but 
then we hear from the field and from people like Mr. Hanson 
that we just don't have the resources to do the job, so we have 
to figure this out.
    The Chairman. Well, we did hear yesterday in our sexual 
assault hearing where we thought dollars were being spent for 
security we are now finding out that some of those dollars are 
being redirected and not going where they need to be. Obviously 
this is outside your lane, but it is an issue that this 
Committee needs to address.
    And thank you, Mr. Filner.
    Mr. Bilirakis.
    Mr. Bilirakis. Thank you very much, Mr. Chairman.
    Dr. Satel, with regard to your proposal, are you saying the 
veteran will not seek treatment, because he or she has 
financial obligations and also possibly because of a stigma?
    And then I want to also--well, why don't you answer that 
question first.
    Dr. Satel. Well, the reason for the financial stipend would 
be because if we expect people to be in treatment, and even if 
the possibility was endorsed of actually requiring it, and I 
know that is very controversial, meaning requiring it as a 
condition of being considered for disability, we certainly 
can't expect someone to be in treatment intensive care before--
intensive care that either takes up a lot of their time where 
they would otherwise be working, or that they are simply not 
fit to work. You can't expect that of them without providing 
income support. That is what I mean.
    Mr. Bilirakis. Yeah, and we definitely have to have this 
stipend if we go forward with this.
    The other question is how long, what kind of a time frame 
are you talking about as far as determining a person's 
disability rating? If you can answer that question as well. I 
guess does it depend on an individual case?
    Dr. Satel. Definitely. Definitely.
    Mr. Bilirakis. Okay. But can you give me maybe a time 
frame, approximate time frame?
    Dr. Satel. You know, for some individuals who are very 
impaired at the time, it could take up to a year. For others, 
it could take a few months.
    Mr. Bilirakis. Thank you.
    Could I ask the panel if they wanted to give their opinion 
whether this proposal has any merit? You are welcome to respond 
if you would like.
    Dr. Seal. I think it is an interesting proposal. 
Immediately I think I was struck with something that I know 
clinically; that is, I know that when a veteran is ready to 
come forward for treatment is probably the best time to treat 
them, and I am a little concerned about the potential for 
coercion or the sense that well, now it is time to get 
treatment and we will pay you to do it and they are not truly 
ready or receptive for treatment.
    I was struck with our previous testimony that when he was 
ready for treatment he, Mr. Hanson, found the right treatment 
and he responded to it, and I see that over and over again.
    I don't think that people all develop PTSD symptoms at the 
same time after leaving the service. I think there is a natural 
history of PTSD. I think some people develop it immediately. In 
some people it can take years to develop. People are ready for 
treatment at different times. Often you hear a ``hitting-
bottom'' phenomenon, so I worry about the institutionalization 
of treatment; or a semi-coercion or payment for treatment, just 
some concerns.
    I am not saying that it is a bad idea across the board, but 
I think we would have to give it a lot of thought to how it was 
implemented.
    Mr. Bilirakis. Okay. General, would you like to speak on 
that?
    General Scott. Well, I think we would have to very 
carefully lay out exactly how we were going to balance 
compensation and treatment.
    Certainly the individual who is clearly disabled, and I 
believe the Secretary has the authority to grant disability on 
pretty short order on a temporary basis and I believe he could 
do that. Certainly a stipend for someone who is significantly 
disabled while undergoing treatment is required as was pointed 
out.
    I think you have to be careful about forcing people into 
treatment who are not ready. But on the other hand, I think we 
have an obligation to try to be sure that all the people who 
are ready are enrolled and getting the treatment, back to Mr. 
Filner's comment earlier about people who commit suicide or do 
things and then they say well, we couldn't get treatment.
    So I think this is a complicated issue and there is no one 
solution fits all, but I do believe that a relationship between 
treatment and compensation and an assessment, which gets at Dr. 
Seal's question, and some follow-up evaluations can be worked 
out in such a way that it is beneficial.
    Mr. Bilirakis. Thank you very much.
    And thank you, I yield back, Mr. Chairman.
    The Chairman. Mr. Michaud?
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Dr. Seal, in your testimony you pointed out that older 
National Guard and Reserve veterans are at higher risk for PTSD 
and depression. Can you speak to why members of the Guard and 
Reserves face these unique mental health challenges?
    Mr. Hanson. Well, I think part of it is the discrepancy of 
taking an older Guard or Reserve member who is established in 
their community or their job and there may not be as much 
training for them. You put them in a war zone, and they may be 
less well-equipped to be in that war zone than active-duty 
personnel. Then they come back and are expected to reintegrate 
into their jobs, their communities, their families, and I think 
the disparity between those two worlds sometimes can be truly 
overwhelming. I think that is why we tend to see that in older 
Guard and Reserve members as compared to younger Guard and 
Reserve members who may be a little less established already in 
jobs, communities, et cetera.
    Mr. Michaud. Thank you.
    Dr. Satel, when we talk about PTSD, a lot of the focus over 
a number of years has been--the last few years anyway--has been 
on OEF/OIF veterans. You know, that being said that that there 
is definitely a significant number of Vietnam veterans with 
PTSD from the Vietnam War.
    In your work, have you seen any unique needs for us 
addressing the Vietnam veterans as it relates to PTSD compared 
to the OEF/OIF veterans?
    Dr. Satel. Well, one thing that is very relevant it seems 
to me to people who are from the Vietnam era is that from a 
developmental standpoint they are now entering the retirement 
phase of life and that is when a lot of folks, not just 
veterans, but a lot of people feel when they finally retire it 
is--they are sometimes very excited about it, but it also can 
be a very stressful dislocating milestone in one's life. It is 
also coincident with aging and illnesses and your spouse 
getting sick, and that is a time where veterans can be 
vulnerable to a recurrence of symptoms that have been dormant 
for decades often. And as I said, we often see that with 
regular civilians where people get kind of, you know, go 
through a period of depression and it acts as that kind of a 
dislocation at that time.
    In the case of veterans who had PTSD symptoms at one time, 
this is the period where they should be alert for reemergence 
of symptoms.
    It is treatable in almost all cases and people do regain 
their footing, but it is a period that can be fragile and we 
should be aware of that.
    Mr. Michaud. In order to address that issue, specifically 
with the Vietnam veterans, what do you think the VA should be 
doing as far as should be doing different type of programs or 
to address that concern that you just raised?
    Dr. Satel. No. Again, it depends on what the person 
presents with. If they present with a severe major depression 
or a full-blown recurrence of symptoms, we would sort of 
symptomatically treat them of course. But then it is more a--
but for many people it is a kind of--it is a kind of 
psychological process where they come to terms with--they have 
to figure out really how to start the second or third, you 
know, part of their life. And again, that is just sort of 
regrouping and rethinking that that many people go through, and 
those strategies are again highly individual and you treat 
everyone, you know, with their own situation and you would want 
to know what their interests were, you know, how people again 
find themselves as they mature.
    Just frankly, a competent clinician, open minded, should be 
able to navigate someone through that phase.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    The Chairman. Would it surprise any of you at the panel, I 
was just looking over some numbers from 2001 Vietnam-era PTSD 
claims, or benefits I guess, 106,801 is the number, the base 
number. In 2010, the number now is 269,000. Does that seem 
inordinate to you? I am sorry, any of you?
    General Scott. I think there are a couple of factors that 
were looked at by the VDBC and others, and one of them was the 
recognition of PTSD as a disability.
    Ten to 15 years ago there was a significant number of 
people in and out of the military, in and out of the veterans' 
community who really thought that PTSD was somewhat of an 
imaginary disease, that it wasn't there, and I think that over 
this period of time between 2001 and the present, it has become 
certainly more widely recognized. This is not to say that there 
was never recognition during that period of time, because the 
clinicians and others there were a lot of books written and 
understanding, but for the average person, veteran or non-
veteran, knowledge and understanding of PTSD is a fairly recent 
phenomena, so that would be point one on the increase.
    People suddenly realized, well, I have some of these 
symptoms, or they would say my husband has some of these 
symptoms, I am going to get him in and get him checked out or 
whatever. So I think that was a part of it.
    Also the opportunity to receive treatment inside the VA, 
you know, in my judgment, increased dramatically over that 
period of time.
    And so whereas in 2000 and 2001, if a person had presented 
and said, you know, I have this, I have that, this is wrong, 
that is wrong, it probably would not have been sort of 
categorized as saying, okay, well, these are symptoms of a 
PTSD, some of them, so we are going to get him into a treatment 
program that the VA now has, which was not present in the past. 
So that is two of them.
    There has also been, and I say this somewhat advisedly, 
some amount of people who as they reached a retirement age were 
looking for perhaps some other, you know, they went through a 
crisis and they realized they had a problem and they presented 
themselves to the VA or to medical authorities and said, well, 
you know, I am really doing poorly here.
    So I think those are three aspects of it, but probably not 
the only three, and I defer to these two clinicians here to 
either amplify that or to refute it.
    Dr. Satel. It sounds right.
    The Chairman. Very good.
    Colonel Johnson.
    Mr. Johnson. Well, thank you, Mr. Chairman, I thank the 
panel for being here today.
    As a veteran myself I have great concern about our young 
men and women that are coming back today experiencing PTSD. I 
have long maintained that there is one segment of our society 
here in America that we owe entitlement to and that is our 
veterans.
    It is vitally important when they come back, I mean they 
are coming back today with experiences that most of us cannot 
imagine. They have seen their friends killed, they have seen 
their friends dismembered, disfigured, maybe even they have 
suffered that themselves, and yet we continue to debate as the 
Chairman and the Ranking Member have said, we continue to have 
these questions over and over and over again about the adequacy 
of the care.
    You know, the veterans, one of the things that help them 
most when they get back is family support.
    Dr. Seal, are there specific programs that reach out to the 
families of the veterans that have PTSD to help them understand 
how to deal with their loved one who is suffering?
    Dr. Seal. Well, I am most informed about our own VA Medical 
Center.
    I do know that nationwide, VA is putting a great emphasis 
on the family, on support of families, and trying to educate 
families as to how they can help detect symptoms of PTSD and 
other mental health problems and how they can help their loved 
one access care.
    Very recently there is a lot of emphasis being directed at 
the family from VA nationwide.
    At our VA, we have a very robust family counseling program. 
I am very happy and pleased to say that when a veteran comes to 
see me and expresses marital problems, problems with parenting, 
or domestic violence issues, that I do have a specific place to 
refer them and I know that they are going to be taken well care 
of. It is not just for the veteran, but it is also for the 
veteran's spouse and/or the children as well. I don't know how 
unique that is, but I know at our VA, it is there and it is a 
very robust program, and I do know that there is a lot of 
attention now in VA nationwide being paid to family support and 
the importance of the family.
    Mr. Johnson. General Scott, did your commission look into 
the family aspects in terms of your study?
    General Scott. We looked into the family aspects of 
veterans disability at large. We looked at some of the issues 
surrounding the quality of life of the veterans who had 
returned and the impact of their quality of life or lack 
thereof on the families.
    We made some recommendations regarding family care. I 
suppose some of the things we did may have been spade work for 
the Family Care Act that was passed here in the last Congress, 
I would hope so.
    But in terms of looking specifically at the impact of 
family members on PTSD or the impact of family members when a 
member of the family suffering from PTSD, we did not look into 
it directly.
    Mr. Johnson. Okay. I will just submit that these veterans 
they go into the--they volunteer, it is a family commitment, it 
is not just a veteran commitment, and I think we need to look 
deeper at the involvement of the family in their rehabilitation 
and their treatment.
    Just a quick question. I heard, you know, nightmares, 
flashbacks. To put these folks on a track to recovery and get 
them ready to go back into the workforce they have to be able 
to work, which means they have to be able to sleep.
    Do you have any idea, are there numbers out there that 
reflect how many of veterans with PTSD suffer from sleep apnea 
or anything like that?
    Dr. Seal. Well, did you want to make a comment?
    Dr. Satel. I would say that sleep disturbance is one of the 
most common symptoms. So you may well have actual 
epidemiological data on it, but impressionistically and 
clinically, the vast majority I think have sleep problems.
    Dr. Seal. It is part of the hyper-arousal symptom cluster 
that you see with PTSD, so it is almost hallmark for most 
veterans who suffer from PTSD, and sometimes if we can actually 
address their individual symptoms, particularly in primary 
care, such as sleep, we can help them be more amenable to core 
PTSD therapy by specialty mental health clinicians.
    So it is extremely important that we focus on individual 
symptoms that are treatable.
    Mr. Johnson. Okay, thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Dr. Seal, I appreciate your evidence-based approach to this 
whole subject. It is important that we have a basis for what we 
expend our resources on in treating veterans, so thank you for 
that hard work.
    What are your specific recommendations for improved 
retention in the mental health programs of some of these 
veterans? You gave some statistics, you didn't say the 
dropouts, but people that stayed in and people that didn't, 
what can the VA do to help retain people in these programs?
    Dr. Seal. Well, I think I made some comments earlier about 
embedding more of the treatment where the veterans present, 
which is primary care, but I would also say that VA has done a 
lot to invest in the VA Medical Home and our PACT teams, which 
are Patient Aligned Care Team nurse care managers who could 
actually be leveraged to make reminder phone calls, conduct a 
therapy called motivational interviewing over the telephone, 
send secure e-mail messages to veterans to remind them of 
appointments, and do even more than that over the phone, which 
would be trying to figure out what the barriers are to staying 
in care.
    It is very difficult for veterans to stay in mental health 
treatment, because honestly, these evidence-based treatments, 
particularly at the beginning are not pleasant. It is not 
pleasant to go over and over your trauma many times, and we 
tend to lose veterans at the second or third sessions where 
they just can't take it anymore, and it is in really important 
that we try to retain them in treatment, because once they get 
over the hump, recovery is definitely possible.
    But we need to really leverage the staff that we have at 
VA, such as our nurses, our outreach workers to help veterans 
stay in treatment, wherever they are, whether it is primary 
care or specialty mental health treatment.
    Mr. McNerney. Would you say that threatening to withhold 
disability payments would be an effective tool?
    Dr. Seal. I think that would be highly coercive.
    Mr. McNerney. Yes, yes, thank you.
    Dr. Seal. And I should add unethical, really.
    Mr. McNerney. Good.
    Dr. Satel, one of the things you said that compensation 
before care can or may complicate treatment and recovery.
    I am glad that you used that in your statement, because 
every individual is going to be different. Sometimes it might 
help as in the case of Daniel Hanson who thought that might 
have been helpful in his case, but I have heard that some of 
the housing programs that require veterans to be in treatment 
and be clean is also a problem because it is a catch-22. If 
they are out on the street, they can't clean up, so it would be 
helpful for a lot of them to have housing provided even if they 
are using.
    And so, I think it is very important to keep that in mind, 
how individual this is rather than trying to say well, geeze, 
we need to withhold treatment or we need to withhold payments 
or anything like that, because that would be I think counter-
productive in most cases or a lot of cases.
    Dr. Satel. Oh, yes, I mean that sounds punitive and that 
certainly is not the intent, in fact someone earlier I believe 
it was Congressman Bilirakis said something about forcing 
people into treatment. Actually what came to mind as the others 
were answering that question is that it seems to me if a 
veteran felt in enough distress to want to come forward and 
file a claim, then there was enough distress and pain to desire 
treatment. But, as Dr. Seal said, a patient might be ready to 
go through desensitization and reexperiencing therapy, or not 
be ready to talk about his or her traumatic experience, which 
parenthetically I might say sometimes I think we impose these 
kinds of reexperiencing therapies too aggressively, but the 
point is he is in distress. There is usually almost always a 
way to engage someone who is in distress and through all kinds 
of things. How are things at home? What is it like being with 
your children again? The simplest things like that. What is 
your day like? You know, that is the kind of approach one might 
take.
    We are not talking about forcing someone to go through 
therapies that they find distressing, I wouldn't even suggest 
that to someone who was a complete volunteer patient. We are 
not going to have you confront or participate in a kind of 
intervention that we felt was against your best interest in the 
short term.
    Mr. McNerney. Good. I mean what we are seeing here even 
with our first witness this morning was that treatment is most 
effective when the patient is ready to accept that treatment, 
so it might be best for us to find a way to encourage the 
patient to get to that point and to make sure that treatment is 
available for anyone who is at that point.
    Dr. Satel. Definitely. We want to engage.
    Actually, Mr. Hanson said so many interesting things. He 
mentioned the holistic approach, which gets to the family 
situation, that was earlier mentioned, as opposed to a constant 
drum beat of emphasis on the military experience.
    Some patients like that sense of being back in a cohort of 
fellows, and some don't. And again, I guess if there is one 
theme that is emerging from this is that there is so much 
individual variation and that is always hard for policy makers 
to reconcile because they obviously have to come up with a more 
generic kind of approach, but there are ways to build room into 
the system.
    Mr. McNerney. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Ms. Buerkle.
    Ms. Buerkle. Thank you, Mr. Chairman, and thank you to our 
panels this morning.
    This issue of veterans being ready or someone coming out of 
the military being ready concerns me, because I think if 
contact is made, if someone calls a clinic or shows up in an 
emergency room or talks to their primary care physician about 
symptoms, I think that the presumption on the part of the VA 
should be he is ready. I don't think we should wait for him to 
bottom out. And I am concerned with what I am hearing is that 
the VA doesn't create that culture, that environment where 
there are degrees of readiness, but we are ready right at the 
beginning to address this issue, and the presumption should be 
that everyone coming home is going to suffer some variation of 
PTSD, that is just the reality of what they are going through, 
and it seems to me that the VA should be prepared for that.
    The military state of mind that I am tough, I can deal with 
that, we all know that is the culture of the military, but the 
VA should be ready to address that and be able to get around 
it, and I am concerned that based on what we heard from Mr. 
Hanson that maybe that is not the case.
    Dr. Satel, do you want to comment on that?
    Dr. Satel. You know, when I was listening to Mr. Hanson, I 
was thinking there were so many other opportunities to 
essentially in his case impose the kind of structure that he 
needed earlier than he got it, and what I am referring to is 
the fact that unfortunately he was arrested he said a number of 
times.
    The criminal justice system, there are veterans mental 
health courts, there are ways to take folks who are within the 
criminal justice system, because that is where there is 
leverage. I do a lot of work with drug addicted people, so that 
is an actual entry point into treatment, and he could have been 
essentially diverted to a drug treatment program. I mean thank 
goodness he didn't leave Teen Challenge, but under some of 
these diversion programs, you know, there are significant 
consequences for leaving and significant rewards in addition to 
recovery and reintegration into society, but another reward is 
that your charges are dropped when you complete them. So that 
was one way for him to come in.
    Another possible way, you know, in retrospect this all 
looks neat, I realize this at the time, it is very difficult, 
but sometimes people who are incredibly out of control can be 
civilly committed by their families. That is difficult, but 
that can happen as well, and it is very hard and families are 
reluctant. I understand that, it is easy for me to say, but I 
mean there are--those kinds of mechanisms are already used in 
the mental health system.
    Ms. Buerkle. It seems to me the VA should be far more 
prepared and way out in front of all of this because of what we 
are seeing and the evidence is there.
    Go ahead, Dr. Seal, then I have another question.
    Dr. Seal. I just really appreciated your comment. I think 
what you are saying is you want VA to be proactive and even 
more aggressive in terms of trying to detect a mental health 
problem if it exists.
    And I mean again, I go back to our model, which is really 
almost--I don't mean to use the word passive as opposed to 
being aggressive, but it is passive in the sense that all new 
OEF/OIF veterans who come into primary care see a primary care 
clinician for 50 minutes. Then we literally walk them over to 
the mental health clinician who is actually a PTSD 
psychologist. They then see that PTSD psychologist for 50 
minutes whether or not they have screened positive for PTSD 
depression or alcohol use.
    We just assume that if you have been to a war zone, you may 
have something to talk about. And if you don't have anything to 
talk about, at least you can hear about services that may be 
available to you when you are ready to talk. And then they see 
the social worker to discuss any benefits that they may be due.
    So that is a program that is in place so that there is no 
question well, do I need this, do I not need that. They just 
get it when they come in.
    Ms. Buerkle. But if we listened to what Mr. Hanson said, he 
filled out a form and based on that initial interview, that 
form seems pretty, you know, black and white, and may depend on 
his outlook that day, and I think there is a bigger picture for 
these vets coming home that it may not just be as simple as ten 
questions on a scale of one to ten. It seems like the scope and 
the examination should go far beyond that.
    And as you mentioned earlier, perhaps more holistic. Why 
are we separating mental health from the physical health? It 
seems to me we need to look at the entire health of that 
veteran and it all works together that he is healthy.
    Just briefly, you heard Mr. Hanson talk about how he felt 
that the VA system was not as personal. He felt that the staff 
maybe didn't quite care as much as he found in Teen Challenge. 
He felt that there was no accountability. That concerns me.
    I don't know if we have time to get that question answered, 
but perhaps if you would like to comment on that very briefly I 
would appreciate it.
    Dr. Seal. Again, I can only really comment from my own 
experience, and I feel like we--I can't speak for every 
clinician and every nurse and every clerk at VA, but I think we 
go the extra mile to try to reach out to veterans that are 
coming in. We know that for every veteran who comes in, that it 
wasn't easy for them to get there, that it took a lot of 
courage to come to VA, that it is not always a pleasant 
experience, and so we welcome them when they get there. We 
acknowledge their military service, and we give them contact 
information. I give them my card, I give them my e-mail. I know 
that I am technically not supposed to e-mail with my veteran 
patients because of VA policy, but if that is the only way they 
can reach me, that is how they reach me. And I have a pretty 
close personal connection with most of the veterans who come 
and see me. That is really all I can speak about, but I know 
that my colleagues in our clinics share that same approach, and 
I have met clinicians from all over the country who are 
dedicated to serving these veterans.
    So it is very tricky, because PTSD by its very nature, and 
some of these other mental health problems, result in avoidance 
of care. It is one of the symptoms of PTSD, and so there is a 
bit of a dance between the patient seeking care and the 
providers wanting to deliver that care, and sometimes it takes 
a while before we can meet people where they are. A lot of the 
motivational work that we can do over the phone with veterans 
or a lot of the education, the psycho education we can give 
veterans, can be very, very helpful in preparing them to accept 
treatment.
    Ms. Buerkle. Thank you. I yield back, Mr. Chairman, thank 
you.
    The Chairman. Mr. Walz.
    Mr. Walz. Well, thank you, Mr. Chairman.
    Again, many of you in this room have heard me say often 
that I am the staunchest supporter of the VA system and the 
harshest critic, and that it is a zero sum game, that if one 
veteran falls through the crack that is one too many.
    I also though am pleased to hear people talking about 
evidence-based policy and practice. Anecdotal evidence is no 
way to drive policy.
    I would also tell, if I could, to the Ranking Member, I 
would say what is past is prologue. Our leadership of this 
Nation told us that the conflict that Mr. Hanson was involved 
in would be weeks, not months and that is how we prepared for 
it, and so the influx of veterans coming afterwards is a result 
of not preparing for that. We have been behind the eight ball 
for years and we are trying to get there.
    With that being said, I certainly want to see us using the 
best policy, the best practices to get the best treatment for 
all these veterans.
    I would tell my colleague from New York I live a few hours 
from the clinic that is being discussed here at St. Paul or in 
Minneapolis and in St. Cloud. The St. Cloud clinic treats 1,100 
inpatients per year, they have a 90 percent completion rate. We 
have data that the evidence is driven. Again, if it failed for 
Mr. Hanson, that is a failure we can't live with. We have to be 
better.
    My point in this hearing is, for us to focus on where the 
VA does well, strengthen those, some suggestions that come up 
to me, pre-deployment and post-deployment assessments to get a 
better baseline of where we are going. Some smart things like 
that.
    I also would ask Dr. Seal, the VA medical center and I 
attend these monthly every month in one of them unannounced, go 
in and talks to folks.
    In Minneapolis, for example, they have a geriatric 
psychiatric team that for 65 and older with complex age-related 
medicals, the team provides outpatient mental health services, 
they bring a multidisciplinary staff of psychiatrists, advanced 
practice nurse specialists and all of that. We are approaching 
this aren't we in some cases from holistic? Do you have that in 
San Francisco?
    Dr. Seal. Yes, we have a geriatrics clinic.
    Mr. Walz. Okay. How do you measure your success in your 
programs?
    Dr. Seal. How do we measure success? Not always at the end 
of treatment. A lot of the work that I do involves large 
national VA databases where we look at diagnoses. We aren't 
always able to see when a diagnosis remits.
    Mr. Walz. Would it be safe to say that the VA probably has 
as extensive data on practices and treatments and outcomes as 
any place in the world? Would that be safe to say?
    Dr. Seal. I don't know.
    Mr. Walz. Would you think it would be better than Teen 
Challenge's research?
    Dr. Seal. I think that----
    Mr. Walz. An outcome? Should we not be measuring these 
things? I say that because I know it was successful for Mr. 
Hanson.
    Dr. Seal. We should definitely be measuring these things, 
and I think individual clinicians within their individual 
therapies do measure PTSD symptoms at the start, in the middle, 
and at the end of treatment.
    Mr. Walz. Okay.
    Dr. Seal. Do I have access to all of that data? Not 
necessarily, because it is confidential patient data, but I 
think individual clinicians in VA are trained in evidence-based 
methods, which do involve assessment pre- and post-treatment.
    Mr. Walz. So we would have a pretty good idea if I said 
that the Minneapolis VA treated 15,185 could I have an idea of 
how many of those patients received at least some form of help 
and we could measure it in terms of getting back to work, 
personal measurements of life satisfaction, and those type of 
things? We could gather that data couldn't we?
    Dr. Seal. You could.
    Mr. Walz. And should we be basing our decisions on how we 
expand programs, work on programs, change programs based on 
that type of data?
    Dr. Seal. I think you should definitely look at the data 
before you decide to make changes.
    Mr. Walz. Okay. Dr. Satel, thank you for joining us again, 
I have become very familiar with your work over the years.
    The case for coercion, tell me just briefly, you have 
worked on that, and I am glad it got brought up. I am very I 
would say concerned would be the right word from a medical 
ethic standpoint, from a human right standpoint, I have read 
your work on medical ethics too and the lack of need to have 
those in large. Am I mischaracterizing that?
    Dr. Satel. Yes, sir.
    Mr. Walz. You said did not have them in large hospitals?
    Dr. Satel. Oh, no, no, no, with all due respect I----
    Mr. Walz. Okay. Explain to me though the case for coercion.
    Dr. Satel. Okay.
    Mr. Walz. Research based case for coercion.
    Dr. Satel. Yeah, that was written, that was a monograph I 
wrote a while ago and it had to do with addiction and that was 
the context I mentioned earlier.
    So we are talking about people who have basically violated 
the law, so it is a different population.
    Mr. Walz. Are you applying this to this though, this idea 
you did put out the idea of possibly withholding benefits as 
use in some ways? Is this not coercion? Is your policy, what 
you are asking for on how we get people into this, is it not 
coercion? Am I mischaracterizing that?
    Dr. Satel. You know, I am actually setting forth various 
kinds of options. One could be that before we call someone 
disabled, before we call them disabled, they have to experience 
some good quality treatment and there is a whole lecture on 
what good quality treatment is. It sounds like you are doing a 
great job, but I am talking about at the point in which we call 
someone disabled. That is very different from not giving 
someone the kind of financial assistance they need and provide, 
you know, making the kind of help that they need available to 
him.
    So we are not withholding. Really almost just changing the 
conceptualization of when a disability claim itself, when the 
whole identity of being a disabled person would kick in.
    Mr. Walz. You know we deal with slippery slope issues here 
all the time. What would stop this from crossing over into the 
physical issue?
    Because the issue we are discussing here is mental health 
parity, and I would argue with the Chairman's point, we have 
increased, we had to bring the VA in here and tell them they 
could advertise mental health parity has now been incorporated 
into law and those types of things.
    How would we not slip into this and say, you know, that we 
are going to wait and see first if you can go back to work 
before we help you with that limp you got from being shot in 
the leg? Is that not a slippery slope you think this would take 
us on?
    Dr. Satel. I think the principals apply across the board. 
No one is talking about withholding help or withholding 
financial care. Again, it is the point at which we consider 
disabled, that is all.
    Mr. Walz. And you think we do that too much, am I right? 
And that isn't how the helping culture is eroding self-
reliance?
    Dr. Satel. Sometimes we do, and sometimes we don't do it 
fast enough. You can see for every over diagnosis there is an 
under diagnosis and a missed diagnosis. All these things occur.
    Mr. Walz. How would you rate the VA if you could overall 
how they care for mental health patients?
    Dr. Satel. I think the VA's associated with major 
universities that have high standards and I think they have 
learned a lot of lessons from the way they approached the 
Vietnam era, which again was with the best of intentions, but 
there were things that we learned that I think we don't do now 
as much which is to say now, well, things are so different 
also.
    A lot of those men, well some women, but mostly men, you 
know, we didn't recognize that psychiatry--didn't recognize it 
until 1980 and then the first Center of Excellence I believe 
didn't start until 1987, so by the time people showed up, they 
had been sick for so long, and often in what--there is a term 
for it, I am not making this term up, it is called malignant 
PTSD that some of them had because of the years of substance 
abuse and years of criminalization.
    So by the time someone appears, then it is so hard to treat 
them, but we have a chance, and we are taking it now, with this 
new generation stepping in, you know.
    Mr. Walz. Well, I appreciate that, and I think we concur on 
that that the earlier before these things take hold the better, 
and it is also holistic in terms of physical, but I would argue 
it is also the employment issue.
    Dr. Satel. Definitely.
    Mr. Walz. And everything else. So thank you for that.
    Thank you, Mr. Chairman, for the extra time.
    The Chairman. Thank you very much. Thank you very much for 
being here today, we appreciate your comments. There may be 
some additional questions that will be asked for the record, we 
would ask that you would respond, if in fact, some come your 
way. Thank you very much.
    I ask the third panel to make their way forward. Ralph 
Ibson, Executive Director of Wounded Warrior Project (WWP); 
Christina Roof, National Acting Legislative Director for 
AMVETS; and Dr. Antonette Zeiss, Acting Deputy Patient Care 
Services Officer for Mental Health for the Veterans Health 
Administration.
    We thank you all for being here today.
    Mr. Ibson, you are recognized.

 STATEMENTS OF RALPH IBSON, NATIONAL POLICY DIRECTOR, WOUNDED 
WARRIOR PROJECT; CHRISTINA M. ROOF, NATIONAL ACTING LEGISLATIVE 
  DIRECTOR, AMERICAN VETERANS (AMVETS); AND ANTONETTE ZEISS, 
 PH.D., ACTING DEPUTY PATIENT CARE SERVICES OFFICER FOR MENTAL 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
  VETERANS AFFAIRS; ACCOMPANIED BY MATTHEW J. FRIEDMAN, M.D., 
 PH.D., EXECUTIVE DIRECTOR, NATIONAL CENTER FOR PTSD, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 MARY SCHOHN, PH.D., ACTING DIRECTOR, OFFICE OF MENTAL HEALTH 
OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
   VETERANS AFFAIRS; AND TOM MURPHY, DIRECTOR, COMPENSATION 
 SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Chairman Miller, Ranking Member Filner, and 
Members of the Committee, thank you for inviting Wounded 
Warrior Project to testify this afternoon.
    WWP's vision is that this will be the most successful, 
well-adjusted generation of veterans in history, but critical 
gaps in VA's mental health system are compromising that vision 
in our view.
    The first large gap, and Ms. Buerkle made reference to it, 
is lack of effective outreach. Given the prevalence of PTSD 
among returning warriors and the risk that lack of treatment 
will result in severe chronic disability, it is concerning to 
us that VA is reaching only about one of every two returning 
veterans.
    In our view VA should approach this issue as more of a 
public health issue.
    In 2008, VA telephoned the approximately half million OEF/
OIF veterans who at that time had not enrolled for VA health 
care and it encouraged them to do so. This was apt recognition, 
in our view, that we must be concerned with the entire OEF/OIF 
veteran population. But a single telephone contact is hardly an 
effective outreach campaign.
    Compounding lack of aggressive outreach, we see Dr. Seal's 
data as very, very powerful and very disturbing. It tells us 
that enrolling for VA care and being seen for a war-related 
mental health problem does not assure that a returning veteran 
will complete a course of treatment or even return for a 
follow-up visit.
    Also troubling is that VA has set a very low performance 
bar for reversing this trend.
    Certainly I think, as evidenced by Dr. Seal's testimony and 
what she described at VA's Medical Center in San Francisco, 
veterans are getting good mental health care at many places in 
VA, but it is worth acknowledging that VA really operates two 
mental health systems, a nationwide network of medical centers 
and outpatient clinics and a much smaller readjustment 
counseling program operating out of community-based Vet 
Centers.
    In our view, the differences between these two systems help 
explain why greater numbers of returning warriors do not pursue 
VA treatment and why many of them discontinue treatment.
    The warriors with whom we work consistently report high 
satisfaction with the Vet Center experience. In essence, the 
strengths of the Vet Center program highlight the limitations 
of the larger system for many of these warriors.
    As Dr. Seal indicated, VA medical centers passively wait 
for veterans to pursue mental health care rather than 
aggressively reaching out to them in their communities on a 
one-on-one basis.
    The larger system gives insufficient attention, in our 
view, to ensuring that those who begin treatment actually 
continue and thrive.
    No doubt it emphasizes, as was discussed, training 
clinicians in evidence-based therapies, but it does much less 
to ensure that those clinicians really understand warriors' 
military culture and the combat experiences they have been 
through.
    And unlike Vet Centers and unlike what Dr. Seal described 
at VAMC San Francisco, most VA medical centers fail to provide 
family members needed mental health services, often resulting 
in those warriors struggling without a healthy support system.
    In 2007, VA developed an important policy directive that 
identifies what mental health services should be available to 
all enrolled veterans no matter where they live, but as VA has 
acknowledged this directive is still not fully implemented. 
Access remains a problem, as many small VA clinics have at best 
limited mental health staff. VA policy directs that facilities 
contract for mental health services where necessary to provide 
that care, but those facilities have generally made only very 
limited use of that authority.
    PTSD and war-related mental health problems can be 
successfully treated, as you have heard this morning, and in 
many cases VA clinicians in Vet Centers are helping veterans 
recover, but we urge that VA focus on closing what we see as 
serious gaps.
    We look to the experience that veterans like Mr. Hanson 
have had. Mr. Hanson is the kind of veteran who could do 
extraordinary work in his community and other communities in 
Minnesota reaching out and working one-on-one with other 
veterans and bringing them into treatment. If he had had a 
successful experience with VA, he would be an extraordinary 
salesperson, unfortunately he didn't have that positive 
experience.
    Likewise in terms of sustaining veterans in treatment, in 
terms of dealing with that retention issue that Dr. Seal 
discussed, a veteran like Mr. Hanson would be a wonderful 
adjunct to a clinical team to work directly with warriors 
having the unique warrior-to-warrior connection that he has.
    Secondly, we would urge VA to launch education and training 
programs for its staff on military culture and the combat 
experience so that the connection is a closer one so that it is 
not a distant or simply ``friendly'' clinician-patient 
relationship as Mr. Hanson described it.
    We would urge that VA provide needed mental health services 
to family members whose own war-related mental health issues 
may diminish their capacity to provide support.
    And we would urge that VA expand the number of its Vet 
Center sites and locate new ones near military facilities.
    We recognize the importance of robustly addressing the full 
range of issues facing returning warriors so that they can 
thrive physically, psychologically, economically.
    Compensation for service-connected disability is certainly 
an earned benefit and critically important to most veterans' 
reintegration and economic empowerment, yet data from recent 
surveys we have conducted underscore that much more work needs 
to be done at the most basic level to achieve better 
coordination and unity of focus between VHA and VBA.
    For example, notwithstanding guidance suggesting that 
compensation and pension (C&P) exams may need to be as long as 
3 hours to fully develop a PTSD claim, one out of every five of 
the warriors who responded to our survey indicated they were 
seen for 30 minutes or less.
    This Committee has emphasized this morning the goal of a 
wellness-focused VA response to mental illness. One step in 
that direction, in our view, would address a problem identified 
by the Disability Commission regarding VA's IU benefit. We 
concur with their recommendation and that of the Institute of 
Medicine that the Individual Unemployability benefit should be 
restructured to encourage its veterans to reenter the 
workforce.
    In closing, Mr. Chairman, while we recognize that VA has 
some excellent mental health treatment programs, our work with 
warriors highlights the gaps plaguing the system, gaps in a 
largely passive approach to outreach, gaps in access to mental 
health care, gaps in sustaining veterans in mental health 
treatment, gaps in clinicians understanding of military culture 
and combat experience, gaps in family support, and gaps in 
coordination with the benefit system.
    We look forward to working with this Committee to help 
close those gaps.
    Thank you.
    [The prepared statement of Mr. Ibson appears on p. 78.]
    Ms. Buerkle. [Presiding.] Thank you, Mr. Ibson.
    Ms. Roof.

                 STATEMENT OF CHRISTINA M. ROOF

    Ms. Roof. Madam Chair, Ranking Member Filner, and 
distinguished Members of the Committee, on behalf of AMVETS, I 
would like to extend our gratitude for being given the 
opportunity to share with you our view and recommendations at 
today's hearing regarding VA's system of mental health care and 
benefits.
    You have my complete statement for the record so today I 
will briefly discuss two areas of concern to AMVETS.
    Sadly suicide has become a too familiar casualty of war. 
Suicide among veterans and servicemembers seems to become an 
epidemic with no end in sight. The rate at which veterans and 
active duty military personnel are taking their own lives has 
surpassed that of the non-veteran population for the first time 
in our Nation's history.
    According to numerous studies performed by the National 
Institutes of Health (NIH), VA, and the U.S. Department of 
Defense (DoD), upwards of 43 percent of veterans having served 
in the recent conflicts will have experienced traumatic events 
resulting in PTSD or other invisible wounds such as depression. 
Left untreated, these invisible wounds have a devastating 
impact on the lives of those veterans and servicemembers who 
suffer in silence, as well as their families.
    AMVETS believes one of the hardest and most humbling 
decisions a veteran can make is to seek care for their 
invisible wounds of war. However, often when these men and 
women reach out to VA for help, they are met with broken 
policies, lengthy procedures, as well as an overall lack of 
communication between VHA and VBA.
    Moreover, these veterans who are brave enough to ask for 
mental health care are encountering a confusing and frustrating 
claims system entrenched in bureaucracy.
    Many of these veterans find VA to be more of a hindrance 
than helpful to their overall well-being and thus choose to 
forego the care and benefits they critically need.
    One of the initial experiences a veteran will have within 
the VA system is with the claims examiner, thus the response 
from VA to a veteran seeking care for their invisible wounds is 
a PTSD claims evaluation without a concurrent offer for 
treatment. Now a potentially fragile situation is made even 
worse.
    VA agency affiliation of the examining claims 
representative may not be clear to a newly enrolled veteran 
filing their first mental health claim.
    Qualitative data suggests veterans who undergo compensation 
examinations report not understanding the distinction between 
an evaluative claims examination with that of a mental health 
care treatment examination.
    Many veterans do not make the distinction between the VHA 
staff who conduct examinations and provide care to that of the 
VBA staff who decide claims and dispense benefits. To many 
veterans they are both simply ``VA staff.''
    For example, a claims examination focuses on data 
collection rather than addressing a veteran's distress. The 
compensation examiner may have to collect information about 
traumatic issues that the veteran is unprepared to address, 
even in a therapeutic setting.
    In addition, a compensation interview often has more time 
constraints and the veteran may feel rushed, coupled with the 
frustrations felt towards the claim examiner who must consider 
not only the veteran's perspective, but also the alternative 
sources of data and may ask questions that challenge the 
veteran's version of events.
    AMVETS urges VHA and VBA to immediately address the current 
confusion between clinical VHA functions and that of forensic 
VBA functions. The lack of education being provided to our 
veterans is causing too many veterans in need to turn away from 
the life-sustaining care and benefits VA has to offer.
    AMVETS second area of concern is with the non-compliance of 
numerous Veterans Integrated Services Networks (VISNs) to 
current VHA directives, policies, and procedures addressing 
mental health care. More specifically VHA Handbook 1160.01.
    In September 2008, VA issued VHA Handbook 1160.01 defining 
the clear minimum clinical requirements of mental health 
services throughout the entire VA health care system. The 
handbook outlines policies and procedures related to suicide 
prevention, specialized PTSD services, 24/7 emergency mental 
health care, and over 100 other issues directly related to the 
treatment and programs of mental health care.
    VHA 1160.01 also clearly outlined the requirement that 
every VAMC and community-based outpatient clinic was to have 
these programs and policies in place no later than the last 
working day of September 2009 unless granted written permission 
by the Secretary.
    Immediately following this deadline, as required by the 
Military Constructions Veterans Affairs and Related Agency 
Appropriations Bill of 2009, the Office of Inspector General 
(OIG) conducted a review of VHA's progress and the 
implementation of the requirements.
    In 2010, OIG's findings on VA's progress were released and 
raised several serious concerns for AMVETS.
    AMVETS found VA's failure to implement numerous critical 
parts of the handbook directly related to suicide prevention 
and mental health care to be unacceptable.
    AMVETS is especially concerned over the following OIG 
findings:
    One, the lack of access to timely treatment within all 
VISNs regarding specialized PTSD residential care program. The 
current wait time for many veterans living in rural or remote 
areas is 6 to 8 weeks.
    Two, VHA's lack of trained personnel to provide intensive 
outpatient services for the treatment of substance abuse. As we 
have seen today, substance abuse can lead to things such as 
homelessness and/or aggravate symptoms of the invisible wounds 
for veterans not receiving the care they have earned through 
their service.
    Three, VA's limited availability of 23-hour observation 
beds for patients at risk of harming themselves or others.
    And finally, VA's failure to have the presence of at least 
one full-time psychologist to provide clinical services to 
veterans in VA community living centers with at least 100 
residents.
    These are only a few of the numerous problems OIG outlined 
in their report. AMVETS finds it to be inexcusable and 
irresponsible that numerous VAMCs and CBOCs are still, in 2011, 
being allowed to operate in a state of non-compliance to the 
VHA Handbook 1160.01.
    In closing, AMVETS believes VA must hold these non-
compliant VAMCs and CBOCs accountable and start taking a more 
proactive approach to insuring our veterans are receiving only 
the highest quality of mental health care they can provide.
    AMVETS further urges Congress to step up the oversight as 
it relates to the full implementation of the VHA Handbook 
1160.01 and mental health care as a whole within the VA health 
care system.
    Until we stop taking a reactionary approach to VA's system 
of mental health care, we are destined to be playing catch up 
and meeting the needs of today's returning war fighters.
    Chairman and distinguished Members of the Committee, this 
concludes my testimony, and I stand ready to answer any 
questions you may have for me.
    Thank you for allowing me to go over my time.
    [The prepared statement of Ms. Roof appears on p. 86.]
    Ms. Buerkle. Thank you very much for your testimony.
    Dr. Zeiss.

              STATEMENT OF ANTONETTE ZEISS, PH.D.

    Ms. Zeiss. Thank you, and I am here accompanied by Dr. Matt 
Friedman, the Director of the National Center for PTSD, Dr. 
Mary Schohn who is the acting lead for the new Office of Mental 
Operations who will have significant responsibility for 
implementation and ensuring that policies are fully 
implemented, and Mr. Tom Murphy from the Veterans Benefits 
Administration. And many issues have been raised.
    I am going to actually do a very abbreviated oral 
testimony, because I think you all have questions and I want to 
address many of the things that have come up.
    Let me focus the testimony first on comments on a couple of 
earlier things and then on the call for evidence-based policy 
and care within VA.
    I guess I would say first in terms of Mr. Hanson's 
testimony that the most moving thing to me and something that 
Dr. Seal addressed, but I also want to address, is his sense of 
not feeling a personal connection at VA.
    My own experience of working for VA for almost 30 years now 
is that this is the most passionate and dedicated group of 
professionals I can imagine working with, and I have worked in 
academic settings and other settings as well, and I would love 
to talk more with Mr. Hanson about his experience and think 
together about how to make sure that the passion we all feel 
for the work we do and for caring for veterans is being 
communicated directly.
    I also want to say that I agree enormously with Dr. Seal's 
comments. In fact, most of the things she was recommending are 
in fact national VA programs. She was talking about them within 
the context of the San Francisco VA, but most of them are 
mentioned in the Uniform Mental Health Services Handbook, and 
in fact, the integrated clinic for returning OEF/OIF veterans 
is present throughout the system led by Dr. Stephen Hunt and is 
staffed with mental health professionals throughout the system. 
I think it is an excellent way to specifically meet the initial 
needs of a number of returning veterans. And then we have to 
stand ready to deliver in many ways beyond just that initial 
care.
    I would say and I am happy to talk with you, the OIG has 
closed all of its recommendations from the report that you 
describe as we have reported on further progress and 
implementation and they have agreed that those recommendations 
have been met and that there is still work to do. We are still 
not at 100-percent implementation. We can talk about that how 
we are absolutely committed to that work, but we are well 
beyond what was in that set of recommendations. We shared the 
same concern you did about making sure that things happened and 
things changed.
    A couple of other things to comment on that have come up 
during the discussion. We have hired since fiscal year 2005, 
7,500 full-time mental health staff, that is mental health 
professionals, psychologists, psychiatrists, nurses, and social 
workers, but also addiction techs, outreach workers, support 
staff of a variety, and the number of veterans who are seen for 
mental health care has increased quite commensurately going up 
from in the less than a million around 800,000 to over 1.2 
million if we look only at specialty mental health care, and up 
to 1.8 million if we are thinking about people who are also 
being seen in integrated care, primary care settings.
    So we are very much expanding care, and we are working as 
Dr. Seal talked about to deliver the most effective evidence-
based care.
    We agree that we need to continue to lay the groundwork and 
ensure that more veterans receive those full courses of care, 
but we do have some evidence that people may not have been 
captured in the early time period her study covered up to 2008, 
but in fact just as with substance abuse treatment people often 
drop out several times before they then engage with a full 
course of treatment, and we are seeing some of those same 
patterns in VA.
    We are also developing increased tools to link people to 
care such as the mobile app for a PTSD coach that Dr. Seal 
mentioned, which after 2 months has been downloaded as a free 
app by over 10,000 people in 37 countries and has the highest 
possible ratings.
    And finally in closing, I would encourage you to look at a 
report that has been submitted to Congress, the ``Government 
Performance and Results Act Review'' that VA participated in 
from fiscal year 2006 through fiscal year 2010, to look at the 
transformation of the VA system for mental health care in that 
time and point out that it concludes that VA mental health care 
was superior to other mental health care offered in the United 
States on most all dimensions surveyed.
    These data speak to the great strides VA has made in mental 
health care. Clearly we have more to do. We share concerns 
about many of the issues that have been raised. We are happy to 
talk about what are the next steps, what are ways in which we 
can continue to act on our passion to serve veterans fully.
    Thank you.
    [The prepared statement of Dr. Zeiss appears on p. 94.]
    Ms. Buerkle. Thank you all very much, I will yield myself 5 
minutes at that time for questions.
    Mr. Ibson, in your opening statement you mentioned that 
there were gaps. Could you perhaps in order of priority mention 
the most glaring gaps and the ones that need the attention, you 
know, our most immediate attention?
    Mr. Ibson. It's difficult to prioritize, but I think you 
put your finger on a powerful point, which is that we should 
assume that all returning veterans are at risk of PTSD, and the 
fact that untreated PTSD can be such a pernicious, disabling 
condition argues that a VA health care system not passively 
rely on notices on its Web site, but that it actually engage 
veterans in their communities and attempt to bring them into 
treatment through more aggressive outreach. That is we urge VA 
to view this as really a public health problem, not simply a 
matter of providing treatment when veterans walk through the 
door.
    And I think secondly the concern with retention, asking the 
question why are veterans not staying in the system, and 
exploring in a more wholehearted way efforts to sustain 
veterans in treatment.
    I think Dr. Seal spoke to a number of ideas. Our 
suggestion, which is actually reflected in Section 304 of the 
Caregiver Law of last year calls on VA to employ returning 
veterans to do peer-outreach and provide peer-support services. 
We think there is an important role for returning veterans who 
have experienced mental health problems and benefited from the 
excellent treatment that can be available to work with their 
peers who may be on the fence, who may be hesitant, who may be 
quick to drop out. I would say those are two of the more 
compelling ways in which we see gaps and would urge that they 
be closed.
    Ms. Buerkle. Thank you.
    Dr. Zeiss yesterday we had a hearing and the Chairman 
alluded to the hearing regarding sexual assaults, and one of 
the most compelling pieces of information that came out from 
that and you get a sense of it this morning is that we can't 
count on every VA facility to be consistent, and so I would 
like you to speak to that a little bit.
    You mention about the staff that you are involved with, and 
I know Dr. Seal earlier mentioned her facility, but how can we 
ensure that the same environment is being created across the VA 
system? It seems to me that needs to be a priority so we can 
ensure it isn't dependent on the facility, it is dependent on 
the VA system as a whole and they are giving our vets what they 
need.
    Ms. Zeiss. Well, I think that is a splendid question. It is 
one of the things that has consumed my energy since coming to 
Central Office, because I completely agree with you that we can 
set important policies based on data, evidence, and what we 
know about gaps and then we have to be sure that they are very 
consistently carried out.
    And I would like to turn to Dr. Schohn, because one of the 
things that has happened just in the last few months is that 
VHA has reorganized to create this Office of Mental Health 
Operations that will be able to interact much more directly 
with VISN directors, with facilities, and really tackle some of 
those issues very directly.
    Dr. SCHOHN. Yes, just in the last few months, VHA has 
reorganized, and part of the reorganization has been to build 
in a clinical presence in operations so the office that I am 
with, the Mental Health Operations Office, is really charged 
with overseeing compliance of things like the handbook. So my 
first job essentially is really to ensure that that has been 
implemented enough in all facilities.
    As Dr. Zeiss mentioned, we are aware that it has not been 
fully implemented. We are concerned about that, and we are 
directly working with the field in terms of identifying what 
are the various implementations, what needs to be done, do we 
need to provide education, do we need to provide staff 
training, you know, what do we need to do in order to make sure 
that those programs are implemented as written?
    As well we will be looking at other areas of concern, 
things that arise in reports like what you saw yesterday. So 
how do we collect that data and then ensure that the field 
actually implements the changes that we are advocating?
    Ms. Buerkle. Thank you. Would it be possible to get that 
reorganization plan to the Committee?
    Ms. Zeiss. Certainly. We can take care of that when we get 
back.
    [The VA subsequently provided the following information:]




    

    Ms. Buerkle. Thank you very much, I would appreciate that.
    I now yield 5 minutes to the Ranking Member of the Health 
Subcommittee, Mr. Michaud.
    Mr. Michaud. Thank you very much, and I want to thank the 
panel as well for testifying today and have heard, you know, 
Mr. Hanson and I heard Dr. Zeiss talk about, yeah, the 
employees really do give that care, in reality you don't hear 
that throughout the country quite frankly. There are VA 
employees who do a really good job and there are those that are 
there and just can't wait to get rid of this paperwork and 
there is no consistency among the VA.
    I heard Ms. Roof talk about the fact that the VA employees 
aren't even following the handbook that they are supposed to 
follow, which is a concern about some of the problems that we 
are seeing and the non-compliance among different VISNs and as 
far as how they move forward on these particular cases and the 
problems that it is causing veterans as far as getting 
services, whether it is dealing with female veterans issues as 
we heard yesterday when we look at sexual assault and rape. And 
the fact that the VA has not done a very good job in that 
regard, when you look at Mr. Hanson this morning talk about how 
he felt that he didn't get the service within the VA, and I 
have heard that complaint as well from a lot of veterans 
throughout the country.
    And I guess my question, particularly when you look at 
mental health type issues for the doctor, actually Mr. Ibson 
mentioned this morning about in his testimony that when the VA 
goes through their evaluation exams, that it is extremely brief 
and superficial.
    How can the VA actually address these issues so that they 
are not brief or superficial and they really give the care that 
the veterans really need so they will not get frustrated and 
try to go elsewhere? Because that is the problem I see as 
veterans getting frustrated and not seeking the care among the 
VA. I mean where is the accountability within the VA system?
    Ms. Zeiss. Well, several things in what you said so let me 
address what I can and then come back to others as needed.
    First of all, in fact we set a standard that veterans who 
are newly referred for mental health care need to be seen. They 
need a 24-hour triage call and diversion to urgent care if it 
is needed, but the main standard is within 14 days then that 
they will have a full diagnosis and beginning of treatment 
plan, and we meet that standard by well over 95 percent. And 
part of what contributes to not meeting the standard is 
veterans who decline to get an appointment within that 2-week 
window.
    Now in a system as huge as ours with over 1.8 million 
veterans being seen for mental health care, there could be in 
that 5 percent that are not meeting that a number of people 
that you hear about and that we are concerned about and that we 
believe we need to be better on. We would like to continue to 
do far better and we want to hear when there are instances 
where people have not gotten the care that the system is set up 
to deliver.
    In terms of the claims interviews, which is I believe what 
Mr. Ibson was talking about when he talked about the brief, 
what I can say is that we have very recently had a study 
completed on PTSD interviews for C&P claims, we will be hearing 
about the outcome of that research very shortly.
    I will ask Dr. Friedman to say just a bit more about that, 
because he has been involved with it, and we will certainly be 
very happy to share with you when that evidence is complete 
what the evidence is actually showing about what is required 
for a full, effective, accurate, and valid PTSD interview and 
what policies we will set and how we will work with mental 
health operations to ensure that they are met.
    Mr. Michaud. Before you answer my concern is, that there 
appears to be a lot of studies and evaluations going on and 
this issue is not new. It has been going on for quite some time 
and it is getting really frustrating because the other big 
issue that we hear, particularly coming from rural States such 
as Maine, is access issues.
    When Congress adopted the Office of Rural Health, we 
provided funding for the Office of Rural Health to really focus 
on the fact that about 40 percent of the veterans live in rural 
areas, that that office is supposed to focus on Office of Rural 
Health. However, when the GAO did their study to see how 
effective the Office of Rural Health has been, the VA can't 
account for over 51 percent of the spending that has occurred 
in the Office of Rural Health. How many veterans that the 
office is supposed to take care of been treated? They can't 
account for that.
    So the accountability issue is a big concern that I have, 
because these are individuals lives, they are families, and I 
am just tired of just study after study without really, really 
focusing on the problem.
    And the other issue that is a big concern is the fact that 
when you look at the studies that do occur within the VA system 
that they don't include individuals such as the veterans 
service organizations (VSOs), individuals who are really 
affected by it as part of that collaborative effort, and that 
is a huge concern, because if you have VA management that is 
going to comprise the Committee that is going to study, you 
have the same individuals and they are going to go in there and 
try and collaborate and what have you, and that is a big 
concern that I have is we are not really focusing on the 
veterans who really need the help.
    As we heard this morning in the different panels, VA, don't 
get me wrong, I think VA does a good job by and large, but 
there is a lot of room for improvement, and when I get, whether 
it is a Inspector General report or a GAO report saying the VA 
can't account for the money that we are giving them and that 
the effect that it is having, I mean that is really concerning.
    When I hear from veterans who are frustrated with a system 
and they go elsewhere for the help because VA is not providing 
that help, that is concerning to me as a Member of Congress, 
and I hope, Doctor, that you take this hearing very seriously 
and you really start focusing on getting results versus doing 
another study and reporting back to Congress. Because all too 
often what happens is after the hearing is done unless we do 
have an aggressive oversight hearing, you know, you get that 
report done, it sits on the shelf and that is the end of it 
until we hear another outrage among the veterans community.
    So I am just getting frustrated with what I see happening 
and hopefully we can do a better job than what we currently 
have had over the past few years.
    Ms. Zeiss. Well, certainly I am trying to convey that in 
fact we are not just studying, we are doing. We have increased 
the number of veterans we are seeing for mental health. We have 
increased the number of mental health staff, we have increased 
the effectiveness of the interventions, and we are putting our 
passions into trying to make the kinds of changes in the VA 
system that you are frustrated about and that we want to see 
those changes too, and we welcome hearing when, you know, what 
are the places where we have not made the progress that you 
would like to see. And it sounds like right now one of those is 
in doing the C&P exams, and I would really love to let Dr. 
Friedman, who is really our expert on PTSD speak to that.
    Dr. Friedman. Well, thank you.
    A number of years ago, there was a meeting between VHA and 
VBA people to see how could we develop a standard that would 
establish a floor so that every C&P exam would meet a minimum 
standard. One of the bases for that was this initiative in 
research and also in clinical evaluation. For years now, we 
have developed a number of excellent assessment tools, some 
wonderful diagnostic scales and other symptom severity scales 
that are not just used in VA, but which are used universally, 
internationally. It seemed to us that we had an evidence base 
for assessment that could very well inform the C&P progress. 
And based on that meeting, a study, which as Dr. Zeiss 
mentioned a few minutes ago, is nearing completion, was set in 
motion with examiners at different VA regional offices 
throughout the country comparing a standard C&P exam with a C&P 
exam that used such an approach--specifically we used the 
clinician administered PTSD scale (CAPS), which is considered 
the gold standard for PTSD assessment and the World Health 
Organization Disability Assessment scale, the WHODAS, which 
again is internationally accepted as the best approach for 
assessing functional status regarded. And so, we have basically 
C&P as usual compared with an evidence-based standardized 
assessment utilizing both the CAPS and WHODAS. Those encounters 
are being videotaped. They are being assessed at the National 
Center for PTSD, and, stay tuned, we will have the results as 
soon as we can get them written up.
    Ms. Zeiss. Let me just add finally if I can keep my voice--
you probably know we do have a mental health rural project 
going on in Maine in VISN 1 as well as in VISN 20, and 19, the 
most rural VISNs that we have, and we are finding that there 
are some very effective things we can do in partnering with 
communities and making sure that we are getting care more 
broadly into your system and we will learn from that to be able 
to spread to other parts of the system as well.
    We agree with you, it is really crucial. And the Office of 
Rural Health has supported us in doing that, but it is our 
Office of Mental Health Service that the really focusing that 
project in VISN 1.
    Ms. Buerkle. Thank you, Mr. Michaud.
    At this time first of all I want to just reiterate and 
emphasize what my colleague and the Ranking Member has talked 
about, and that is the sense of urgency that lives are being 
lost and people are slipping through the cracks who need our 
help, and they are men and women who have sacrificed so much 
for this country. So our duty is even greater.
    So I would really encourage the Veterans Affairs to work 
hard and diligently and give us an action plan as to how we are 
going to address these issues. The gaps that Mr. Ibson talked 
about, that we talked about earlier that shows that the VA is 
getting out in front of this. We are not just going to be 
reactionary, we understand, we appreciate the fact how these 
young men and women are suffering overseas as they protect our 
Nation, and what you are going to do to get out in front of 
this to help them. So I can't emphasize that enough, time is of 
the essence.
    At this time I want to take a moment to recognize the 
presence of Andrea Sawyer. Andrea is the spouse of an OIF 
veteran who has 100-percent service-connected rating for PTSD.
    Andrea has been kind enough to submit testimony for the 
record outlining her observations of the VA mental health care 
system, and in short she has made the following suggestions.
    Treatment must be timely and available. Treatment must be 
appropriately timed and tailored to address the severity of the 
symptoms. Treatment must be practical. Treatment must be 
culturally competent. Community options should be available. 
And communication between the VBA and the VHA need to improve.
    I would encourage all of my colleagues to read Andrea's 
very compelling testimony, and I want to thank Andrea for being 
here and for providing us with that testimony. Thank you very 
much.
    [The prepared statement of Ms. Sawyer appears on p. 63.]
    Ms. Buerkle. Are there any other questions? At this time I 
ask unanimous consent that all Members have 5 legislative days 
to revise and extend their remarks and include extraneous 
material for the record on today's hearing. Hearing no 
objection so ordered.
    This hearing is now adjourned.
    [Whereupon, at 1:07 p.m., the Committee was adjourned.]











                            A P P E N D I X

                              ----------                              

           Prepared Statement of Hon. Jeff Miller, Chairman,
                  Full Committee on Veterans' Affairs
    Good morning. Thank you to our witnesses in attendance, and welcome 
to the Committee on Veterans' Affairs hearing entitled, ``Mental 
Health: Bridging the Gap Between Care and Compensation for Veterans.''
    On May 10, the United States Court of Appeals for the Ninth Circuit 
issued a decision that was heavily critical of the care and 
compensation VA provides to veterans with mental illness. The Court 
cited VA's ``unchecked incompetence'' and the ``unnecessary grief and 
privation'' that delays in treatment and benefits cause veterans and 
families.
    I am not here this morning to judge the Court's decision . . . I'll 
leave that to others. But the heart of the Court's analysis of the 
issue is something with which all of us need to be concerned. Namely, 
is VA's system of care and benefits improving the health and wellness 
of veterans suffering from mental illness?
    On behalf of a grateful Nation, we've invested heavily in this 
system over the last decade to improve access and make treatment 
options that experts say are effective more readily available. But the 
question remains, are veterans--especially those returning from combat 
with the invisible wounds of war--on a road to recovery and able to 
live full, productive lives?
    Recovery, restoration, and wellness . . . these should be 
overarching objectives of all VA's programs. Yet when I look at trends 
in disability ratings for veterans with mental illness I see a 
confusing picture.
    On one hand we have a medical system that boasts of evidence-based 
therapies, improved access, and high quality of care. On the other we 
have data from VA indicating that veterans with mental illness only get 
progressively worse. These confounding facts raise the question: Are 
VA's health and disability compensation programs oriented towards VA's 
mission of recovery and wellness?
    I am not the first who has noted this trend or suggested the need 
for closer integration of VA programs.
    A 2005 report from the VA Inspector General concluded the 
following: ``Based on our review of PTSD claims files, we observed that 
the rating evaluation level typically increased over time, indicating 
the veteran's PTSD condition had worsened. Generally, once a PTSD 
rating was assigned, it was increased over time until the veteran was 
paid at the 100 percent rate.''
    We have a 2007 report from the Veterans' Disability Benefits 
Commission--and we'll hear from the Chair of that Commission on our 
second panel--which recommended that ``a new, holistic approach to PTSD 
should be considered. This approach should couple PTSD treatment, 
compensation, and vocational assessment.''
    Most recently, we have the Administration raising red flags. In its 
Fiscal Year 2010 Performance and Accountability Report VA commented on 
how well its Veterans' Benefits Administration collaborates with the 
Veterans Health Administration when providing services to veterans with 
mental illness.
    The report suggested that with recovery as the essential goal to 
helping veterans with PTSD, that perhaps VBA and VHA were working at 
cross purposes. Let me quote from that report: ``With the advent of the 
Recovery Model as central to the treatment of mental health disorders, 
the current system fails to support and may even create disincentives 
to recovery.''
    Today, we will move beyond numbers that simply tell us how many 
veterans use the system and get at the fundamental question of whether 
they are on a road to leading full, productive lives.
    For veterans who don't seek VA care, we need to know why. We need 
to know if there are inherent disincentives to recovery. We need to 
know if the quality of treatment provided at VA is a reason many seek 
care elsewhere. We need to know what is effective and what isn't.
    Quoting from a recent policy paper from the Wounded Warrior 
Project, ``VA's focus on the high percentage of veterans who have been 
treated begs such questions as, how effective was that treatment, and 
how many more need treatment but resist seeking it?'' I couldn't agree 
more.
    It is our duty at this Committee to ask these tough questions. The 
veterans for whom this system was created demand it of us.
    We are fortunate to have with us on our first panel Mr. Daniel 
Hanson. Dan served in Iraq, then came home troubled in mind, trying to 
cope with the loss of so many of his fellow Marines. His is a story I 
hope everyone listens closely to as a cautionary tale of where we may 
be inadvertently headed. Looking back, Dan has some interesting 
thoughts of what it would have taken to get him into treatment sooner. 
And, just as important, he's got something to say about how he 
ultimately found help outside of VA's system.
    On our second panel we have Dr. Sally Satel, resident scholar at 
the American Enterprise Institute. Dr. Satel will share with us the 
principles surrounding what she believes would be a more effective 
system of care and compensation for veterans seeking mental health 
treatment. As I mentioned we also have the former Chairman of the 
Veterans' Disability Benefits Commission with us, General Terry Scott. 
We also have a VA clinician, Dr. Karen Seal, who will share with us her 
findings on health care utilization of Iraq and Afghanistan veterans.
    Finally, on our third panel, we will hear the administration's 
views, and the views of two important veterans' organizations, AMVETS 
and the Wounded Warrior Project.
    Again, I thank everyone for being here today. I now yield to the 
Ranking Member, Mr. Filner.

                                 
             Prepared Statement of Hon. Bob Filner, Ranking
         Democratic Member, Full Committee on Veterans' Affairs
    Thank you, Mr. Chairman, for holding this very important hearing 
today.
    Over the last 4 years, I have raised serious concerns with the 
backlog of claims for our veterans. There are a record number of our 
servicemen and women returning home with scars from the war and now is 
not the time to delay their benefits.
    The report released last year by the VA Inspector General focusing 
on the delay of our servicemembers getting an appointment for a medical 
exam in order to process their claim for compensation is just another 
example of how the VA is failing our veterans.
    The VA system has many obstacles for our warriors by putting them 
through numerous medical exams for each individual ailment for which 
they are filing a claim. The VA could easily streamline this process 
and allow the veteran to receive one complete medical exam to expedite 
the claims process, alleviate the stress on our veterans, and save our 
veterans and taxpayers money.
    The recent decision issued by the 9th Circuit Court of Appeals in 
Veterans for Common Sense and Veterans United for Truth v. Shinseki 
found that veterans have a property interest conferred upon them by the 
Constitution to both VA benefits and health care.
    Ruling for the veteran plaintiffs, the 9th Circuit went a step 
further to conclude that because these are property interests, delaying 
access to health care or the adjudication of claims, violates veterans' 
due process rights guaranteed by the Fifth Amendment.
    I agree with this ruling wholeheartedly and am disappointed that 
the VA has not done more to fix the problem.
    We know that on average, every day, 18 veterans commit suicide in 
this country. We also know that 1 in 5 servicemembers of our current 
conflicts will suffer from PTSD and, unfortunately, the suicide rate 
for these brave men and women is about 1 suicide every 36 hours. Many 
of them, as outlined in the ruling, will be left undiagnosed, untreated 
and uncompensated. This is a travesty and an outrage.
    Last year, the VA Inspector General's office made recommendations 
for the Veterans Health Administration and the Veterans Benefits 
Administration to collaborate more effectively and share information on 
issues affecting the timely delivery of exams. I am disappointed that 
we are still discussing this issue 15 months after the findings and 
recommendations.
    The VA is not committing sufficient resources to meet the demands 
of our warriors when they return home. I hope that VA will address 
these shortfalls and I expect them to come to the table with a plan to 
fix the problem.
    Mr. Chairman, I look forward to the testimony this morning.
                                 
                 Prepared Statement of Hon. John Barrow
    Thank you Chairman Miller and Ranking Member Filner for holding 
this hearing on mental health treatment.
    It is our duty and obligation to ensure that when our troops come 
home we provide them the mental health services they not only need, but 
the services they have earned. Unfortunately, we have failed to provide 
adequate mental health treatment. Too often our veterans afflicted with 
mental illness go undiagnosed and untreated.
    One group of veterans we have failed to provide for adequately are 
those in rural areas. Veterans living in rural areas face all the same 
challenges that veterans in urban areas face with the added stress of 
long travel to receive care. For example, if a veteran in Statesboro, 
GA needs routine mental health treatment, he would be forced to travel 
over an hour and a half to get to the closest VA health facility. That 
is too far to travel for routine mental health treatment. A veteran in 
Statesboro should be able to travel a short and convenient distance for 
routine mental health treatment.
    I look forward to hearing ways we can more effectively provide 
mental health to our veterans, and I look forward to working with this 
Committee to provide more effective mental health treatment. We need to 
be certain that VA is providing high quality mental health treatment, 
while ensuring that veterans can conveniently and quickly use VA's 
health services.

                                 

                Prepared Statement of Daniel J. Hanson,
                    South St. Paul, MI (OIF Veteran)
    My name is Daniel Joseph Hanson and I am 27 years old. I joined the 
United States Marine Corps in January 2003. I was eventually assigned 
to 2d Battalion, 4th Marines and in February 2004 was deployed to Ar-
Ramadi Iraq. The deployment started with one of our Marines shooting 
himself in the head and killing himself. It was not long before we 
started losing men and funerals seemed to become a regular thing. It 
was hard to know that you had just talked to someone the day before and 
now you were saluting an empty pair of combat boots, an upside down M-
16 and a pair of dog tags. When it was all over in October 2004 we lost 
a total of 35 Marines.
    On our `cool down' period before returning we had a few classes 
discussing what each person had seen and how they were dealing with it. 
For me it was very difficult to talk about anything that bothered me 
because I was not an infantryman and felt as if I did not have the 
right to raise my hand because of it. I felt as if I was subpar because 
the other people in my battalion had been through much worse and I was 
weak if I couldn't handle the things that I went through. After a few 
classes we all returned from the deployment and shortly after went on 
leave. That is all that we went through in regards to post deployment, 
a few classes to make sure that if we had any traumatic events we made 
sure we let somebody know.
    I was deployed a second time to Okinawa, Japan in 2005. At this 
point I was married and had a child on the way. Upon returning from 
Okinawa, I had my son and began preparations to get out of the Marine 
Corps. I was drinking almost every single day, getting in fights and 
was very depressed. I got out of the Marine Corps in January 2007 and 
decided I was out of control and needed to get help.
    Before I was released from active duty, a friend and fellow Marine 
hanged himself in the basement of his home with an electrical wire. He 
had gone to the Saint Cloud VA Medical Center seeking help, but was 
turned away. A couple weeks later (February 7th, 2007) my good friend 
and father figure Sergeant Major J.J. Ellis was killed in combat. His 
funeral at Arlington National Cemetery got me to start drinking just a 
few short weeks after I was trying to get things together again. Then 
on March 23, 2007, my brother and best friend, who was also a Marine, 
hanged himself in the basement of his home. Travis was working with the 
VA Medical Center, but was not willing to open up to them about his 
internal struggles.
    At that point I really went off the deep end. I started working 
with the VA Medical Center on an outpatient basis. I struggled with 
anxiety and depression which eventually led to a lot of destruction. In 
August of 2007 I separated from my wife and eventually got divorced, 
after I got another woman pregnant while I was still married. I started 
racking up DUI after DUI and spent some time in jail. I went to the 
Saint Cloud VA Medical Center and went through the Dual Diagnosis 
Program. There was good content and it was very informative. However, 
it lacked any sort of discipline and there was a gentleman that was 
smoking meth in the stairwell at one point in time. It seemed more like 
something that would effectively be able to teach people about what 
drugs and alcohol can do to a person, but there was not a whole lot of 
real life application. Also, there was no aftercare so once I was cut 
loose I was pretty much on my own. I still did followup at the 
Minneapolis VA Medical Center, but I was so far gone outpatient would 
not suffice.
    About a month after I completed the Dual Diagnosis Program, I 
attempted to kill myself by swallowing a large amount of prescribed 
pills. I woke up in the Saint Cloud VA Medical Center and was put up in 
the psych ward. I was put on a 72-hour hold and then released. There 
was almost no followup after my departure from my 72-hour hold and then 
I was just thrown back into my life again. I continued to drink, cheat, 
and live a life of anger. I started using drugs again because the 
alcohol was not doing enough to help me cope during the day. I got 
another DUI and found myself in jail yet again. A week after my last 
DUI, I found myself looking at a lot of jail time. I was scared, broken 
and wanted to die yet again. One week later, I checked myself into 
Minnesota Teen Challenge, which is a 13-15 month faith based program.
    The Minneapolis VA Medical Center does not offer anything close to 
a 13-15 month long inpatient treatment program. I was walking around 
wanting to die every single day, month after month, and no 30-, 60-, or 
90-day program would have been able to get me to where I needed to be. 
A year removed from the world that had just become too much for me and 
that I hated seemed like way too much to commit to, but it has saved my 
life. Minnesota Teen Challenge changed me more than I ever thought 
possible. I have completely changed my thoughts, actions, and attitude 
over the last year. It was a struggle and I considered leaving many 
times, but that is because I have always been a person that always took 
the easy way out. I now want to live and I want to live a successful 
life free of any chemicals.
    While at Minnesota Teen Challenge, one of the biggest struggles 
that I dealt with was not having the funds to complete the program. I 
was not able to get the VA to fund the program while I was attending so 
I put in a claim to have my disability raised. I fell behind in child 
support, bills and eventually my payments to Minnesota Teen Challenge. 
It made things very difficult in the midst of me trying to get my life 
straightened out. I finally got my claim completed one day after my 
graduation and up until then I thought I was going to have to sleep in 
my car to come out to Washington, D.C. to testify on March 3rd of last 
year.
    There are a lot of things that the Department of Veterans Affairs 
does well, but there are several I believe that they could do much 
better. First, they do not provide any long term care at all. The 
longest program that I know about is the Dual Diagnosis Program at the 
Saint Cloud VA Medical Center and I believe that it is only 90 days at 
the most. The problems that I picked up over the years of bad living 
were not going to go away in a matter of months. There are a lot of 
veterans I know that walk around in constant pain and depression 
because they have never been able to overcome the root of their 
problems. A program that lasts for a year or more is much more likely 
to help a person, and help them not just cope with their problems, but 
get rid of them all together. Minnesota Teen Challenge has changed my 
life from wanting to die every day to wanting to get up every day 
because I finally have a passion to live. Second, there was never any 
accountability in my experiences with the VA system. If I missed 
appointments or just stopped calling all together it did not seem to 
really matter to anyone. I felt like I was just another number going 
through the revolving door of head doctors that had to talk to me. I 
had the opportunity to work with a lot of great VA employees over my 
time there, but I never really felt connected. Never thought anyone 
really cared. Third, there are a lot of great organizations that are 
not connected to the Government, but are not being utilized because it 
may be more expensive. The VA cannot possibly take care of all the 
hurting veterans on their own and I believe that being able to utilize 
the resources of organizations not connected to the VA is necessary to 
help all of them.
    I know that when I was discharged from the Marine Corps I was not a 
healthy individual, but I certainly would have not let anyone know 
that. I began getting treatment at the Minneapolis VA Medical Center, 
but I was holding back considerably. If I was forced to go into 
treatment I am sure that I would have saved myself and most importantly 
my family a lot of pain and hurt. For me it was a way to get a pay 
check without having to do anything for it in return.
    I believe that it would be in the best interest of veterans that 
are struggling to have compensation withheld if they are not willing to 
get some sort of help. If the Government was able to set up some sort 
of incentive based program to encourage hurting veterans to take the 
time and make the effort to get help. I know that if I would have 
gotten that kick in the butt I needed I would have been much more 
receptive to getting help. As a veteran that used to be struggling with 
addiction and mental disorders I can honestly say that getting help was 
never really something I took seriously. But why would I take it 
seriously? I thought that I was able to get through anything on my own 
and I was pretty much indestructible. It didn't matter what was going 
wrong in my life because I could always find a way to blame it on 
someone else or to find an excuse that got me through from a day-to-day 
basis. I needed someone to tell me that it was not alright and if I 
didn't get help there was going to be some serious consequences for my 
actions. I was, at the time, a grown adult capable of making `grown up' 
decisions, but to be honest I was not very `in touch' with reality. A 
good example of this was my financial decisions during this time. The 
amount of money that I wasted is astronomical and yet the amount of 
debt I still racked up is even more unbelievable. I was often times 
using my compensation money to fuel my drinking and carousing, but when 
that ran out I started using credit cards. I mention this because it is 
just an example of the many reasons that I needed to get help, but I 
chose not to because I was able to afford not to.
    Another issue I believe needs to be addressed is rehab and 
counseling that is strictly with other veterans. I went through 
Minnesota Teen Challenge which is a 13-15 month rehabilitation program 
that is set up primarily for nonveterans. I was able to work on myself 
at Minnesota Teen Challenge and then once a week go to the Minneapolis 
VA Medical Center to work on my service-related problems. In my 
personal opinion that is a big reason for my success throughout the 
program as well as my continued success today. It was important for me 
to get my service-related issues dealt with, but for me to be able to 
go back to a program that didn't solely concentrate on these issues was 
crucial. It was much easier for me to blend in and not feel like I 
always had to talk about my service-related issues, instead I was able 
to take a much more in depth look at where a lot of my issues started.
    I would not be where I am now without the help from the Department 
of Veterans Affairs, but I could have gotten here a lot sooner. I have 
watched my friends and family who are veterans suffer through many 
invisible wounds, and there is no reason for it. I appreciate your time 
and the opportunity to share my testimony.

                                 
    Prepared Statement of Karen H. Seal, M.D., MPH, Staff Physician,
 Medical Service, San Francisco Department of Veterans Affairs Medical
  Center, Veterans Health Administration, U.S. Department of Veterans
     Affairs, and Associate Professor in Residence of Medicine and 
                              Psychiatry,
                University of California, San Francisco
                           Executive Summary
Mental Health Problems in OEF/OIF Veterans in VA Health Care

    PTSD rates in OEF/OIF Veterans in VA health care have increased 
steadily since the conflicts began, followed by increasing rates of 
depression. Younger active duty Veterans appear to be at particularly 
high risk for PTSD; older National Guard and Reserve Veterans are at 
higher risk for PTSD and depression. Rates of depression, anxiety, and 
eating disorders are higher in women than men; female Veterans who 
experienced military sexual trauma are at heightened risk for 
developing PTSD. Appreciating subgroup differences in the prevalence 
and types of mental health disorders can help guide more targeted 
interventions and treatments, as well as future research efforts.

Mental Health Services Utilization in OEF/OIF Veterans

    The majority (80 percent) of OEF/OIF Veterans that received new 
PTSD diagnoses attended at least one VA mental health follow-up visit 
in the first year of diagnosis. However, less than 10 percent with new 
PTSD diagnoses attended a minimum number of mental health sessions 
within a time frame required for evidence-based PTSD treatment. Being 
young (under age 25) and male, having received a mental health 
diagnosis from a non-mental health clinic (i.e., primary care), and 
living far from a VA facility (>25 miles) were associated with failing 
to receive adequate PTSD treatment. Because adequate evidence-based 
PTSD treatment may prevent chronic PTSD, VA must continue to develop 
interventions designed to improve retention in mental health treatment. 
In contrast, despite underutilization of mental health services, those 
with mental health disorders disproportionately used VA primary care 
medical services. Thus, models that integrate primary care and mental 
health services may improve engagement in mental health treatment, and, 
at the same time, address co-occurring physical complaints.

Barriers to VA Mental Health Care

    Patient barriers to mental health care among OEF/OIF Veterans 
include stigma, logistical barriers, and even the symptoms of the 
mental health disorders themselves. Avoidance in PTSD, apathy in 
depression, and denial and self-medication with drugs and alcohol may 
prevent Veterans from seeking care. In addition, VA has not always been 
able to keep pace with the demand for mental health services. System 
barriers include shortages of mental health personnel trained in 
evidence-based treatments and lack of universal access to telemental 
health care, particularly in rural VA facilities. While information 
technology security is important, excessive concerns may be impeding 
the development of more novel Internet and telephone-based mental 
health treatment options. Privacy concerns about the Department of 
Defense's access to Veterans' electronic medical records have 
discouraged some Veterans from coming forward and disclosing symptoms.

Improving Access to and Retention in Mental Health Treatment for OEF/
        OIF Veterans

    Capitalizing on the propensity for OEF/OIF Veterans with mental 
health problems to receive care in VA primary care settings, VA might 
consider further restructuring VA services such that more specialty 
mental health providers trained in evidence-based mental health 
treatments are embedded within primary care. In addition, new clinical 
resources available through Patient Aligned Care Teams (PACT) in VA 
primary care (i.e., Nurse Care Managers) could be leveraged to 
facilitate enhanced engagement of Veterans in mental health treatment. 
For instance, PACT nurses could act as motivational coaches or could 
help provide Veterans access to new technologies such as the VA 
Internet site, ``My HealtheVet'' or smart phone applications such as 
``PTSD Coach'' to enhance access to online mental health treatments or 
treatment adjuncts. There is also a need for more research to develop 
and test modified evidence-based treatments for PTSD and other mental 
health problems that are better suited to primary care settings.

Conclusions

    OEF/OIF Veterans have extremely high rates of accruing military 
service-related mental health problems. Despite this large burden of 
mental illness, many OEF/OIF Veterans do not access or receive an 
adequate course of mental health treatment. Veterans with mental health 
disorders disproportionately use VA primary care medical services. 
Recognizing the advances that VA has already made in VA Primary Care-
Mental Health Integration, and more recently, the Patient-Aligned Care 
Team (PACT) model, VA is poised to address many of the remaining system 
barriers to mental health care for OEF/OIF Veterans by incorporating 
more specialty mental health care within VA primary care to meet the 
growing needs of this current generation of men and women returning 
from war.

                               __________

    It has been nearly 10 years since the current conflicts began and 
over 2.1 million servicemembers have served in OEF and OIF. Of these, 
over 1.2 million have separated from active duty service and have 
become eligible for VA services. Many soldiers have endured multiple 
tours of duty and most have experienced combat. Making the transition 
from war zone to home has been challenging, especially for veterans who 
have sustained physical injuries, as well as for those who have 
developed mental health problems. Based on prior DoD, VA, and 
nationally representative samples of OEF/OIF Veterans, the prevalence 
of mental health disorders has steadily increased: between 19 percent 
and 42 percent of OEF/OIF veterans have been estimated to suffer from 
deployment-related mental health problems (Milliken et al., 2007; 
Tanielian & Jaycox, 2008). The most recent data released from the VA 
Environmental Epidemiology Service (January 18, 2011) indicate that 
331,514 (51 percent) of 654,348 VA-enrolled Veterans have received 
mental health diagnoses and 177,149 (27 percent) have received post-
traumatic stress (PTSD) diagnoses. These data confirm that the burden 
of mental health diagnoses has continued to increase since the 
conflicts began in 2001.
    The mental health prevalence estimates our research group provides 
are based on data our group has acquired from VA national 
administrative databases which contain mental health diagnostic codes 
associated with VA clinical visits. The use of diagnostic codes has 
been shown to be a valid proxy for estimating disease prevalence, but 
is subject to reporting biases and some misclassification errors. Our 
findings are based on the entire population of OEF/OIF veterans who 
sought VA health care nationwide and thus are not based on a nationally 
representative sample of OEF/OIF Veterans. Of note, our findings have 
been consistent with other published studies of nationally 
representative samples of OEF/OIF Veterans.
    In one of our earlier studies (Seal et. al, 2009), of 289,328 Iraq 
and Afghanistan Veterans who were first-time users of VA health care 
after separation from OEF and/or OIF military service, we found that 
new mental health diagnoses increased 6-fold from 6 percent in April 
2002 to 37 percent by March 31, 2008. Thus, by 2008 over 1 of every 3 
Veterans had received one or more mental health diagnoses. Moreover, 
with each additional year of follow-up, we observed the accrual of 
additional mental health diagnoses in individual Veterans. Similarly, 
Milliken and colleagues demonstrated increases in mental health 
problems among OEF/OIF soldiers who were screened again several months 
after returning home compared to rates immediately after returning 
(Miliken et al., 2007). There are several factors that contribute to 
delayed onset of mental health diagnoses. There may be stigma leading 
to reluctance to disclose mental health problems until those problems 
interfere with functioning (Hoge et al., 2004). Some military service-
related mental health problems only appear months to years after combat 
(Solomon et al., 2006) and somatization or co-morbidity often confound 
accurate mental health diagnosis (Kessler et al., 1995). The VA policy 
change that extended free VA military service-related health care to 5 
years from 2 years post-discharge has likely increased our ability to 
detect mental illness in OEF/OIF Veterans. Now our challenge is to 
engage Veterans with mental health problems in care.
    Several other key findings regarding the prevalence of mental 
health disorders have emerged from our recently published studies (Seal 
et al., 2009; Maguen et al., 2010; Seal et al., 2011):

          Among the 106,726 OEF/OIF Veterans with mental health 
        diagnoses, by study end (2008), two thirds had more than one 
        co-occurring mental health diagnosis: approximately one-third 
        had two mental health diagnoses and another third had 3 or more 
        different mental health diagnoses, increasing diagnostic 
        complexity and complicating treatment.
          Overall, from 2002 to 2008, the rate of PTSD had 
        increased from 0.2 percent to 22 percent (62,929); with a rapid 
        increase in PTSD in the first quarter of 2003 following the 
        invasion of Iraq. Greater combat exposure was associated with 
        higher risk for PTSD in active duty Veterans.
          Age and component type mattered: Active duty Veterans 
        less than age 25 years had 2 to 5 times higher rates of PTSD, 
        alcohol and drug use disorder diagnoses compared to active duty 
        Veterans over age 40. In contrast, among National Guard/Reserve 
        Veterans, risk for PTSD and depression were significantly 
        higher in Veterans over age 40 compared to their younger 
        counterparts less than age 25.
          Rates of depression diagnoses in OEF/OIF Veterans 
        paralleled increases in PTSD with 50,432 (17 percent) Veterans 
        diagnosed with depression by 2008. PTSD and depression were 
        highly comorbid with as many as 70 percent of Veterans 
        suffering from both conditions.
          Women OEF/OIF Veterans were at significantly higher 
        risk for depression than men; women Veterans were also at 
        significantly higher risk for anxiety disorders and eating 
        disorders than their male counterparts.
          Thirty-one percent of women with PTSD compared with 1 
        percent of men with PTSD screened positive for a history of 
        military sexual trauma (MST). Women Veterans with MST were over 
        four times more likely to develop PTSD than OEF/OIF female 
        Veterans without MST.
          Overall, over 11 percent of OEF/OIF Veterans received 
        substance use disorder diagnoses. Male Veterans had over twice 
        the risk for substance use disorders as female Veterans. Among 
        Veterans with substance use disorders, 55-75 percent had 
        comorbid PTSD or depression.

    In summary, PTSD rates in treatment-seeking Veterans in VA health 
care have increased steadily since the conflicts began, closely 
followed by increasing rates of depression diagnoses. Particular 
subgroups of OEF/OIF Veterans appear at higher risk for mental health 
diagnoses. Younger active duty Veterans appear to be at particularly 
high risk for PTSD likely due to higher combat exposure. Older National 
Guard and Reserve Veterans were at higher risk for PTSD and depression 
than younger National Guard/Reserve Veterans. Further investigation of 
the causes of mental health diagnoses in older Guard/Reserve Veterans 
is warranted because measures of greater combat exposure were not 
consistently associated with mental health diagnoses. One explanation 
is that when called to arms, older Guard/Reserve members are more 
established in civilian life and may be less well prepared for combat, 
making their transition to war zone and home again more stressful. 
Regarding the relatively low prevalence rates of drug use disorders in 
OEF/OIF Veterans in our sample, stigma, fear of negative repercussions, 
and lack of universal screening for illicit substances in VA may have 
reduced the number of drug use disorders reported and detected. 
Finally, there are pronounced gender differences in military service-
related mental health disorders: Rates of depression, anxiety and 
eating disorders were elevated in women compared to men; female 
Veterans who experienced MST were at extremely high risk for developing 
PTSD. Appreciating subgroup differences in the prevalences and types of 
mental health disorders can help guide more targeted interventions and 
treatments, as well as future research efforts.

Mental Health Services Utilization in OEF/OIF Veterans

Overview

    The Department of Veterans Affairs (VA) health care system is the 
single largest provider of health care for OEF/OIF Veterans with over 
50 percent of all returned combat Veterans enrolled. This is 
historically high for VA; only 10 percent of Vietnam Veterans enrolled 
in VA health care (Kulka et al., 1990). Since 2001, the VA had provided 
OEF/OIF Veterans 2 years of free military service-related health care 
from the time of service separation, a benefit which was extended to 5 
years in 2008 (``National Defense Authorization Act of 2008''). Most of 
the over 150 VA medical centers in the United States offer a complete 
spectrum of mental health services, including over 140 PTSD specialty 
clinics. For rural Veterans living far from a VA medical center, over 
900 VA community-based outpatient clinics offer basic health care and 
some offer basic mental health services. After the 5-year period of 
combat-related health coverage, OEF/OIF Veterans are eligible to 
continue to use VA health care services without charge (if service-
connected) or are assessed a nominal co-pay scaled to income. Of note, 
OEF/OIF Veterans who have health insurance through employment, school 
or otherwise, may seek non-VA health care services in their 
communities, and VA data systems do not capture non-VA health care 
utilization.
    Early, adequate evidence-based mental health treatment has been 
shown to prevent mental health disorders, such as PTSD, from becoming 
chronic (Bryant et al., 2003). Multiple studies of Veterans and 
civilians reveal however that a substantial proportion of those 
suffering from mental health problems either do not access, delay, or 
fail to complete an adequate course of specialty mental health 
treatment (Hoge et al., 2004; Tanielian & Jaycox, 2008; Wang et al., 
2005). Studies have shown that mental health disorders other than PTSD, 
such as depression and substance use disorders may be managed in 
primary care as opposed to specialty mental health (Batten & Pollack, 
2008). Some specific symptoms of PTSD, such as insomnia, may be managed 
by primary care clinicians in primary care. However, consistent with 
the Institute of Medicine's finding that only two mental health 
therapies have demonstrated efficacy for PTSD, Cognitive Processing 
Therapy and Prolonged Exposure Therapy, the VA recommends that Veterans 
with a PTSD diagnosis receive definitive treatment by mental health 
providers trained in these evidence-based therapies, which usually 
occurs in mental health clinics (Institute of Medicine's Committee on 
Treatment of Posttraumatic Stress Disorder, 2007). Evidence-based PTSD 
treatments typically require a minimum of 9 or more sessions, ideally 
spaced at weekly intervals (Foa et al., 2007; Monson et al., 2006).

Mental Health Services Utilization in OEF/OIF Veterans using VA health 
        care (2002-2008)

    Of nearly 50,000 OEF/OIF Veterans with newly diagnosed PTSD, 80 
percent compared to 49 percent of Veterans receiving mental health 
diagnoses other than PTSD had at least one VA mental health visit in 
the first year of diagnosis. Nevertheless, only 9.5 percent with new 
PTSD diagnoses attended 9 or more follow-up sessions in 15 weeks or 
less after receiving their diagnosis. When the follow-up period was 
extended to 1 year, a larger proportion, 27 percent, attended 9 or more 
mental health sessions. Among OEF/OIF Veterans receiving mental health 
diagnoses other than PTSD (e.g., depression), only 4 percent attended 9 
or more follow-up sessions in 15 weeks or less and slightly more, 9 
percent, attended 9 or more sessions when the follow-up period was 
extended to 1 year. Our study was limited in that we lacked information 
about non-VA mental health treatment utilization and the specific type 
of mental health treatment received. Thus, we can draw no firm 
conclusions about the adequacy and intensity of mental health care for 
OEF/OIF Veterans since we lack data on care received outside the VA 
system. Nevertheless, VA is currently the single largest provider of 
health care for OEF/OIF Veterans and, of those with new PTSD diagnoses, 
in the first year of diagnosis, under 10 percent appear to have 
received what would approximate evidence-based mental health treatment 
for PTSD at a VA facility, and those with other mental health diagnoses 
received an even lower intensity of VA care.
    Our study revealed that factors such as being young (under age 25) 
and male, factors linked to a greater likelihood of receiving a PTSD 
diagnosis, were also associated with a failure to receive minimally 
adequate PTSD treatment. These findings may reflect the symptoms of 
PTSD itself, including avoidance, denial and comorbid disorders such as 
depression and substance abuse. In young male Veterans, stigma likely 
also plays a major role (Hoge et al., 2004). In addition, we found that 
having received a mental health diagnosis from a non-mental health 
clinic (i.e., primary care) and living far from a VA facility (>25 
miles) were associated with failing to receive adequate PTSD treatment. 
Veterans who receive PTSD diagnoses from VA primary care may be less 
symptomatic than those receiving diagnoses from mental health clinics 
and less in need of specialty mental health treatment or prefer primary 
care-based treatments. Indeed, many mental health problems of OEF/OIF 
Veterans other than PTSD, such as depression, may be effectively 
managed in primary care. In fact, we found that among OEF/OIF Veterans 
receiving mental health diagnoses other than PTSD, more than 85 percent 
had attended at least one primary care visit in the year following 
diagnosis, the majority of which were coded to indicate that a mental 
health concern had been discussed. It is also possible that Veterans 
who receive PTSD diagnoses from non-mental health clinics or who live 
far from VA services fall through the cracks in the referral for 
specialty mental health care. In sum, our research findings support 
ongoing implementation efforts by VA leadership to promote expanded 
access and adherence to specialty mental health care, especially for 
rural Veterans (Zeiss & Karlin, 2008).
    Our results suggest that OEF/OIF Veterans may, in fact, be more 
likely than Vietnam-era Veterans to have had at least one initial VA 
mental health follow-up visit after receiving a new mental health 
diagnosis. In the National Vietnam Veterans Readjustment Study (NVVRS), 
a nationally representative sample of Vietnam-era Veterans, a much 
lower proportion of Vietnam Veterans (30 percent) reported having 
sought any mental health treatment and only 7.5 percent used VA mental 
health services (Kulka et al., 1990). A more recent study demonstrated 
that after adjustments for potential confounding, variables such as age 
and the complexity of mental health disorders were more important 
predictors of whether Veterans received mental health treatment, as 
opposed to which era they served (Harpaz-Rotem & Rosenheck, 2011).
    It stands to reason that OEF/OIF Veterans would be more likely than 
prior-era veterans to have had at least an initial mental health visit. 
In comparison to Vietnam-era Veterans, a higher proportion of OEF/OIF 
Veterans has experienced ``front-line'' combat exposure and has 
survived their injuries (Gawande, 2004), which has been associated with 
the development of mental health disorders and increased need for 
mental health services (Hoge et al., 2007). Unlike in prior eras, 
Congress extended health coverage for OEF/OIF veterans to 55 years 
after service separation. Many newly returned OEF/OIF veterans facing 
economic hardship have taken advantage of blanket VA health care 
coverage and have used VA services. Also, different from prior eras, 
the Department of Defense, in an effort to reduce stigma, now openly 
discusses combat-related stress with active duty servicemembers. 
Similarly, widespread media attention focused on mental health 
disorders in Iraq and Afghanistan Veterans has lowered the threshold 
for recently returned Veterans to seek care. Finally, both the VA and 
the military have implemented population-based post-deployment mental 
health screening programs and routinely refer Veterans who screen 
positive for further mental health assessment and/or treatment (Hoge et 
al., 2006; Seal et al., 2008), all factors which support initial VA 
mental health services utilization.
    Nevertheless, despite initial use of VA mental health services 
among OEF/OIF Veterans, retention in VA mental health services appears 
less robust. The strongest predictor of retention in VA mental health 
treatment services in our study, as in others, was ``need'' for mental 
health treatment (Spoont et al., 2010). Veterans receiving PTSD 
diagnoses (as opposed to other mental health diagnoses) and those 
receiving additional comorbid mental health diagnoses in conjunction 
with PTSD were more likely to remain in care and receive minimally 
adequate PTSD treatment. Unfortunately, compared to studies of 
civilians however, retention in VA mental health treatment appears 
inferior. For instance, the National Comorbidity Survey Replication 
Study, a population-based survey of 9,282 U.S. civilian adults, found 
that 48 percent of patients with any mental disorder (including PTSD) 
reported having received at least ``minimally adequate therapy,'' 
defined by evidence-based national mental health treatment guidelines, 
within the first year of diagnosis (Wang et al., 2005). In contrast, 
similar to our findings, a RAND Corporation study reported that a much 
lower proportion, 25 percent of a nationally representative sample of 
OEF/OIF Veterans with PTSD and depression, received ``minimally 
adequate therapy'' within the first year of diagnosis (Tanielian & 
Jaycox, 2008).
    In summary, we found that the majority of OEF/OIF Veterans that 
received new mental health diagnoses, including PTSD, attended at least 
one mental health follow-up visit in the year after mental health 
diagnosis. However, the vast majority of OEF/OIF Veterans with new PTSD 
diagnoses failed to attend a minimum number of mental health sessions 
within a recommended time frame required for evidence-based PTSD 
treatment. Because early, evidence-based PTSD treatment may prevent 
chronic PTSD, it will be important that the VA, in its mission to 
provide the best care for returning combat Veterans, continue to 
develop and implement interventions to improve retention in mental 
health treatment, with particular attention to the needs of more 
vulnerable OEF/OIF Veterans.

Utilization of VA Primary Care in OEF/OIF Veterans with Mental Health 
        Problems

    Despite underutilization of mental health services, those with 
mental health disorders disproportionately use VA primary care medical 
services compared to OEF/OIF Veterans without mental health problems. 
Frayne et al. examined non-mental health medical care among 90,558 
Veterans from 2005 through 2006 and found that those with a diagnosis 
of PTSD had more medical diagnoses and greater primary care service 
utilization than those without a mental health diagnosis (Frayne et 
al., 2010). Another article published by Cohen et al. in our group, 
found an increased prevalence of cardiovascular risk factors (i.e. 
hypertension, high cholesterol, smoking, and obesity) in OEF/OIF 
Veterans with PTSD compared to Veterans with mental health conditions 
other than PTSD, or no mental health conditions (Cohen et al., 2010). 
In a related study, Cohen et al. reported that Veterans with PTSD 
consumed almost twice as much primary medical care as those without a 
mental health diagnosis (Cohen et al., 2010). There are several 
possible explanations for these findings: The traumatic events that 
caused PTSD might have also caused physical injury requiring medical 
attention; somatic symptoms and stigma associated with PTSD may have 
motivated Veterans to seek VA primary care; PTSD may be associated with 
high-risk behaviors (e.g. alcohol abuse) leading to physical health 
problems, and finally, increased contact with the medical system 
through PTSD treatment, may have led to increased detection of other 
physical problems. To the extent that we fail to retain Veterans in an 
adequate course of mental health treatment, we may continue to grapple 
with pervasive and chronic comorbid physical and behavioral problems in 
VA primary care clinics. Because most individuals with PTSD, including 
OEF/OIF Veterans, pursue medical treatment in primary care, models that 
integrate primary care and mental health treatment may improve both 
engagement and retention of patients in mental health care, while 
simultaneously addressing co-occurring physical complaints.

Barriers to VA Mental Health Care

Patient Barriers

    There have been numerous reports of barriers to mental health care 
for OEF/OIF Veterans. Our data and the work of others indicate that 
while there are indeed barriers to access and initiation of mental 
health treatment, longer-term retention in mental health treatment is 
far more problematic (Seal et al., 2010; Seal et al., 2011, in press; 
Spoont et al., 2011; Harpaz-Rotem & Rosenheck, 2011). Barriers to 
engagement in mental health treatment have generally been categorized 
into patient-related barriers and system barriers. Patient barriers 
have been well-described and include: (1) Stigma regarding mental 
illness-concerns about being perceived as weak by family, friends, 
colleagues, or within one's culture for coming forward with mental 
health problems, (2) ``Battlemind''--not recognizing or believing that 
behaviors such as hypervigilance that were adaptive in the war zone are 
now maladaptive in civilian life, and thus not seeking or accepting 
mental health treatment, (3) Beliefs and attitudes that mental health 
treatment, including psychoactive medication, is not effective or even 
dangerous, (4) Logistical barriers such as job, school, family 
obligations, geographical distance, and lack of transportation, (5) 
Symptoms of mental health disorders themselves, such as avoidance in 
PTSD, apathy in depression, and denial in drug and alcohol abuse, and 
(6) Self-medication with drugs and alcohol that may temporarily mask 
symptoms.

VA System Barriers

    The Institute of Medicine (IOM) identified six aims for improvement 
of the quality of mental health care. These included safety, 
effectiveness, patient-centeredness, timeliness, efficiency, and equity 
(Institute of Medicine, 2006). Consistent with these aims, the VA has 
made numerous strides toward improving the delivery of mental health 
treatment for OEF/OIF Veterans by greatly increasing mental health 
capacity and services. For instance, in order to improve identification 
and treatment of Veterans with mental health disorders, since 2004, the 
VA has conducted universal post-deployment mental health screening of 
OEF/OIF Veterans who receive care at VA facilities (Seal et al., 2008) 
In addition, in 2007, the VA initiated an expansion of mental health 
services capacity, which included an increase in the number of mental 
health staff assigned to more rural VA clinics, an increase in the use 
of video-teleconferencing services (``telemental health'') to increase 
access to specialty mental health care for rural Veterans, and the 
implementation of the Primary Care Mental Health Integration initiative 
to co-locate mental health providers in primary care settings (Zeiss & 
Karlin, 2008). Indeed, the new VA primary care Patient Aligned Care 
Team (PACT) model is consistent with IOM principals to improve the 
quality of mental health care by identifying a mental health provider 
that is associated with each of the primary care PACT teams to provide 
timely and efficient mental health care to Veterans within primary 
care.
    Nevertheless, with ever-increasing numbers of OEF/OIF Veterans 
presenting with mental health problems, VA has not always been able to 
keep pace with the demand for services, particularly in more rural VA 
facilities. From my perspective, there are several VA system barriers 
which are remediable and require our attention:

          There are shortages of mental health staff 
        (psychologists and social workers) who are trained in evidence-
        based therapies for PTSD, particularly in more rural VA 
        community-based outpatient clinics.
          There is a lack of universal access to telemental 
        health services for Veterans receiving care at more rural VA 
        community-based outpatient clinics to provide access to 
        specialty mental health clinicians based at VA medical centers.
          Information technology (IT) security is important, 
        yet excessive concerns about IT security may be slowing the 
        development and use of more novel Internet and telephone-based 
        mental health treatment options that may appeal to younger 
        Veterans.
          Veterans continue to complain about difficulties 
        navigating the VA system to schedule appointments, long wait 
        times for appointments, and shortages of drop-in appointments, 
        which limit access to care.
          Limited mental health treatment resources for 
        families and children of Veterans, as well as the lack of 
        childcare limits mental health treatment options for Veterans 
        and their families; particularly affecting Women Veterans.
          In an effort to enhance information exchange between 
        the Department of Defense (DoD) and the VA, there is concern 
        that Veterans' confidential electronic medical records will be 
        viewed by DoD, causing some Veterans to be reticent about 
        disclosing sensitive mental health concerns such as substance 
        abuse issues, interpersonal violence, and sexual identity 
        issues, which limits their ability to receive treatment for 
        these problems at VA.

Enhancing Access to and Retention in Mental Health Treatment for OEF/
        OIF Veterans

    Capitalizing on the propensity for OEF/OIF Veterans to receive care 
in VA primary care settings, one strategy to further enhance engagement 
in mental health services is to further co-locate and integrate 
specialty mental health services, such as evidence-based PTSD 
treatment, within primary care. Despite the VA Primary Care Mental 
Health Integration initiative, even in model programs, these embedded 
mental health providers (many of whom are social workers) typically 
provide further assessment of positive mental health screens, specialty 
mental health referrals, medication management, and brief supportive 
therapies, but rarely provide evidence-based mental health treatments 
(Possemato et al., 2011). Use of specialty mental health services has 
been associated with greater retention in mental health treatment, and 
in turn, improved clinical outcomes (Wang et al., 2005). There are 
several ways to provide greater access to specialty mental health 
treatment through primary care. Below are a few possible suggestions:

          Restructure VA services such that specialty mental 
        health providers trained in evidence-based mental health 
        treatments are co-located and fully integrated within primary 
        care. This requires a new holistic paradigm for VA primary care 
        that views mental health care as part of primary care. This may 
        even involve infrastructure changes to existing medical clinics 
        to accommodate the co-location of more mental health providers 
        in primary care. These structural changes could literally 
        ``break down walls'' that exist between medical and mental 
        health services, overcome stigma, and narrow the gap between 
        primary care and mental health. For instance, pre-scheduling 
        mental health visits to occur at the same time as primary care 
        visits, as we do in our one-stop Integrated Care Clinic at the 
        San Francisco VA Medical Center, will make it more likely that 
        patients will attend and be retained in mental health.
          Leverage new clinical resources available through 
        Patient Aligned Care Teams (PACT) in VA primary care. Nurse 
        Care Managers in primary care PACT teams are currently being 
        trained nationwide through the VA National Center for 
        Prevention to conduct motivational coaching through a new VA 
        program called ``TEACH'' (Tuning in, Evaluation, Assessment, 
        Communication and Honoring the patient). Primary care PACT 
        nurses could conceivably conduct brief telephone motivational 
        coaching sessions to remind and motivate Veterans to attend 
        their mental health appointments. As an alternative to the 
        telephone, nurses could use the new VA Internet application, 
        ``My HealtheVet'' to securely e-mail Veterans about upcoming 
        mental health visits, a communication modality that 
        particularly appeals to younger Veterans. In addition, 
        consistent with the evidence-based collaborative care model for 
        depression treatment, nurses could feed back relevant clinical 
        information from patients to mental health and primary care 
        providers to promote more efficient, coordinated, and effective 
        care.
          Exploit new technologies to deliver mental health 
        treatment through VA primary care in rural settings where there 
        are limited or no specialty mental health services. For 
        instance, PACT nurses could coordinate telemental health visits 
        at VA community-based outpatient clinics with specialty mental 
        health providers based at VA medical centers. For patients who 
        need care, but are unable to travel to any VA facility, VA 
        might give serious consideration to newer technologies that 
        bring mental health care into patients' homes. Examples include 
        the delivery of evidence-based mental health treatments over 
        the telephone or through ``Skype,'' the use of smart phone 
        applications such as ``PTSD Coach'' as an adjunct to mental 
        health treatment, and the use of the Internet to deliver mental 
        health treatments through VA sites such as ``My HealtheVet'' or 
        other state-of-the-art DoD-sponsored Web sites such as 
        www.afterdeployment.org, which provides online evidence-based 
        mental health treatment. These Internet-based treatments could 
        be facilitated by VA therapists who could conduct regular 
        telephone check-ins with patients. These innovations will 
        require re-visiting some of VA's current IT security policies.
          Support further research to develop and test the 
        implementation of modified evidence-based treatments for PTSD 
        and other mental health problems in primary care. There is a 
        need to develop and test PTSD treatments that are briefer and 
        better suited for primary care. In addition, there is a need to 
        develop and test integrated treatments for PTSD that 
        simultaneously address substance abuse or other behavioral 
        (e.g. smoking) or physical health problems (e,g, chronic pain) 
        in the context of PTSD treatment, since PTSD is highly comorbid 
        with other mental and physical health problems. In this vein, 
        the incorporation of complementary and alternative modalities 
        in the treatment of PTSD, such as exercise, yoga, and 
        acupuncture can be used to help motivate engagement in mental 
        health treatment and may help to improve symptoms and overall 
        physical and emotional well-being of Veterans suffering with 
        mental illness.

Conclusion

    In summary, OEF/OIF Veterans have extremely high rates of accruing 
military service-related mental health problems. Despite this large 
burden of mental illness, because of patient and system barriers to VA 
mental health care, many OEF/OIF Veterans do not access or receive an 
adequate course of mental health treatment. In contrast, despite 
underutilization of mental health services, combat Veterans with mental 
health disorders disproportionately use VA primary care medical 
services. Recognizing the advances that VA has already made in VA 
Primary Care-Mental Health Integration, and more recently, the Patient-
Aligned Care Team (PACT) model, VA is poised to address many of the 
remaining system barriers to mental health care for OEF/OIF Veterans by 
incorporating more specialty mental health care within VA primary care. 
VA has been a pioneer in our national health care system, learning and 
growing through vast clinical experience and the enterprise of VA 
health services research. Given the current epidemic of mental health 
problems in OEF/OIF Veterans, coupled with budgetary constraints, we 
will again need to challenge ourselves to ``think outside of the box'' 
to develop and implement new systems of care, new technologies, and new 
services to meet the needs of this current generation of men and women 
who have served our Country.

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of mental health problems among active and reserve component soldiers 
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Y., & Stevens, S. (2006). Cognitive processing therapy for veterans 
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Schohn M, Labbe A, Strutynski K. Treatment of Department of Veterans 
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Psychol Services. 2011 Vol 8(2):82-93.
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Veterans Administration postdeployment mental health screening of 
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CR. Trends and risk factors for mental health diagnoses among Iraq and 
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2002-2008. Am J Public Health. Sep 2009;99(9):1651-1658.
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Reducing Barriers to Mental Health and Social Services for Iraq and 
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longitudinal study. Am J Psychiatry 2006;163(4):659-66.
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veterans after a PTSD diagnosis in PTSD, mental health, or general 
medical clinics. Psychiatr Serv. 2010 Jan;61(1):58-63
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Psychological and cognitive injuries, their consequences, and services 
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Kessler, R. (2005). Failure and delay in initial treatment contact 
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73-78.

                                 
      Prepared Statement of Lieutenant General James Terry Scott,
  USA (Ret.), Chairman, Advisory Committee on Disability Compensation
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee: It is my pleasure to appear before you today representing 
the Advisory Committee on Disability Compensation. The Committee is 
chartered by the Secretary of Veterans Affairs under the provisions of 
38 U.S.C. in compliance with P.L. 110-389 to advise the Secretary with 
respect to the maintenance and periodic readjustment of the VA Schedule 
for Rating Disabilities. Our charter is to ``(A)ssemble and review 
relevant information relating to the needs of veterans with 
disabilities; provide information relating to the character of 
disabilities arising from service in the Armed Forces; provide an 
ongoing assessment of the effectiveness of the VA's Schedule for Rating 
Disabilities; an provide on going advice on the most appropriate means 
of responding to the needs of veterans relating to disability 
compensation in the future''.
    The Committee has met twenty nine times and has forwarded two 
reports to the Secretary that addressed our efforts as of September 30, 
2010 and fulfilled the statutory requirement to submit a report by 
October 31, 2010. (Copies of these reports were furnished to majority 
and minority staff in both Houses of Congress.) The Secretary of 
Veterans Affairs responded to the interim report on February 23, 2010. 
(Copies provided for the Record).
    Our focus has been in three areas of disability compensation: 
Requirements and methodology for reviewing and updating the VASRD; 
adequacy and sequencing of transition compensation and procedures for 
servicemembers transitioning to veteran status with special emphasis on 
seriously ill or wounded servicemembers; and disability compensation 
for non-economic loss (often referred to as quality of life).
    After coordination with the Secretary's office and senior VA staff, 
we have added review of individual unemployment and the review of the 
methodology for determining presumptions to our agenda. Recently, we 
were asked to review the appeals process as it pertains to the timely 
and accurate award of disability compensation.
    Your letter of invitation asked me to ``(P)resent the views of the 
Department on the serious questions that have been raised about the VA 
mental health care system and the Department's ability to provide 
timely, effective and accessible care and benefits to veterans 
struggling with mental illness''. I believe that the representatives of 
the Department are more current and better qualified to present the 
view of the Department. I am offering my views based on the analysis, 
findings, and recommendations of the Veterans Disability Benefits 
Commission (VDBC) that I had the privilege of chairing from 2004-2007.
    Discussions with the Committee staff included a request that I 
review the pertinent findings and recommendations of the Veterans 
Disability Benefits Commission (VDBC) that met from 2004-2007 and made 
113 recommendations covering a wide range of Veterans disability 
issues. Specifically, I was asked to discuss the VDBC work on the topic 
of integration among compensation, treatment, vocational assessment and 
training, and follow up examination for Veterans suffering from mental 
disability, to include PTSD.
    It is important to acknowledge the significant progress that VA has 
made in adopting and implementing many of the VDBC recommendations and 
many of the recommendations of the Advisory Committee.
    A master plan for reviewing and updating the entire VASRD body 
system by body system is published. A dedicated staff is working on 
this important project and making significant progress. A draft of the 
revised mental health body system is prepared and under review. 
Significant progress is underway on four other body systems with 
initial conferences set for October 2011 to begin review of three more 
body systems.
    Disability Benefits Questionnaires are being developed and tested 
that simplify the process of evaluating conditions.
    Additional adjudicators are being hired and trained.
    VA and DoD have established working groups at all levels of the 
organizations to ensure improved transition from soldier to veteran.
    Pertinent to today's hearing, the VDBC invested significant time 
and effort analyzing the then current methods of diagnosing, 
evaluating, and adjudicating the claims of veterans suffering from 
mental illness including PTSD. Principal source documents used in the 
analysis were a 2005 report by the VA Office of the Inspector General 
that summarized the trends in PTSD claims and compensation from FY 
1999-2004 and an Institute of Medicine study competed in 2006 titled 
``Posttraumatic Stress Disorder: Diagnosis and Assessment''. These 
studies and the testimony of veterans, family members, medical 
professionals, and VA subject experts provided the basis for the six 
recommendations the VDBC offered. They are;

    Recommendation 5.28

    VA should develop and implement new criteria specific to post-
traumatic stress disorder in the VA Schedule for Rating Disabilities. 
Base those criteria on the Diagnostic and Statistical Manual of Mental 
Disorders and consider a multidimensional framework for characterizing 
disability caused by post-traumatic stress disorder. (This 
recommendation is addressed by the revision of the pertinent VASRD 
section).

    Recommendation 5.29

    VA should consider a baseline level of benefits described by the 
Institute of Medicine to include health care as an incentive for 
recovery for post-traumatic stress disorder as it relapses and remits. 
(This recommendation is yet to be addressed and will likely be 
addressed as part of the comprehensive approach described in 
Recommendation 5.30)

    Recommendation 5.30

    VA should establish a holistic approach that couples post-traumatic 
stress disorder treatment, compensation, and vocational assessment. 
Reevaluation should occur every 2-3 years to gauge treatment 
effectiveness and encourage wellness. (This recommendation is the 
central issue in recasting VA approach to all mental illness including 
PTSD)

    Recommendation 5.31

    The post-traumatic stress disorder examination process: 
Psychological testing should be conducted at the discretion of the 
examining clinician. VA should identify and implement an appropriate 
replacement for the Global Assessment of Functioning. Post-traumatic 
stress disorder data collection and research:
    VA should conduct more detailed research on military sexual assault 
and post-traumatic stress disorder and develop and disseminate 
reference materials for raters.

    Recommendation 5.32

    A national standardized training program should be developed for VA 
and VA-contracted clinicians who conduct compensation and pension 
psychiatric evaluations. This training program should emphasize 
diagnostic criteria for post-traumatic stress disorder and comorbid 
conditions with overlapping symptoms, as set for the Diagnostic and 
Statistical Manual of Mental Disorders. (Implementing this 
recommendation will address the reported inconsistencies in diagnosis 
and evaluation of veterans claiming mental illness).

    Recommendation 5.33

    VA should establish a certification program for raters who deal 
with claims for post-traumatic stress disorder (PTSD), as well as 
provide training to support the certification program and periodic 
recertification. PTSD certification requirements should be regularly 
reviewed and updated to include medical advances and to reflect lessons 
learned. The program should provide specialized training on the 
psychological and medical issues (including comorbidities) that 
characterize the claimant population, and give guidance on how to 
appropriately manage commonly encountered rating problems. 
(Implementing this recommendation will also help address the reported 
inconsistencies in diagnosis and evaluation of veteran claiming mental 
illness. Consolidating the adjudicating of mental illness claims in a 
few centers of excellence may also assist in the timely, accurate and 
consistent award of mental disabilities).
    The key recommendation of the VDBC regarding significant change to 
the VA approach to diagnosing, evaluating, adjudicating and treating 
mental disability is to create a linkage among compensation, treatment, 
vocational assessment/rehabilitation, and follow up examinations to 
determine efficacy of treatment. The benefits of linking treatment, 
compensation, vocational assessment, and periodic reevaluation include 
the potential to reduce homelessness and suicide as well as evaluate 
the effectiveness of treatment programs. Most importantly, it greatly 
improves the opportunity for a veteran suffering from mental disability 
to maximize his/her future contributions to society.
    This is a controversial recommendation in the sense that it 
dramatically changes the role of the Department in evaluating and 
treating mental disability. The principal arguments against the linkage 
are that it will be viewed by some stakeholders as a mechanism to 
reduce disability payments and that it differs from how the Department 
addresses physical disabilities. Both of these arguments can be 
addressed with carefully written and explained regulation and/or policy 
directives. Recommendation 5.29 offers an approach to compensation that 
recognizes the relapsing and remitting nature of mental illness. 
Regarding the differences in approach to physical versus mental 
disabilities, there is significant evidence that individuals with 
mental disabilities are less likely to seek and maintain a treatment 
regimen than those with physical disabilities.
    The VDBC recommendation to link compensation, treatment, vocational 
assessment/training, and periodic reevaluations offers an opportunity 
to reduce homelessness, suicide and substance abuse among veterans 
suffering from mental disabilities, particularly PTSD. Such an approach 
should offer long term help for mentally disabled veterans and improve 
their chances for maximum integration into society.
    Thank you for the opportunity to present this recommendation to you 
and for your consideration and attention.

                                 
                Prepared Statement of Sally Satel, M.D.,
            Resident Scholar, American Enterprise Institute
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee, thank you for the invitation to appear before the Committee. 
My name is Sally Satel. I am a psychiatrist who formerly worked with 
disabled Vietnam veterans at the West Haven VA Medical Center in 
Connecticut from 1988-1993. Currently, I am a resident scholar at the 
American Enterprise Institute (and work, part-time, at a local 
methadone clinic). I have been interested in applying the lessons we 
learned in treating Vietnam veterans to the new generation of service 
personnel returning from Iraq and Afghanistan.
    At issue is the relationship between mental health treatment and 
compensation benefits. I have been asked to discuss the implications of 
granting disability status and benefits to veterans with psychiatric 
diagnoses before they have been treated for their mental health 
problems.

The Problem: Disabled yet Untreated

    Much has been said about the different goals of two agencies within 
the Department of Veterans' Affairs: The Veterans' Health 
Administration, which provides treatment for veterans, and the 
Veterans' Benefits Administration, which adjudicates disability claims. 
In theory (and reality) veterans can apply for and receive disability 
entitlements for a psychiatric condition for which they never receive 
treatment. Yet treatment and rehabilitation could reasonably resolve or 
improve the suffering that prompted the veteran to seek compensation in 
the first place.
    How many veterans fall through the gap between care and 
compensation is a question that the Committee is investigating. The 
scope is important, but there is little question that the problem 
exists.
    At best, the missions of the two agencies can be integrated to 
enhance the welfare of veterans. Yet as policymakers consider the 
optimal administrative arrangement, it will be important to bear in 
mind the potential for inadvertent consequences--namely, that 
prematurely granting disability compensation may, in some cases, derail 
rather than speed veterans on their path to recovery.

Goals of Disability Benefits

    Before considering the interaction between treatment and 
compensation--how they work in concert for the benefit of the veteran 
or at cross purposes to his or her detriment--a brief overview of 
disability compensation is in order.
    According to the 2007 VA Benefits Commission the goal of disability 
benefits ``should be rehabilitation and reintegration into civilian 
life to the maximum extent possible'' and ``should be provided [to] 
compensate for the consequences of service-connected disability on 
earnings capacity, the ability to engage in usual life activities, and 
quality of life.'' \1\
---------------------------------------------------------------------------
    \1\ Veterans' Disability Benefits Commission. Honoring the Call to 
Duty: Veterans' Disability Benefits in the 21st Century, Oct. 2007 p. 
3.
---------------------------------------------------------------------------
    At this time, the DVA is formulating a rating schedule for mental 
disorders. According to the Office of Mental Health Services, 
Department of Veterans, the new version will ``shift the emphasis from 
disabling symptoms to a functional impairment model that focuses on 
work and income.'' \2\
---------------------------------------------------------------------------
    \2\ Testimony of A. Zeiss, Dept. Veterans' Affairs, June 14, 2011 
(Bridging the Gap Between Care and Compensation for Veterans, House 
Veterans' Affairs Committee).
---------------------------------------------------------------------------
    According to the current rating system, an individual with a 
service-connected rating of 100 percent is unemployable and highly 
symptomatic; a 50 percent rating corresponds to ``occupational and 
social impairment with reduced reliability and productivity due to such 
symptoms [of PTSD, depression, anxiety]; difficulty in establishing and 
maintaining effective work and social relationships.'' A 30 percent 
rating reflects ``occupational and social impairment with occasional 
decrease in work efficiency and intermittent periods of inability to 
perform occupational tasks.''
    Thus, both the current and future metrics emphasize diminished 
function as a core feature of what it means to be disabled. This, in 
turn, underscores the value of compensation as a mechanism for enabling 
and enhancing patient social function--and a key facet of function is 
work, as I will discuss.

Benefits and Treatment Integration

    The standard rating assessment by VBA benefit examiners relies upon 
clinical ``comp and pension'' (C and P) exams conducted by VHA 
psychiatrists and psychologists. These clinician-examiners, acting 
strictly in an evaluative rather than a therapeutic role, base their 
conclusions about diagnosis, functional impairment, and relationship of 
impairment to military service, upon existing military, medical, 
psychiatric records. They also meet with applicants for face to face 
interviews. Typically, treatment is not discussed; it is simply not 
part of the C and P encounter.
    To remedy this situation, veterans who have received a C and P 
evaluation for mental health disability, whether or not they go on to 
receive a compensation award, should receive care for that problem. 
Failure to direct the veteran to care is akin to diagnosing someone 
with a broken leg and then not setting it. Given that C and P 
examinations are a common point of contact with the VA for veterans, 
they afford optimal opportunities (or more strongly, the imperative) 
for the clinician-evaluators to encourage veterans to obtain care.\3\
---------------------------------------------------------------------------
    \3\ Rosen MI, Compensation examinations for PTSD--An opportunity 
for treatment? J Res Rehab Devel (2010) vol 47, no. 5: xv-xxii at 
www.rehab.research.va.gov/jour/10/475/pdf/rosen.pdf.

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Benefits and Treatment at Cross Purposes

    The importance of linking treatment with benefits is a point of 
general consensus among those who have reviewed the topic of mental 
health and compensation (e.g., VA Benefits Commission, Institute of 
Medicine.) There is less agreement, however, surrounding the thorny 
questions raised by the process of disability assessment itself.
    First, how competently can comp and pension examiners assess a 
veteran's functional impairment and potential for recovery if he or she 
has not yet undergone a course of treatment and rehabilitation? This is 
a complicated matter. After all, gauging mental injury in the wake of 
war is not as straightforward as assessing, say, a lost limb or other 
physical wound. At what point, for example, do normal, if painful, 
readjustment difficulties become so troubling as to qualify as a mental 
illness? How can clinicians predict which patients will recover when 
the odds of success depend so greatly on nonmedical factors, including 
the veteran's own expectations for recovery; availability of social 
support; and the intimate meaning the patient makes of his or her 
distress, wartime hardships and sacrifice?
    Second, at what point after a soldier is discharged from the 
military should the VA try to determine his or her potential for 
recovery and employability. what is the optimal timing of treatment 
relative to claims-filing?
    Paradox of Compensation: Granting disability benefits prematurely--
especially at the level of unemployability (e.g., 100 percent, 
Individual Unemployability)--may not always in the best interest of the 
veteran and the veteran's family. Consider the example below, based on 
an actual case.
    A young soldier, let's call him Joe, was wounded in Afghanistan. 
His physical injuries heal, but his mind remains tormented. Sudden 
noises make him jump out of his skin. He is flooded with memories of a 
bloody firefight, tormented by nightmares, can barely concentrate, and 
feels emotionally detached from everything and everybody. At 23 years 
old, the soldier is about to be discharged from the military. Fearing 
he'll never be able to hold a job or fully function in society he 
applies for ``total'' disability (the maximum designation, which 
provides roughly $2,300 per month) compensation for PTSD from the DVA. 
This soldier has resigned himself to a life of chronic mental illness. 
On its face, this seems only logical, and granting the benefits seems 
humane. But in reality it is probably the last thing the young soldier-
turning-veteran needs--because compensation will confirm his fears that 
he is indeed beyond recovery.
    While a sad verdict for anyone, it is especially tragic for someone 
only in his twenties. Injured soldiers can apply for and receive VA 
disability benefits even before they have been discharged from the 
military--and, remarkably, before they have even been given the 
psychiatric treatment that could help them considerably. Imagine 
telling someone with a spinal injury that he'll never walk again--
before he has had surgery and physical therapy. A rush to judgment 
about the prognosis of psychic injuries carries serious long-term 
consequences insofar as a veteran who is unwittingly encouraged to see 
himself as beyond repair risks fulfilling that prophecy. ``Why should I 
bother with treatment?'' he might think. A terrible mistake, of course, 
as the period after separation from the service is when mental wounds 
are fresh and thus most responsive to therapeutic intervention, 
including medication.
    Told he is disabled, the veteran and his family may assume--often 
incorrectly--that he is no longer able to work. At home on disability, 
he risks adopting a ``sick role'' that ends up depriving him of the 
estimable therapeutic value of work. Lost are the sense of purpose work 
gives (or at least the distraction from depressive rumination it 
provides), the daily structure it affords, and the opportunity for 
socializing and cultivating friendships. The longer he is unemployed, 
the more his confidence in his ability and motivation to work erodes 
and his skills atrophy.
    Once a patient is caught in such a downward spiral of invalidism, 
it can be hard to throttle back out. What's more, compensation 
contingent upon being sick often creates a perverse incentive to remain 
sick. For example, even if a veteran wants very much to work, he 
understandably fears losing the financial safety net if he leaves the 
disability rolls to take a job that ends up proving too much for him. 
This is how full disability status can undermine the possibility of 
recovery.
    Without question, some veterans will remain so irretrievably 
damaged by their war experience that they cannot participate in the 
competitive workplace. But the system, well-intentioned though it 
surely is, must, at the same time, adequately protect young veterans 
from a premature verdict of invalidism.
    Implications for timing: To the extent that granting disability may 
inadvertently undermine reintegration, a treatment first approach is 
logical. This sequence would begin with treatment, moves to 
rehabilitation, and then--if necessary--goes on to assessment for 
disability status.
    The transition between military and civilian life is a critical 
juncture marked by acute feelings of flux and dislocation. Young men 
and women who are suffering from military-related mental illness will 
benefit most when they pursue treatment with the goal of recovery 
before labeling themselves beyond hope of improvement--and thus a 
candidate for high level or full service-connected disability status. 
Judging an individual disabled by a mental illness--worse, doomed to a 
life of invalidism in instances of unemployability determinations--
before he or she has even had a course of therapy and rehabilitation is 
drastically premature.
    Trauma-related distress and disorders should be treated early when 
symptoms are most responsive to treatment. There are excellent 
treatments for the component parts of PTSD (e.g., the phobias, anxiety, 
depression, existential dislocation). Treatments include 
desensitization protocols (such as Virtual Iraq), cognitive-behavioral 
therapy, psychotherapy, and medication. There is often a period in 
which treatment and rehabilitation overlap.
    In general, clinical optimism is warranted and must be communicated 
to patients. While demoralization is not a formal diagnosis, in my 
experience, it can be the difference between someone who throws in the 
towel and someone who prevails.
    In addition to the importance of a forward-looking stance is the 
extent to which problems of reintegration are managed. This is why 
quality rehabilitation addresses marital discord, readjustment to 
civilian life as well as to being a parent, vocational training, and 
financial concerns. Some veterans will need help with skills in 
relating to family, friends, neighbors, colleagues, and bosses. When 
day to day hassles are made more manageable, the patient feels more in 
control. Not only can he or she tolerate some symptoms better (e.g., 
sleep problems, distressing memories), those symptoms will likely fade 
faster. The veteran will be less likely to ascribe morbid 
interpretations to symptoms and to less apt to feel discouraged.
    Does Compensation Discourage Treatment Participation? A 2007 report 
on PTSD compensation by the Institute of Medicine concluded that 
disability benefits for combat-related PTSD do not pose a disincentive 
to Vietnam veterans' participation in treatment or their treatment 
outcomes.\4\ Notably, an analysis by the DVA Inspector General found a 
large drop off in treatment use once 100 percent disability status was 
attained. But the other studies surveyed by the IOM found little or no 
difference in treatment engagement and symptom change between 
compensation-seeking/compensation-granted Vietnam veterans and non-
compensation seeking veterans.
---------------------------------------------------------------------------
    \4\ PTSD Compensation and Military Service, 2007 The National 
Academies Press, Washington D.C., Chapter 6.
---------------------------------------------------------------------------
    The striking aspect of these studies, in my view, is how little 
they revealed about the subjects' real-world functioning. (Moreover, 
the study subjects were Vietnam veterans with chronic PTSD, a group 
that might not be readily comparable to younger cohorts). Granted, 
attendance at treatment sessions and measurable reductions in symptoms 
is encouraging, but this is only a part of the picture. Without some 
kind of productive work, the goals of compensation as set forth by the 
Commission and the VA (fostering reintegration, rehabilitation, and 
quality of life) are not likely to be achieved.

Options

    Treatment entry facilitated at point of compensation evaluation--
This represents a straight-forward mechanism for leveraging a major 
goal of disability compensation: rehabilitation. A critical feature of 
this arrangement would be periodic re-evaluations at 2-5 year intervals 
to assess progress and continued applicability of disability status.
    Treatment First--As discussed, making a determination about a 
veteran's future functional capacity--that is, the degree of ongoing 
disability--before he or she has had the opportunity for care is 
difficult, if not impossible.
    For patients needing intensive treatment who are too fragile for 
employment, the VA should consider a living stipend for the veteran and 
his or her family during the course of care. In addition to providing 
income support, the stipend would allay the stress of financial 
insecurity that would surely undermine the veteran's clinical progress. 
If meaningful functional deficits persist following a substantial 
course of treatment and rehabilitation, the veteran would then file a 
disability claim.

Conclusion

    Returning from war is a major existential project. Imparting 
meaning to one's wartime experience, reconfiguring personal identity, 
and reimagining one's future take time. Sometimes the emotional 
intensity can be overwhelming--especially when coupled with nightmares 
and high anxiety or depression--and even warrants professional help. 
When this happens, veterans, like Joe, should receive a message of 
promise and hope. This means a prescription for quality treatment and 
rehabilitation--ideally before the patient applies for disability 
status.
    Everyone who fights in a war is changed by it, but few are 
irreparably damaged. For those who never regain their civilian footing 
despite the best treatment, full and generous disability compensation 
is their due. Otherwise, it is reckless to allow a young veteran to 
surrender to his psychological wounds without first urging him to 
pursue recovery. Conferring disability status upon a veteran before his 
prospects for recovery are known can make the long journey home harder 
than it already is.

                                 
           Prepared Statement of Ralph Ibson, National Policy
                   Director, Wounded Warrior Project
    Chairman Miller, Ranking Member Filner and Members of the 
Committee:
    Thank you for inviting Wounded Warrior Project (WWP) to testify 
this morning.
    With WWP's mission of honoring and empowering those wounded in 
Afghanistan and Iraq, our vision is to foster the most successful, 
well-adjusted generation of veterans in our Nation's history. The 
mental health of our returning warriors is among our very highest 
priorities.
    Given that priority, we are greatly concerned that there are 
critical gaps in VA's approach to meeting the mental health needs of 
returning veterans, and no apparent plans for closing those gaps. So we 
particularly welcome this hearing.
    The U.S. Court of Appeals for the Ninth Circuit recently 
characterized the VA's mental health care system as beset by 
``egregious problems'' and ``unchecked incompetence,'' leading the 
court to conclude that veterans are denied rights relating to timely 
mental health care. That characterization unfairly characterizes 
thousands of dedicated VA health care professionals and tends to 
undermine confidence in a system that has a vital role to play. But 
there are problems beyond the capability of individual VA clinicians to 
remedy. Judicial resolution of the points of law raised in the Ninth 
Circuit case are not likely to remedy the more wide-ranging problems in 
VA's mental health system.

Despite the goal of intervening early, VA is failing to reach most 
        returning veterans:

    VA reports that nearly 600 thousand, or 49 percent of all, OEF/OIF 
veterans have been evaluated and seen as outpatients in its health care 
facilities, and reports further that approximately one in four showed 
signs of PTSD.\1\ But more than half of all OIF/OEF veterans have not 
enrolled for VA care. Unique aspects of this war--including the 
frequency and intensity of exposure to combat experiences; guerilla 
warfare in urban environments; and the risks of suffering or witnessing 
violence--are strongly associated with a risk of chronic post-traumatic 
stress disorder.\2\ The lasting mental health toll of the wars in Iraq 
and Afghanistan are likely to increase over time for those who deploy 
more than once, do not get needed services, or face increased demands 
and stressors following deployment.\3\ Chronic post-service mental 
health problems like PTSD are pernicious, disabling, and represent a 
significant public health problem. Indeed mental health is integral to 
overall health. So it is vitally important to intervene early to reduce 
the risk of chronicity.
---------------------------------------------------------------------------
    \1\ VA Office of Public Health and Environmental Hazards, 
``Analysis of VA Health Care Utilization among Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans,'' October 
2010.
    \2\ National Center for PTSD. ``National Center for PTSD 
FactSheet.'' Brett T. Litz, ``The Unique Circumstances and Mental 
Health Impact of the Wars in Afghanistan and Iraq,'' January 2007 
http://www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/
Veterans3/Veterans_Articles/5uniquecircumstancesIraq-Afghanistanwar.pdf 
(accessed 10 June 2011).
    \3\ Ibid.
---------------------------------------------------------------------------
    In 2008, VA instituted an initiative to call the approximately half 
million OEF/OIF veterans who had not enrolled for VA health care and 
encourage them to do so. This unprecedented initiative was apt 
recognition that we must be concerned not just about those returning 
veterans who come to VA's doors, but about the entire OIF/OEF 
population. But a single telephone contact is hardly enough of an 
outreach campaign.

VA has not been successful in retaining veterans in treatment:

    Until recently, little had been known about OEF/OIF veterans' 
actual utilization of VA mental health care. The first comprehensive 
study of VA mental health services' use in that population found that 
of nearly 50,000 OEF/OIF veterans with new PTSD diagnoses, fewer than 
10 percent appeared to have received evidence-based mental health 
treatment for PTSD (that is, attending 9 or more mental health 
treatment sessions in 15 weeks) at a VA facility; 20 percent of those 
veterans did not have a single mental health follow up visit in the 
first year after diagnosis.\4\
---------------------------------------------------------------------------
    \4\ Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas 
Metzler, Li Ren, Daniel Bertenthal, and Charles Marmar, ``VA Mental 
Health Service Utilization in Iraq and Afghanistan Veterans in the 
First Year of Receiving New Mental Health Diagnoses,'' Journal of 
Traumatic Stress, 2010.
---------------------------------------------------------------------------
    These data raise a disturbing concern. They show that enrolling for 
VA care and being seen for a war-related mental health problem does not 
assure that a returning veteran will complete a course of treatment or 
that treatment will necessarily be successful.
    Even more disturbing, VA has set a very low bar for reversing this 
trend. Consider performance measures reported in VA budget submissions. 
One measure calls for tracking the percentage of OEF/OIF veterans with 
a primary diagnosis of PTSD who receive a minimum of 8 psychotherapy 
sessions within a 14-week period. The FY 2010 performance goal for that 
measure was only 20 percent.\5\ In other words, having only one in five 
veterans attend about half of a recommended number of treatment 
sessions constituted ``success.'' This year's budget submission shows 
that actual performance fell short of even that very modest goal, with 
only 11 percent of PTSD patients receiving that minimum.\6\ In 
contrast, VA is meeting its performance target that 97 percent of 
veterans are screened for PTSD.\7\ This wide gap between VA's high rate 
of identifying veterans who have PTSD and its low targets for 
successful treatment is very troubling.
---------------------------------------------------------------------------
    \5\ Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 
2, p. 1J-5.
    \6\ Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 
2, p. 1G-7.
    \7\ Ibid.
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                    Two VA ``Mental Health'' Systems
    VA, of course, operates a vast health care system, and there are 
surely pockets of excellence--just as it employs many excellent, 
dedicated clinicians. It is somewhat misleading, however, to speak of 
``the VA mental health system,'' because not only is there wide 
variability across VA, but in some respects VA can be said to operate 
two mental health systems. First, VA provides a full range of mental 
health services through its nationwide network of medical centers and 
outpatient clinics. That system has increasingly emphasized the 
provision of ``evidence-based-,'' recovery-oriented care. VA's much 
smaller Readjustment Counseling program--operating out of community-
based ``Vet Centers'' across the country--provides individual and group 
counseling (including family counseling) to assist veterans to readjust 
from service in a combat theater. In some areas, these two ``systems'' 
work closely together; in others, there is relatively little 
coordination between them.
    The differences between these two systems may help explain why 
greater numbers of veterans do not pursue VA treatment, and why those 
who do often discontinue.
    In our daily, close work with warriors and their families, WWP 
staff consistently hear of high levels of satisfaction with their Vet 
Center experience. Warriors struggling with combat stress or PTSD 
typically laud Vet Center staff, who are often combat veterans 
themselves and who convey understanding and acceptance of warriors' 
problems.
    In contrast with the relative informality of Vet Centers, young 
warriors experience VA treatment facilities as unwelcoming, geared to a 
much older population, and as rigid, difficult settings to navigate. 
Warriors have characterized clinical staff as too quick to rely on 
drugs, and as often lacking in understanding of military culture and 
combat. Medical center and clinic staff sometimes have more experience 
treating individuals who have PTSD related to an auto accident or 
domestic abuse than to combat. VA treatment facilities have had little 
or nothing to offer family members. Unlike Vet Centers that have an 
outreach mission, VA treatment facilities conduct little or no direct 
outreach--placing the burden on the veteran to seek treatment.
    In essence, the strengths of the Readjustment Counseling program 
highlight the limitations and weaknesses that afflict the larger 
system. Too often, that larger system----

          Passively waits for veterans to pursue mental health 
        care, rather than aggressively seeking out warriors one-on-one 
        who may be at-risk;
          Gives insufficient attention to ensuring that those 
        who begin treatment continue and thrive;
          Emphasizes training clinicians in so-called evidence-
        based therapies but fails to ensure that they have real 
        understanding of, and relate effectively to, OEF/OIF veterans' 
        military culture and combat experiences;
          Fails to provide family members needed mental health 
        services, often resulting in warriors struggling without a 
        healthy support system;
          Largely fails to establish effective linkages and 
        partnerships with the communities where warriors live and work, 
        and where reintegration ultimately must occur.

    Perhaps the most disturbing perception warriors have expressed 
regarding their experiences with VA mental health treatment is that VA 
officials operate in a way that too often seems aimed at serving the VA 
rather than the veteran.

                         Richmond: A Case Study

    In describing what it termed its ``FY 11-13 Transformational Plan 
to Improve Veterans' Mental Health,'' VA emphasizes its core reliance 
on providing evidence-based, recovery-oriented, veteran-centric care. 
But when those three concepts are not in alignment, experience now 
suggests that the veteran's voice may go unheard.
    Consider VA's handling of PTSD support groups at the Hunter Homes 
McGuire Department of Veterans Affairs Medical Center in Richmond, VA 
(Richmond VA). Last year, officials at the Richmond VA advised its PTSD 
therapy groups of its intention to phase out and, effective January 
2011, terminate those PTSD therapy groups. Richmond VA had run several 
such groups which had met weekly since 2005. One of those groups (the 
``Young Guns'') included veterans who served in Iraq and Afghanistan 
and were struggling with often-severe mental health conditions.
    The Young Guns group was disturbed by these plans and petitioned 
the medical center director to reinstate the group. The petition, which 
was signed by 27 members of the group, explained both the importance to 
the members of the group therapy and expressed their strong view that 
VA's alternative--for the group to operate as a community-based peer 
group--was not an effective substitute.\8\ While WWP also urged the 
Medical Center Director to reinstate the group at the medical center, 
the director's reply stated that ``while these . . . PTSD groups have 
proven effective in providing environments of social support . . . , 
they are not classified as active treatment for PTSD symptoms.'' The 
upshot of the medical center director's ignoring the veterans' strong 
views and proceeding with the plans was that only 7 members of the 
Young Guns group attended the initial ``community-based'' group meeting 
(which was neither adequately staffed or facilitated). Most have 
dropped out altogether--having lost trust, feeling ``discarded'', or in 
some instances--because it is no longer a ``VA group''--they could no 
longer get approval to take time off from jobs.
---------------------------------------------------------------------------
    \8\ WWP would be pleased to provide, at the Committee's request, a 
copy of the petition and subsequent WWP correspondence on the issue 
with VA officials.
---------------------------------------------------------------------------
    Veterans too often confront a gap between well-intentioned VA 
policy and real-world practice. In this instance, the applicable VA 
policy (set forth in a handbook setting minimal clinical requirements 
for mental health care) is clear and on point:

     The specifications in this Handbook for enhanced access, evidence-
based care, and recovery or rehabilitation must not be interpreted as 
deemphasizing respect for the needs of those who have been receiving 
supportive care. No longstanding supportive groups are to be 
discontinued without consideration of patient preference, planning for 
further treatment, and the need for an adequate process of termination 
or transfer. (Emphasis added.)

    Throughout our efforts to advocate for these warriors--writing to 
the Medical Center Director, meeting with VA Central Office officials, 
meeting with the Medical Center Director, and finally writing to the 
Secretary--VA's position at every level remained inflexible. Honoring 
the veterans' wishes was simply not considered a VA option and while 
numerous ``alternatives'' were listed, few took into consideration the 
sensitivities of these particular patients.
    The Richmond matter is stunning in several respects. While a 
recently conducted WWP survey indicated that as many as 15 other VA 
medical centers have terminated PTSD support groups, the Richmond VA 
case appears unique in its utter disregard for the veterans' wishes, 
and in Central Office's acquiescence in that medical center's position. 
Secondly, VA did not terminate an ineffective program at Richmond VA. 
Medical Center officials even acknowledged that it was helping the 
veterans. VA's cavalier insistence on the appropriateness of 
transferring responsibility for a therapeutically-beneficial modality 
from VA to an inexperienced community entity appears altogether 
unprecedented.
    VA Mental Health Care Policy: Still in Transition, Ignoring Gaps
    This hearing asks in part whether VA is able to provide timely, 
effective, and accessible care to veterans struggling with mental 
illness. VA has certainly instituted policies that are designed to 
achieve those goals. But as the above-cited situation at the Richmond 
VA illustrates, the gap between VA mental-health policy and practice 
can be wide.
    In 2007, VA developed an important detailed policy directive that 
identifies what mental health policies should be available to all 
enrolled veterans who need them, no matter where they receive care, and 
sets certain timeliness standards for scheduling treatment.\9\ But as 
VA acknowledged in testifying before the Senate Veterans Affairs 
Committee on May 25th, those directives are still not fully 
implemented. Funding is not the problem, VA testified.
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform 
Mental Health Services in VA Medical Centers and Clinics.
---------------------------------------------------------------------------
    The fact that a policy aimed at setting basic standards of access 
and timeliness in VA mental health care has yet to be fully 
implemented--4 years after the policy is set--has profound 
ramifications for warriors struggling with war-related mental health 
problems, and who face barriers to needed VA treatment. Of VA's many 
``top priorities'', the mental health of this generation of warriors 
should be of utmost importance as it will directly impact other areas 
of concern such as physical wellness, success in employment and 
education, and homelessness.
    Geographic barriers are often the most prominent obstacle to health 
care access, and can have serious repercussions on the veteran's 
overall health. Research suggests that veterans with mental health 
needs are generally less willing to travel long distances for needed 
treatment than veterans with other health problems and that critical 
aspects of a veteran's mental health treatment (including timeliness of 
treatment and the intensity of the services the veteran ultimately 
receives) are affected by how geographically accessible the care 
is.\10\
---------------------------------------------------------------------------
    \10\ Benjamin Druss and Robert Rosenheck, ``Use of Medical Services 
by Veterans with Mental Disorders,'' Psychosomatics 38(1997) 454.
---------------------------------------------------------------------------
    VA faces a particular challenge in providing rural veterans access 
to mental health care. VA has stated that of all veterans who use VA 
health care, roughly 39 percent reside in rural areas and an additional 
2 percent reside in highly rural areas; \11\ over 92 percent of 
enrollees reside within 1 hour of a VA facility, and 98.5 percent are 
within 90 minutes.\12\ But many of these VA facilities are small 
community-based outpatient clinics (CBOC's) that offer very limited or 
no mental health services.\13\ Overall, CBOC's are limited in their 
capacity to provide specialized or even routine mental health care. 
Indeed, under current VHA policy, large CBOC's (those serving 5,000 or 
more unique veterans each year), mid-sized CBOC's (serving between 
1,500 and 5,000 unique veterans annually), and smaller CBOC's (serving 
fewer than 1,500 veterans annually) have the option to meet their 
mental health provision requirements by referring patients to 
``geographically accessible'' VA medical centers.\14\ CBOC's are only 
required to offer mental health services to rural veterans in the 
absence of a ``geographically accessible'' medical center.\15\ Notably, 
current policy does not define what constitutes ``geographic 
inaccessibility.'' Moreover, in those instances in which small and mid-
sized CBOC's do have mental health staff, VA does not require the CBOC 
to provide any evening or weekend hours to accommodate veterans who 
work and cannot easily take time off for treatment sessions.
---------------------------------------------------------------------------
    \11\ Testimony of Gerald Cross, Acting Principal Deputy 
Undersecretary for Health Department of Veterans' Affairs, before the 
House Committee on Veterans' Affairs, Subcommittee on Health, 
(Washington DC:April 18, 2007), http://www.va.gov/OCA/testimony/hvac/
sh/070418GC.asp.
    \12\ Ibid.
    \13\ John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray 
Carlson, Robert R. Davila, Graham Hill, et al, ``Invisible Wounds: 
Serving Servicemembers and Veterans with PTSD and TBI,'' National 
Council on Disability, 4 March 2009, National Council on Disability, 
[www.ncd.gov/newsroom/publications/2009/veterans.doc], Accessed 14 May 
2009, 46.
    \14\ VHA Handbook 1160.01, 8.
    \15\ Ibid., 18.
---------------------------------------------------------------------------
    Since long-distance travel to VA facilities represents a formidable 
barrier to veterans' availing themselves of mental health treatment, it 
is important that VA provide community-based options for veterans who 
would otherwise face such barriers. VA policy--as reflected in the 
uniform services handbook--calls for ensuring the availability of 
needed mental health services, to include providing such services 
through contracts, fee-basis non-VA care, or sharing agreements, when 
VA facilities cannot provide the care directly.\16\ But VA officials 
have informally admitted that, despite the policy, VA facilities have 
generally made only very limited use of this new authority--often 
leaving veterans without good options.
---------------------------------------------------------------------------
    \16\ VHA Handbook 1160.01, paragraphs 13.i.; 13.k.; 23.f.(1)(c); 
23.h.(2)(b); 28.d.(1).
---------------------------------------------------------------------------
    Yet there is evidence that this rural access problem could be 
overcome if there were the will to meet it. In Montana, for example, 
the VA Montana Health Care System has been contracting for mental 
health services since 2001. According to a report by the VA Office of 
Inspector General (OIG), more than 2,000 Montana veterans were treated 
under contracts with community mental health centers in FY 2007, and 
more than 250 were treated under fee-basis arrangements with 27 private 
therapists.\17\ The OIG report also indicates that the VA Montana 
Health Care System has sponsored trainings for contract and fee-basis 
providers in evidence-based treatments.\18\
---------------------------------------------------------------------------
    \17\ VA Office of Inspector General, Access to VA Mental Health 
Care for Montana Veterans, (March 31, 2009), 4-5.
    \18\ Ibid., 63.
---------------------------------------------------------------------------
    It is not enough for VA simply to promulgate policies and 
directives on access-to-care and timeliness. Surely we owe those 
suffering from war-related mental health conditions real access to 
timely, effective care, not the hollow promise of a policy that is 
still not fully implemented 4 years later.
    Finally, a 4-year-old policy must itself be open to re-assessment. 
VA must continue to adapt to the needs of younger veterans whose 
obligations to employers, school, or young children may compound the 
challenge of pursuing mental health care. To illustrate, a recent WWP 
survey found that among veterans who are currently participating in VA 
medical center and Vet Center support groups, 29 percent said they are 
considering no longer attending due to the location of the group being 
far from their place of work or home. Another 39 percent of respondents 
indicated they are considering no longer attending because groups are 
held at a time that interferes with their work schedule.
  Needed: A Veteran-Centered Approach to the Mental Health of OEF/OIF 
                                Veterans
    PTSD and other war-related mental health problems can be 
successfully treated--and in many cases, VA clinicians and Vet Center 
counselors are helping veterans recover. But, as discussed above, VA is 
not reaching enough of our warriors, and is not giving sufficient 
priority to keeping veterans in treatment long enough to gain its 
benefits. What can VA do, beyond fully implementing its policies and 
commitments? What should it do? We've asked our own warriors these 
questions, as well as consulted with experts. Our recommendations 
follow:
    Outreach: WWP recommends that VA adopt and implement an aggressive 
outreach campaign through its medical centers, employing OEF/OIF 
warriors--who have dealt with combat stress themselves--to conduct 
direct, one-on-one peer-outreach. Current approaches simply fail to 
reach many veterans. For example, post-deployment briefings that 
encourage veterans to enroll for VA care tend to be ill-timed, or too 
general and impersonal to address the warriors' issues. An outreach 
strategy must also take account of many warriors' reluctance to pursue 
treatment. An approach that reaches out to engage the veteran in his or 
her community, and provides support, encouragement, and helpful 
information for navigating that system can be impactful. VA leaders for 
too long have limited such outreach efforts to Vet Centers. Given what 
amounts to a public health challenge with regard to warriors at risk of 
PTSD, there is a profound need for a broad VA effort to conduct one-on-
one peer outreach to engage warriors and family in their communities.
    Cultural competence education: WWP urges that VA mount major 
education and training efforts to assure that its mental health 
clinicians understand the experience of combat and the warrior culture, 
and can relate effectively to these young veterans. Health care 
providers, to be effective, must be ``culturally competent''--that is, 
must understand and be responsive to the diverse cultures they serve. 
WWP often hears from warriors of frustration with VA clinicians and 
staff who, in contrast to what many have experienced in Vet Centers, 
did not appear to understand PTSD, the experience of combat, or the 
warrior culture. Rather than winning trust and engaging warriors in 
treatment, clinical staff are often perceived as ignorant of military 
culture or even as dismissive. Warriors reported frustration with 
clinicians who in some instances do not appear to understand combat-
related PTSD, or who pathologize them or characterized PTSD as a 
psychological ``disorder'' rather than an expected reaction to 
combat.\19\ Dramatically improving the cultural competence of clinical 
AND administrative staff who serve OEF/OIF veterans through training, 
standard-setting, etc.--and markedly improving patient-education--must 
be high priorities.
---------------------------------------------------------------------------
    \19\ Id, 9, 51.
---------------------------------------------------------------------------
    Peer-to-peer support: WWP recommends that VA employ and train peers 
(combat veterans who have themselves experienced post-traumatic 
stress). In describing highly positive experiences at Vet Centers, 
warriors emphasized the importance of being helped by peers on the Vet 
Center staff--combat veterans who themselves have experienced combat 
stress and who (in their words) ``get it.'' Given the inherent 
challenges facing a patient in a medical setting and data showing high 
percentages discontinuing treatment, it is important to have the 
support of a peer who, as a member of the treatment team, can be both 
an advocate and support. Public Law 111-163 requires VA within 180 days 
of enactment to provide peer-outreach and peer-support services to OEF/
OIF veterans along with mental health services, and to contract with a 
national nonprofit mental health organization to train OEF/OIF veterans 
to provide such services. It is critical that the Department design and 
establish a national peer-support program, initiate recruitment of OEF/
OIF veterans for a system-wide cohort of peer-support-specialists and 
institute the required training at the earliest possible date.
    Provide family mental health services: One of the strongest factors 
that help warriors in their recovery is the level of support from loved 
ones.\20\ Yet the impact of lengthy, multiple deployments on family may 
diminish their capacity to provide the depth of support the veteran 
needs. One survey of Army spouses found that nearly 20 percent had 
significant symptoms of depression or anxiety.\21\ While Vet Centers 
have provided counseling and group therapy to family members, VA 
medical facilities have offered little more than ``patient education'' 
despite statutory authority to provide mental health services. It took 
VA nearly 2 years to implement a legislative requirement to provide 
marriage and family counseling.\22\ Section 304 of Public Law 111-163 
directs VA to go further and provide needed mental health services to 
immediate family of veterans to assist in readjustment, or in the 
veteran's recovery from injury or illness. This provision--covering the 
3-year period beginning on return from deployment--must be rapidly 
implemented, particularly given its time-limit on this needed help.
---------------------------------------------------------------------------
    \20\ C.W. Hoge, Once a Warrior Always a Warrior: Navigating the 
Transition from Combat to Home, (Globe Pequot Press, 2010), 28.
    \21\ Ibid, 259.
    \22\ Veterans Health Administration, IL 10-2010-013, ``Expansion of 
Authority to Provide Mental Health and Other Services to Families of 
Veterans,'' August 30, 2010.
---------------------------------------------------------------------------
    Expand the reach and impact of VA Vet Centers: Although many OEF/
OIF veterans have been reluctant to pursue mental health treatment at 
VA medical centers, Vet Centers have had success with outreach and 
working with this population. Given that one in two OEF/OIF veterans 
have not enrolled for VA care and many are likely to be experiencing 
combat-stress problems, WWP recommends that VA increase the number of 
Vet Center locations, and give priority to locating new centers in 
close proximity to military facilities. As Congress recognized in 
Public Law 111-163, Vet Centers--in addition to their work with 
veterans--can be an important asset in helping active duty, guard, and 
reserve servicemembers deal with post-traumatic stress. Vet Centers can 
serve as an important asset to VA medical centers as well, and we urge 
greater coordination and referral between the two.
    Foster community-reintegration: VA mental health care can play an 
important role in early identification and treatment of mental health 
conditions. Yet success in addressing combat-related PTSD is not simply 
a matter of a veteran's getting professional help, but of learning to 
navigate the transition from combat to home.\23\ In addition to coping 
with the often disabling symptoms, many OEF/OIF veterans with PTSD, and 
wounded warriors generally, are likely also struggling to readjust to a 
``new normal,'' and to uncertainties about finances, employment, 
education, career and their place in the community. While some find 
their way to VA programs, no single VA program necessarily addresses 
the range of issues these young veterans face, and few, if any, of 
those programs are embedded in the veteran's community. VA and 
community each has a distinct role to play. The path of a veteran's 
transition, and successful community-reintegration, must ultimately 
occur in that community. For some veterans that success may require a 
community--the collective efforts of local community partners--
businesses, a community college, the faith community, veterans' service 
organizations, and agencies of local government--all playing a role. 
Yet there are relatively few communities dedicated, and effectively 
organized, to help returning veterans and their families reintegrate 
successfully, and other instances where VA and veterans' communities 
are not closely aligned. The experience of still other communities, 
however, suggests that linking critical VA programs with committed 
community engagement can make a marked difference to warriors' 
realizing successful reintegration. With relatively few communities 
organized to support and assist wounded warriors, WWP urges the 
establishment of a grant program to provide seed money to encourage 
local entities to mobilize key community sectors to work as partners in 
support of veterans' reintegration. In short, a grant to a community 
leadership entity (which, in any given community, might be a non-profit 
agency, the mayor's office, a community college, etc.) could be the 
focal point for mounting a community group to work with a VA medical 
center or Vet Center to support veterans and their families on their 
path to community reintegration. There is ample precedent for use of 
modest grants to stimulate the development of community-based 
coalitions working in concert with government to provide successful 
wraparound services.\24\
---------------------------------------------------------------------------
    \23\ Hoge; Once a Warrior Always a Warrior.
    \24\ M. Libby, M. Austin. ``Building a Coalition of Non-Profit 
Agencies to Collaborate with a County Health and Human Services 
Agency.'' Administration in Social Work. 26,4(2002): 81-99.
---------------------------------------------------------------------------
    We have offered most of these recommendations to VA officials, and 
have urged them to implement section 304 of Public Law 111-163. The 
response was little different from the responses we received in 
advocating on behalf of the veterans in Richmond. In essence, the 
message seems to be, ``No thank you, we'll do it our way, and we'll do 
it when we get to it.''
    But the stakes are high! With a generation of combat warriors at 
risk of chronic health problems associated with combat stress, VA and 
Congress can have few higher priorities, in our view, than to institute 
such recommendations. To that end, WWP expects to provide the Committee 
draft legislation to incorporate these recommendations later this 
month.
         Coordination with the Veterans Benefits Administration
    WWP recognizes the importance of robustly addressing the full range 
of issues facing returning warriors so that they can thrive--
physically, psychologically and economically. Compensation for service-
connected disability is not only an earned benefit, it is critically 
important to most veterans' reintegration and economic empowerment.
    As recognized by this Committee, VA has yet to achieve the goal of 
being a department that provides ``wraparound'' services that 
seamlessly and effectively integrate Veterans Health Administration 
(VHA) services and Veterans Benefits Administration (VBA). A panel of 
the National Academy of Public Administration addressed that important 
goal. It reported that care and benefits to veterans could be improved 
if VA management, organization, coordination, and business practices 
were transformed with the aim of improving outcomes for veterans, 
rather than simply aiming to improve operational processes.\25\ That 
National Academy panel provided VA detailed recommendations 
constituting a comprehensive blueprint for such a transformation.\26\ 
At its core was an emphasis on the importance of leadership commitment 
to creating and maintaining veteran-centered systems, including a ``no 
wrong door'' policy to ensure receipt of appropriate guidance 
regardless of point of contact. The Academy provided VA a vision, 
strategy and detailed recommendations for organizing and delivering 
veteran-centered services.
---------------------------------------------------------------------------
    \25\ National Academy of Public Administration, ``After Yellow 
Ribbons: Providing Veteran-Centered Services,'' October 2008, p. ix.
    \26\ Ibids.
---------------------------------------------------------------------------
    Data from a very recent WWP survey of wounded warriors regarding 
their experience with VA adjudication of original claims for service-
connection for PTSD underscores the point that much more work remains 
to be done to achieve better coordination and unity of focus between 
VHA and VBA. More than one in five survey respondents indicated that 
the compensation and pension (C&P) examination associated with the 
adjudication of that claim was 30 minutes or less in duration. Prior 
testimony before this Committee regarding an Institute of Medicine 
study on PTSD compensation reflected keen concern that VA mental health 
professionals often fail to adhere to recommended examination 
protocols:

     ``Testimony presented to our Committee indicated that clinicians 
often feel pressured to severely constrain the time that they devote to 
conducting a PTSD Compensation and Pension (``C&P'') examination--
sometimes as little as 20 minutes--even though the protocol suggested 
in a best practice manual developed by the VA National Center for PTSD 
can take 3 hours or more to properly complete.'' \27\
---------------------------------------------------------------------------
    \27\ Dean G. Kilpatrick, Ph.D., Committee on Veterans' Compensation 
for Posttraumatic Stress Disorder, Institute of Medicine, Testimony 
before House Veterans' Affairs Committee Hearing on ``The U.S. 
Department of Veterans Affairs Schedule for Rating Disabilities'' Feb. 
6, 2008, accessed at: http://veterans.house.gov/hearings/ 
Testimony.aspx?TID=638&Newsid=2075
&Name=%20Dean%20G.%20Kilpatrick,%20Ph.D.

    Hurried, or less than comprehensive, C&P examinations heighten the 
risk of adverse outcomes, additional appeals, and long delays in 
affording veterans the benefits to which they are entitled. VHA and VBA 
must do more to actively address the concerns the IOM panel voiced.
    Our survey also addressed a related issue in asking warriors, 
``have you been diagnosed and treated for PTSD at a VA medical center 
or clinic since deployment to Iraq or Afghanistan, but--despite that VA 
treatment--been denied service-connection for PTSD?'' Approximately one 
in four respondents answered in the affirmative. These data suggest a 
profound disconnect between the two administrations--inexplicable to 
warriors and, we trust, to the Committee as well.
    This Committee has emphasized the goal of a wellness-focused VA 
response to mental illness. One important step in that direction, in 
our view, would address a problem--rooted in the regulations governing 
VA's compensation program--that impedes numbers of wounded warriors 
from overcoming disability and regaining productive life. VA 
regulations have long provided a mechanism to address the situation 
where the rating schedule would assign a less than a 100 percent rating 
but the veteran is nevertheless unable to work because of that service-
connected condition. Accordingly, in instances where a veteran has a 
disability rating of 60 percent of higher, or multiple disabilities 
with a combined total rating, VA may grant a 100 percent disability 
rating when it determines the veteran is ``unable to follow a 
substantially gainful occupation as a result of service-connected 
disabilities.'' This Individual Unemployability (IU) rating results in 
a very substantial increase in the veteran's compensation. But while 
veterans receiving IU are compensated at the same monetary level as 
those who receive a 100 percent rating, the implications for employment 
drastically differ. A veteran who receives a schedular rating of 100 
percent is not precluded from gainful employment. But for veterans 
receiving IU, a return to the workforce for longer than 12 months or at 
an income level that exceeds the Federal poverty line can result in a 
loss of the IU benefit, and a subsequent reduction in financial 
compensation. For some veterans, this can spell a sudden loss of as 
much as $1700 in monthly income. Both the Institute of Medicine (IOM) 
and Veterans' Disability Benefits Commission have recognized this 
decrease as a ``cash-cliff'' that may deter some veterans from 
attempting to re-enter the workforce.\28\
---------------------------------------------------------------------------
    \28\ Institute of Medicine. A 21st Century System for Evaluating 
Veterans for Disability Benefits. Committee on Medical Evaluation of 
Veterans for Disability Compensation, National Academies Press, 2007, 
250, and Veterans' Disability Benefits Commission, Honoring the Call to 
Duty: Veterans Disability Benefits in the 21st Century, October 2007, 
243.
---------------------------------------------------------------------------
    We concur with the recommendations of the IOM and VA Disability 
Commission that the IU benefit should be restructured to encourage 
veterans to reenter the workforce. The experience of the Social 
Security Administration (SSA)--which has had success piloting a 
gradual, step down approach to reducing benefits for beneficiaries who 
return to employment--offers a helpful model. SSA's experience has 
shown that, for those reentering the workplace, a gradual rather than 
sudden reduction in disability benefits not only allowed participants 
to minimize the financial risk of returning to work, but over time 
participants actually increased their earning levels above what they 
would have received in disability payments.\29\ Inherent in this 
approach is the underlying assumption that individuals with 
disabilities can and will re-enter the workforce if benefits are 
structured to encourage that opportunity. Recognizing that employment 
often acts as a powerful tool in recovery and is an important aspect of 
community reintegration for this young generation of warriors, WWP 
recommends that VA revise the IU benefit accordingly.
---------------------------------------------------------------------------
    \29\ Social Security Administration. ``Benefit Offset Pilot 
Demonstration--Connecticut Final Report.'' September 2009, Accessed at: 
http://www.ssa.gov/disabilityresearch/offsetpilot.htm.
---------------------------------------------------------------------------
                                Summary
    In closing, let us emphasize that VA can have few higher goals than 
to help veterans who bear the psychic scars of combat regain mental 
health and thrive. But a Department of Veterans Affairs that comes 
before this Committee--as it too often does--with only a list of 
pertinent mental-health ``programs'' and ``initiatives''--is a 
Department destined to fail many of these warriors, as it failed 
warriors at the Richmond VA. Regrettably, there are wide gaps between 
those programs and initiatives, and our warriors' needs.
    While we recognize and acknowledge that VA conducts some quality 
programs and laudable initiatives, our work with warriors struggling 
with mental health issues reminds us daily of the gaps plaguing the 
system: gaps arising from VA's largely- passive approach to outreach; 
gaps in access to mental health care in a system still marked by wide 
variability; gaps in sustaining veterans in mental health care; gaps in 
clinicians' understanding of military culture and the combat 
experience; gaps in family support; and gaps in coordination with the 
benefits system. We look forward to working with this Committee to 
close these gaps and to witness the development of a truly 
transformative veteran-centered approach to VA mental health care and 
benefits.

                                 
        Prepared Statement of Christina M. Roof, National Acting
            Legislative Director, American Veterans (AMVETS)
    Chairman Miller, Ranking Member Filner and distinguished Members of 
the Committee, on behalf of AMVETS, I would like to extend our 
gratitude for being given the opportunity to share with you our views 
and recommendations at today's hearing regarding ``Mental Health: 
Bridging the Gap Between Care and Compensation for Veterans.''
    AMVETS feels privileged in having been a leader, since 1944, in 
helping to preserve the freedoms secured by America's Armed Forces. 
Today our organization prides itself on the continuation of this 
tradition, as well as our undaunted dedication to ensuring that every 
past and present member of the Armed Forces receives all of their due 
entitlements. These individuals, who have devoted their entire lives to 
upholding our values and freedoms, deserve nothing but the highest 
quality of care we, as a Nation, have to offer.
    As we are all aware the suicide rates among veterans and 
servicemembers has become a sort of ``epidemic'' and the rates at which 
these men and women are taking their own lives has surpassed that of 
their non-veteran population counterparts for the first time in 
recorded history. Unfortunately, due to the methods the Department of 
Veterans Affairs' (VA) utilizes in tracking suicide rates, AMVETS fears 
the rate is actually much higher than VA reports. The Department of 
Defense's (DoD) rates tend to be more accurate given the daily 
oversight they have over their personnel. However, AMVETS also believes 
DoD's reported number to be lower than the actual number due to the 
discrepancies in the reported causes of death. Regardless of the exact 
number, AMVETS believes that even one veterans or servicemember life 
lost to suicide is one too many.
    As of December 2009, approximately 1.1 million OIF/OEF veterans, of 
the 1.7 million who have served or are serving in these conflicts, had 
transitioned out of active duty out service.\1\ According to multiple 
studies performed by the National Institute of Health, Department of 
Veterans Affairs (VA) and Department of Defense (DoD) upwards of 43 
percent of veterans having served in Operations Enduring Freedom, Iraqi 
Freedom and New Dawn, as well as the war in Afghanistan, will have 
experienced traumatic events causing Post-Traumatic Stress Disorder 
(PTSD) or other psychological disorders such as depression. Left 
untreated, these invisible wounds can have a devastating impact on the 
lives of those veterans and servicemembers who suffer in silence. 
Unfortunately, even though there has been an effort to remove the 
stigmas associated with psychological wounds in recent years by VA and 
DoD leadership, their message has failed to reach the everyday 
servicemember and veteran. Theses stigmas still seem to be ever so 
present and seeking assistance is often viewed as a sign of weakness or 
lack of resiliency among those who have been trained to be strong and 
fearless. We must step up our efforts in removing stigmas and 
immediately develop and implement newer, more confidential ways of 
offering assistance to those who need it most if we wish to end the 
cycle of preventable suicides plaguing today's veteran and military 
communities. Moreover, there needs to be numerous changes and 
corrections in the policies and procedures within the Veterans Health 
Administration (VHA) and the Veterans benefit Administration (VBA).
---------------------------------------------------------------------------
    \1\ VHA Office of Public Health and Environmental Hazards. 
Washington (DC): Department of Veterans Affairs; 2009. Analysis of VA 
health care utilization among U.S. Global War of Terrorism (GWOT) 
veterans [Internet] [cited 2010 Apr 28].
---------------------------------------------------------------------------
    One of the hardest and most humbling decisions a veteran can make 
in their life, is to seek care and assistance for their invisible 
wounds of war. However, given the broken policies and lengthy 
procedures, as well as an overall lack of communication between VHA and 
VBA, veterans seeking care and assistance are often met with a 
confusing and frustrating claims system entrenched in bureaucracy. Many 
of these veterans find VA to be more of a hindrance, than helpful, to 
their overall wellbeing and thus chose to stop receiving the care and 
benefits they critically need. One of the initial experiences a newly 
enrolled veteran will have within the VA system is with a claims 
examiner. Thus, the response to a PTSD claim is an evaluation without a 
concurrent offer of treatment has now potentially caused adversarial 
situation to be made worse.
    In 2010 changes were made to the VA regulation governing PTSD 
disability claims. The regulation, 38 CFR 3.304(f)(3), allows for the 
veteran's lay statement to satisfy the establishment of an 
``occurrence'' under specific criteria. Title 38 requires the 
occurrence must be ``related to fear of hostile military or terrorist 
activity and a VA psychiatrist or psychologist, or contract equivalent, 
confirms that the claimed stressor is adequate to support a diagnosis 
of PTSD and the veteran's symptoms are related to the claimed 
stressor.'' While this change was for the better and seems relatively 
straightforward, it is yet to be seen as to how well the VA is 
implementing the criteria and if the claims process will be improved. 
Furthermore, the process may prove more lengthy due to the fact VA has 
implemented a case-by-case review of the facts surrounding each claim. 
The VA claims representative will need to verify that the facts given 
by the veteran are true, including duty locations and service or 
campaign medals, prior to the veteran being scheduled for an exam. 
Thus, certain medals are now sufficient to schedule a PTSD examination. 
For example, VA Compensation has concluded that a veteran's receipt of 
the Vietnam Service Medal or Vietnam Campaign Medal is sufficient proof 
that the veteran service in a hostile military environment. This also 
includes veterans aboard ships in ``blue water''. Therefore, veterans 
with either of these medals should be able to pass the first threshold 
of proving the occurrence. Once the claim is verified, an examination 
should be immediately scheduled.
    However, veterans filing new claims know they will have to wait in 
a very long, continuously growing, pending claims line. They will stand 
behind a quarter of a million men and women waiting over 125 days, many 
of which, about 43 percent, will just to be told if their claim is not 
approved. PTSD claims alone have increased 125 percent over the past 
few years according to VA.
    The compensation examiner has a responsibility to VBA to obtain 
information to adjudicate a claim, and as such, the examination serves 
a societal need rather than a treatment need. In fulfilling this 
societal need, compensation examiners are put into an evaluative role 
that can alienate the veteran being evaluated.\2\ For example, the 
compensation examiner may have to collect information about traumatic 
issues that the veteran is unprepared to address therapeutically. A 
compensation examination focuses on data collection rather than 
addressing veteran distress. In addition, a compensation interview 
often has more time constraints than multisession clinical treatment, 
and the veteran may feel rushed. Limited time is available to focus on 
helping the veteran process his or her subjective experience. An 
examiner must consider not only the veteran's perspective but also 
alternative sources of data and may ask questions that challenge the 
veteran's version of events.\3\
---------------------------------------------------------------------------
    \2\ Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: 
Role conflict in serving as both psychotherapist and expert witness. Am 
J Psychiatry. 1997;154(4):448-56. [PMID: 9090330].
    \3\ (Rosen MI. Compensation examinations for PTSD-An opportunity 
for treatment? J Rehabil Res Dev. 2010; 47(5):xv-xxii.
---------------------------------------------------------------------------
    Based on the number of compensation claims that have been filed for 
recent conflicts and the number filed in past wars, a conservative 
estimate is that 50 percent of OIF/OEF veterans will apply for some 
service-connected compensation, which is only slightly higher than the 
44 percent of Gulf War veterans who applied. It is likely that a 
majority of those who apply are actually those who are at least 
partially disabled. In studies describing pre-OIF/OEF cohorts, award 
rates ranging from 33 to 72 percent for PTSD have been reported. More 
recently, a review of 2,400 PTSD claims decided during 2007 and 2008 
indicated 42.5 percent were denied and an additional 2.9 percent were 
rated at 0 percent (veterans had the diagnosis but were not disabled by 
it); 1.54 percent were rated at 100 percent and the rest fell in 
between as shown in the Figure.\4\
---------------------------------------------------------------------------
    \4\ Marc I. Rosen (Department of Psychiatry, VA Connecticut Health 
Care System, West Haven, CT 2010 Mar 18.






        Figure.
        Service-connected compensation awards from sample of post-
        traumatic stress disorder claims, 2007 to 2008 (N = 2,400).

    Considerable public pressure exists to improve the process of 
evaluating compensation claims and engaging veterans in treatment. 
AMVETS believes as a direct result of the pressure to adjudicate 
claims, partnered with limited initial and continuing education of VBA 
personnel is resulting in unwanted and avoidable circumstances for 
veterans seeking VA care and benefits.
    At present, VA compensation examiners complete online training to 
become credentialed to conduct compensation examinations. In this 
training video, the compensation examiner explains to a veteran that 
the purpose of the examination is not to conduct counseling but to 
``document your experiences.'' VA regulations further reinforce this 
boundary between the evaluator and the clinician by noting that the 
evaluation should be conducted by someone who is not providing clinical 
care to the claimant. The Automated Medical Information Exchange (AMIE) 
worksheets for conducting the compensation examination require a 
directive interview to elicit the plethora of specific information that 
is required to process a claim, yet there is no recommendation in the 
AMIE that treatment be offered to the veteran who has just been asked 
to relive traumas from their past service.
    These procedures are consistent with the tradition in psychiatry 
that ``clinical'' and ``forensic'' functions be performed by separate 
clinicians, and disability evaluations have been considered to be a 
particular type of forensic evaluation. The American Academy of 
Psychiatry and the Law Ethics Guidelines recommend this explicitly: 
``At the beginning of a forensic evaluation, care should be taken to 
explicitly inform the evaluee that the psychiatrist is not the 
evaluee's `doctor.' '' Acknowledging the fact that evaluees may fall 
into the patient role anyway because of setting, wish, and having 
vented, the guidelines continue, ``Psychiatrists have a continuing 
obligation to be sensitive to the fact that although a warning has been 
given, the evaluee may develop the belief that there is a treatment 
relationship''. This also shows to be the case when examining the 
relationship between the veteran, claims examiner and physician.
    The VA agency affiliation of the examining clinician may not be 
clear to veterans filing claims. Qualitative data suggests that 
veterans who undergo compensation examinations report not understanding 
the distinction between an evaluative examination and a treatment 
examination-after all, both are conducted by mental health 
professionals. Veterans may not make the distinction between the VHA 
staff who conduct examinations and the VBA staff who decide claims and 
dispense benefits. Both are ``VA staff.'' This is a problem that must 
immediately be addressed by VHA and VBA. Veterans need to fully 
understand the different roles VHA and VBA have in their treatment and 
care. AMVETS believes too many veterans forego VHA care simply because 
of a bad experience with VBA.
    A recent VA OIG investigation revealed a high number of errors 
being made on disability claims evaluations filed by veterans suffering 
from Traumatic Brain Injuries (TBI) and Post-Traumatic Stress Disorder 
(PTSD). There was an overall 23 percent error rate in all the OIG-
reviewed cases. Most of these errors had a direct impact on the 
veteran's disability rating and benefits.
    OIG also examined 16,000 disability files based solely on PTSD 
claims. OIG found there was no way the claims processors could be 
accurate with the limited training and experience they possessed. VA 
noted the largest number of mistakes were made verifying specific 
events qualifying for PTSD benefits. OIG found inexperienced and 
undertrained processors caused most problematic errors in TBI and PTSD 
claims. The errors themselves ranged in cause, and retraining should be 
completed by the end of June according to VA officials AMVETS spoke 
with. AMVETS hopes this Committee will have the strictest of oversight 
in ensuring all VBA staff receive the training necessary to avoid 
incidents such as this in the future. It is important to remember these 
are not simply statics and errors rates, but rather real life veterans 
who are struggling and depend on VHA and VBA to sustain their quality 
of life.
    Compensation and pension (C&P) examination reports are available to 
VA clinicians but are located in a different portion of the VA's 
electronic medical record than most other clinical information and, are 
infrequently consulted by clinicians. Compensation examiners have 
access to clinical records for the period preceding the examination and 
are expected to dictate a report soon after interviewing the veteran. 
AMVETS has serious concerns as to whether or not claims examiners are 
properly trained to read the medical diagnosis and background 
information contained within the veteran's record. Medical appointments 
made or kept after the interview are not typically part of the 
examiner's report and attendance at subsequent treatment might be an 
issue if the veteran's claim is denied. A recent VA Compensation 
Service Bulletin, released in April 2011, sought to eliminate 
processing ambiguity relating to PTSD claims. Regional Offices 
nationwide have been largely critiqued because of erratic application 
of rating criteria. The current bulletins are intended in part to 
decrease the overall 23 percent of improper claims processing. AMVETS 
is eager to see if these new practices will actually improve the 
processing of mental health related claims.
    Finally, when discussing the claims process as it related to 
benefits and care for psychological wounds, AMVETS strongly recommends 
a focus on quality instead of quantity when processing claims. AMVETS 
believes this must start with the Rater Veteran Service 
Representative's (RVSR) initial training. AMVETS recommends extending 
the initial training RVSRs' receive, regularly have current RVSRs' 
participate in continuing education and that all training take place at 
an offsite location. RVSRs must have access to uniform, high quality 
and in depth training regardless of what location they will be assigned 
to perform their job. Off site training will eliminate new trainers 
from being taught incorrect or bias practices that are often picked up 
when training occurs on site. Furthermore, AMVETS recommends current 
RVSRs be mandated to participate in regular continuing education 
classes so that they may stay up to date on any and all changes to 
current laws and regulations. AMVETS also recommends stronger 
enforcement of annual reviews in order to identify the strengths and 
weakness of every individual rater. The only way the backlog of mental 
health claims can be decreased is through educating the RVSRs in order 
to have all claims rated correctly the first time.
    AMVETS second area of concern is the noncompliance of numerous 
VISNs to current VHA directives, policies and procedures addressing 
mental health. In 2003 the President of the United States formed a 
commission to investigate the United States mental health care system. 
This Committee issued ``The 2003 President's New Freedom Commission 
Report,'' which identified 6 goals and made 19 broad recommendations 
for transforming the delivery of mental health services in the U.S.
    In 2004 VHA developed its 5 year ``Mental Health Strategic Plan,'' 
(MHSP) that included over 200 initiatives to improve mental heath care 
within VA. Since the MHSP was organized by goals and recommendations 
made by the Commission's 2003 report, rather than by a mental health 
program or operational focus, many of the MHSP initiatives did not make 
clear what specific actions should take place to achieve their goals. 
Therefore, many of the initiatives set forth by the MHSP are not 
measureable.
    With Congressional approval of the VHA Comprehensive Mental Health 
Strategic Plan in 2004, it received additional funding in 2005 through 
the Mental Health Enhancement Initiative. In June 2008 VHA Handbook was 
issued outlining the specific goals and established what are to be the 
minimum clinical requirements for all VHA Mental Health Services. It 
delineates the essential components of the mental health program that 
is to be implemented nationally. However, many felt that the handbook 
was still to broad, so in Sept. 2008 VHA re-issued VHA Handbook 1160.01 
defining more clearly the minimum clinical requirements of mental 
health services. Another important fact is the handbook also specifies 
that all parts of the handbook must be provided to each VA Medical 
Facility (VAMC) and Community-Based Outpatient Clinic (CBOC) and that 
all VA medical facilities and CBOC's are to have these requirements in 
place no later than the last working day of September 2009, unless 
otherwise written granted permission by the Secretary of VA. VHA 
ensured congress that the distribution of this handbook would be 
followed by the distribution of the metrics that would be used to 
ensure the implementation of all of its requirements, and when fully 
implemented the handbook's requirements will complete the patient care 
recommendations of the Mental Health Strategic Plan, and its vision of 
a system providing ready access to comprehensive, evidence-based care 
would be realized. The opening statements published in VHA Handbook 
1160.01, VHA states ``VHA employees are encouraged to become familiar 
with the statutory and regulatory eligibility and enrollment criteria 
for each of the programs discussed in this handbook, and to consult 
their respective VHA program office or business office as needed.''
    VHA states that because they are responsible for mental health care 
to a defined population, that it is their responsibility to ensure 
ready access to care for new patients, as well as for the continuity 
and quality of care for established ones. They continue by adding ``At 
a time when large numbers of veterans are returning from deployment and 
combat, ensuring access to care for patients in need must be considered 
VA's highest priority.'' Finally VHA affirms that ``Every program 
element described in this handbook must be understood as an integrated 
component of overall health care.'' The hand book also states ``Each 
Veterans Integrated Service Network (VISN) must request approval from 
the Deputy Under Secretary for Operations and Management for 
modifications and exceptions for requirements that cannot be met in FY 
2009 with available and projected resources.''
    The following is a short list of specific services and programs in 
the VHA 1160.01 Handbook:

          Suicide Prevention
          Specialized PTSD Services
          Gender-Specific Care and Military Sexual Trauma
          24/7 Emergency Mental Health Care
          Seriously Mentally Ill and Rehabilitation/Recovery 
        Services
          Inpatient Care
          Care Transitions (discharge from medical care with 
        instructions)
          Substance Abuse Disorders
          Homeless Programs
          Incarcerated Veterans Programs
          Elder Care (integration of mental health into medical 
        care)
          Access to Trained Mental Health Staff

    As required by the Military Construction, Veterans Affairs, and 
Related Agencies Appropriation Bill, fiscal year 2009 (FY 09'), the VA 
Office of Inspector General (OIG) conducted a review of VHA's progress 
in implementing the recommendations of the Mental Health Strategic Plan 
as outlined by VHA 1160.01. AMVETS found OIG's findings released in 
2010 quite troubling at best. Given the fact VHA was given over 5 years 
and upwards of $38 billion to develop and implement the critical issues 
addressed in VHA 1160.01, AMVETS finds it to be inexcusable and 
irresponsible that numerous VAMCs and CBOCs are still, in 2011, being 
allowed to operate in a state of noncompliance.
    OIG's findings on the progress of VHA 1160.01 implementation raised 
several concerns for AMVETS. The following is a list of OIG findings 
AMVETS believes must be corrected immediately:

          Accessing timely treatment within all VISNs regarding 
        specialized post-traumatic stress disorder (PTSD) residential 
        program. The current wait time for many veterans living in 
        rural and remote areas of the country is 6 to 8 weeks.
          VHA's lack of ability and trained personnel in 
        providing Intensive Outpatient Services (at least 3 hours per 
        day at least 3 days per week) for the treatment of substance 
        use disorders. As we have seen substance abuse can lead to 
        homelessness and many other problems for veterans not receiving 
        the care they need and are entitled to through their service.
          The limited availability of 23-hour observation beds 
        for patients at risk of harming themselves or others.
          The limited and sometimes non-existent availability 
        of substitution therapy for narcotic dependence to veterans 
        seeking care.
          The failure of numerous VAMCs in providing a 
        Psychosocial Rehabilitation and Recovery Center Program at 
        facilities with more than 1,500 Serious Mental Illness or 
        Impairment (SMI) patients. This includes, but is not limited to 
        schizophrenia, bi-polar mania, sociopathic or homicidal 
        tendencies and suicidal behaviors.
          The failure to have the presence of at least one 
        full-time psychologist to provide clinical services to veterans 
        in VA community living centers (formerly nursing home care 
        units) with at least 100 residents.
          VHA 1160.01 also specifies that all VAMCs and VL 
        CBOCs must have: specialized outpatient PTSD programs and the 
        ability to provide care and support for veterans with PTSD and 
        either a PTSD clinical team (PCT) or PTSD specialists. Overall 
        the data indicates the presence of specialized PTSD or clinical 
        teams (the Handbook requirement) at 79 percent of sites and 49 
        percent of VAMC's had actual PTSD clinics. Very important is 
        the fact that PCT are responsible for training all onsite staff 
        on how to properly treat and interact with veterans suffering 
        PTSD.
          Finally, the Handbook (VHA 1160.01) states that 
        medical centers with 1,500 or more current patients included on 
        the National Psychosis Registry (NPR) must have an outpatient 
        psychosocial rehabilitation recovery center (PRRC). PRRC 
        programs treat patients with serious mental illness (primarily 
        schizophrenia and other psychosis) following stabilization of 
        an acute phase of illness. OIG found that best case scenario 
        was 33 percent of facilities with 1,500 or more ``seriously 
        mentally-ill patients'' (SMI) were compliant. Furthermore, OIG 
        explained they encountered such extreme difficulties regarding 
        this section of the handbook outlining treatment and policies 
        for VA's largest facilities treating 1,500 or more patients 
        diagnosed as severely mentally ill, their only recommendation 
        is as follows:

           ''We cannot distinguish which other psychosocial 
        rehabilitation programs are functionally non-approved PRRCs and 
        which other psychosocial rehabilitation programs have not 
        progressed toward functioning as PRRCs. Administrative data 
        support provision of either an approved PRRC or other 
        psychosocial rehabilitation program at 33-55 percent of all 
        VAMCs with more than 1,500 SMI patients during October 2009. As 
        this represents a best case scenario, more work needs to be 
        done to achieve system-wide implementation of PRRC programs at 
        sites with more than 1,500 SMI patients.''

    From OIG's findings it appears to AMVETS that VA does not currently 
utilize a system to reliably track their own provisions and utilization 
of these therapies and policies on the national level. This is very 
disturbing given the fact that the number of patients seeking care from 
VA who served in OEF/OIF/OND has risen to over 25 percent of the 
initially projected totals and the fact that veteran suicide rates 
continue to rise. Furthermore, VA/VHA set their own objectives and 
expectations for the implementation timeline of the handbook and yet to 
date has failed to meet said deadlines according to OIG. VHA 1160.01 
outlines uniform policies and procedures for the treatment of some of 
the most prevalent health conditions afflicting today's returning 
troops and provides numerous improvements upon current care models for 
veterans of all eras.
    While AMVETS understands what a daunting undertaking the handbook 
posed itself to be, again VA was given over 5 years and appropriated 
billions of dollars to implement the required changes, as well as 
multiple opportunities to express concerns or problems they were 
encountering to Congress. Numerous hearings and OIG reports measuring 
the implementation of the handbook clearly illustrated the troubles VA 
was experiencing implementing the handbook and many of the OIG reports 
showed VA to be behind schedule in their `implementation processes,' 
however VA officials repeatedly told Congress they would meet the 
September 30, 2009 deadline. To date the handbook remains partially 
implemented. AMVETS believes VA and Congress must start taking a more 
proactive approach in ensuring our veterans are receiving all the 
necessary mental health care. Until we stop taking a ``reactionary'' 
approach to bettering the VA system of mental health we are destined to 
be playing ``catch up'' in meeting the needs of today's returning war 
fighters.
    AMVETS must stress the urgency of the handbook's implementation. 
According to VA, the needs of OIF/OEF/OND veterans for mental health 
services are even greater, with almost 45 percent having been evaluated 
for, or having received, a possible diagnosis of a mental health 
disorder. Another recent study by the American Council on Disabilities 
found that 30 to 45 percent of all servicemembers returning from Iraq 
and Afghanistan have been clinically diagnosed with PTSD, depression, 
TBI and/or dual diagnoses of these illnesses and injuries. AMVETS notes 
that there are still many of returning servicemembers who have not yet 
sought treatment for their psychological wounds, skewing the aforesaid 
numbers. AMVETS also stresses the urgency of plan completion by 
recommending a more attentive oversight process, and an empowered 
organizational structure to inform that oversight accountability.
    Another important part of bridging the gap within VA's mental 
health care that needs to be addressed involves the services available 
to members of the National Guard and Reserve. The suicide rates among 
this population continue to rise at a rate this country has never seen. 
AMVETS believes this can be partially attributed to the lack of 
services available to this group of servicemembers. On June 6, 2010 the 
Walter Reed Army Institute of Research released the findings of their 
first study. The study focused on the mental health and functional 
impairments of returning National Guardsmen and the progression of 
symptoms over time. The study outlined statistics on PTSD, depression 
and other psychiatric, and some physical, diagnoses. It is important to 
note that this study was conducted through self reporting and two 
mailed surveys. These surveys were distributed to 18,305, composed of 
Iraq war veterans from four different units and two National Guard 
infantry brigade combat teams. Part of this study reported up to 14 
percent of returning servicemembers suffer at least one symptom of 
PTSD. The symptoms studied ranged from nightmares to physical violence. 
The study went on to explain the strictest definition, defined as high 
incidence rates and serious impairment of normal functioning, found a 
PTSD rate of between 5.6 percent and 11.3 percent, with depression 
ranging from 5 to 8.5 percent. Those numbers affirm many past studies 
on PTSD and depression prevalence among returning servicemembers. We 
all agree that mending our servicemembers' psychological wounds is just 
as important as mending the physical ones. In contrast we obviously do 
not all agree on the most effective and responsible way of reporting 
and educating the public and the DoD communities.
    The Army National Guard had the highest rate of suicide among the 
service branches in 2010.
    Using the National Guard as an operational force in the Global War 
on Terror will require a more accessible mental health program for 
servicemembers, veterans and their families post deployment in order 
both to provide the care they deserve as veterans and to maintain the 
necessary medical readiness required by current deployment cycles. 
Members of the National Guard, Reserve and their families rely heavily 
on VA for mental health care services and resources post deployment. In 
2009, Congress recognized this need through the passing of ``The 
Caregivers and Veterans Omnibus Health Services Act of 2009,'' now 
known as Public Law 111-163, enacted May 6, 2010. P.L. 111-163 requires 
VA to provide enhanced mental health services to veterans and their 
immediate family members. Unfortunately, distressing developments have 
emerged since the passage of P.L. 111-163. One of these developments is 
VA's failure to implement Section 304 of P.L. 111-163. Section 304 
requires VA, no later than 180 days after its passage or by November 6, 
2010, to establish a program that provides mental health services to 
the Guard and Reserve members under VA care, as well as to the 
immediate family members of veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom. To date VA has failed to implement the program 
as required by P.L. 111-163. AMVETS and other member organizations 
within the VSO/MSO community fear VA has no intention to implement P.L. 
111-163, Section 304, beyond allowing the Vet Centers to continue to 
provide counseling to families of qualified veterans. Unfortunately, 
Vet Center counseling, even though very good, does not provide the full 
range of mental health services veterans or their immediate family 
members may need.
    Furthermore, VA is required by P.L. 111-163, Section 304 to 
contract out with private entities in rural communities to bridge the 
geographical barriers preventing many of our veterans and their 
families from receiving mental health treatment and care. AMVETS 
requests this Committee to closely monitor the implementation of 
Section 304,\5\ which to date has not occurred. It has been clearly 
illustrated through VA's numerous actions, and lack thereof, that only 
the strictest of oversight by Congress will ensure the proper and 
timely implementation of P.L. 111-163.
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    \5\ P.L. 111-163, SEC. 304. PROGRAM ON READJUSTMENT AND MENTAL 
HEALTH CARE SERVICES FOR VETERANS WHO SERVED IN OPERATION ENDURING 
FREEDOM AND OPERATION IRAQI FREEDOM.

    (a)  Program Required--Not later than 180 days after the date of 
the enactment of this Act, the Secretary of Veterans Affairs shall 
establish a program to provide--

        (1)  to veterans of Operation Enduring Freedom and Operation 
Iraqi Freedom, particularly veterans who served in such operations 
while in the National Guard and the Reserves--

          (A)  peer outreach services;
          (B)  peer support services;
          (C)  readjustment counseling and services described in 
section 1712(A) of title 38, United States Code; and
          (D)  mental health services; and

        (2)  to members of the immediate family of veterans described 
in paragraph (1), during the 3-year period beginning on the date of the 
return of such veterans from deployment in Operation Enduring Freedom 
or Operation Iraqi Freedom, education, support, counseling, and mental 
health services to assist in--

          (A)  the readjustment of such veterans to civilian life;
          (B)  in the case such veterans have an injury or illness 
incurred during such deployment, the recovery of such veterans from 
such injury or illness; and
          (C)  the readjustment of the family following the return of 
such veterans.

    (b)  Contracts With Community Mental Health Centers and Other 
Qualified Entities--In carrying out the program required by subsection 
(a), the Secretary may contract with community mental health centers 
and other qualified entities to provide the services required by such 
subsection only in areas the Secretary determines are not adequately 
served by other health care facilities or vet centers of the Department 
of Veterans Affairs. Such contracts shall require each contracting 
community health center or entity--

        (1)  to the extent practicable, to use telehealth services for 
the delivery of services required by subsection (a);
        (2)  to the extent practicable, to employ veterans trained 
under subsection (c) in the provision of services covered by that 
subsection;
        (3)  to participate in the training program conducted in 
accordance with subsection (d);
        (4)  to comply with applicable protocols of the Department 
before incurring any liability on behalf of the Department for the 
provision of services required by subsection (a);
        (5)  for each veteran for whom a community mental health center 
or other qualified entity provides mental health services under such 
contract, to provide the Department with such clinical summary 
information as the Secretary shall require;
        (6)  to submit annual reports to the Secretary containing, with 
respect to the program required by subsection (a) and for the last full 
calendar year ending before the submittal of such report--

          (A)  the number of the veterans served, veterans diagnosed, 
and courses of treatment provided to veterans as part of the program 
required by subsection (a); and
          (B)  demographic information for such services, diagnoses, 
and courses of treatment; and

        (7)  to meet such other requirements as the Secretary shall 
require.

    (c)  Training of Veterans for Provision of Peer-outreach and Peer-
support Services--In carrying out the program required by subsection 
(a), the Secretary shall contract with a national not-for-profit mental 
health organization to carry out a national program of training for 
veterans described in subsection (a) to provide the services described 
in subparagraphs (A) and (B) of paragraph (1) of such subsection.
    (d)  Training of Clinicians for Provision of Services--The 
Secretary shall conduct a training program for clinicians of community 
mental health centers or entities that have contracts with the 
Secretary under subsection (b) to ensure that such clinicians can 
provide the services required by subsection (a) in a manner that--

        (1)  recognizes factors that are unique to the experience of 
veterans who served on active duty in Operation Enduring Freedom or 
Operation Iraqi Freedom (including their combat and military training 
experiences); and
        (2)  uses best practices and technologies.

    (e)  Vet Center Defined--In this section, the term `vet center' 
means a center for readjustment counseling and related mental health 
services for veterans under section 1712A of title 38, United States 
Code.
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    Our National Guard and Reserve veterans of OIF/OEF/OND for the most 
part are still serving with their units and are still subject to 
deployment. It is historical anomaly for VA to be caring for veterans 
still subject to redeployment. To create a seamless medical transition 
from active duty to VA and then back to active duty will require 
improved medical screenings of these men and women before their initial 
release from DoD. AMVETS believes it will be essential for DoD and VA 
to have a clearer system of communication if they wish to properly 
identify the medical issues requiring care and to avoid redeploying 
servicemembers who should stay stateside for treatment of psychological 
wounds. AMVETS believes DoD needs to responsibly share the cost with VA 
in funding mental health care for our National Guard and Reserve 
members between deployments, which to date remains an unmet readiness 
need.
    It is imperative for DoD to ensure at the end of every deployment 
all returning servicemembers be examined confidentially at their home 
station or base by a qualified mental health care provider. This would 
help correct the underreporting of psychological health symptoms on 
``Post Deployment Health Assessment'' (PDHA) forms, which are currently 
being processed either in theater or at demobilization sites which in 
most cases are far removed from home. The PDHA is a self assessment 
questionnaire given to returning servicemembers and is subject to the 
instruction that reporting a serious medical condition may result in 
the servicemember being medically held on active duty at the 
demobilization site far from home or medically discharged. These brave 
men and women would rather suppress any psychological wound before they 
ever let their units deploy without them. Moreover, rather than risk 
being retained on active duty and further separated from their 
families, many members of the Guard and Reserve are not reporting or 
are underreporting their psychological wounds on the PDHA in order to 
return home as soon as possible and to avoid being medically 
discharged. As a consequence, unreported psychological health symptoms 
that are best treated expeditiously are going untreated because they 
are not being captured at this earliest post deployment opportunity. 
This underreporting of service-connected injuries not only delays VA 
treatment but could also prejudice later VA disability claims filed by 
transitioning servicemembers. Prior inconsistent medical statements can 
have a very negative impact on subsequent VA disability claims as well. 
Furthermore, AMVETS believes VA must implement a stronger mental health 
screening process for all newly enrolled veterans. This will assist VA 
in identifying veterans with mental health issues that may have slipped 
through the cracks at DoD. AMVETS also strongly recommends immediate, 
joint VA and DoD, development and implementation of stronger post 
deployment and transition mental health assessments in order to 
identify and treat these wounds at their start, rather than later when 
these untreated wounds have been amplified by more deployments or 
simply by being allowed to fester over time without the necessary 
medical treatment. If VA and DoD want to stop the avoidable trend of 
increased suicides among those under their care they need to take a 
more proactive approach to treatment. As the increasing suicide rates 
among our veteran and military communities have shown us, 
``reactionary'' care models do not work.
    At all stages of PTSD and depression, treatment is time sensitive 
but this is particularly so after onset as the illness could persist 
for a lifetime if not promptly and adequately treated and could render 
the member permanently disabled. The effects of this permanent 
disability on the member's entire family can be devastating. AMVETS 
believes it is absolutely imperative that all servicemembers returning 
from deployment be screened with full confidentiality, while still on 
active duty by trained and qualified mental health care providers from 
VA staff and/or qualified health care providers from the civilian 
community when the demand exceeds the resources DoD and VA can provide. 
Prompt diagnosis and treatment will help to mitigate the lasting 
effects of these psychological wounds. Furthermore, AMVETS believes DoD 
and VA must do a better job in removing the fear and stigmas associated 
with seeking care for mental health issues. AMVETS believes admitting 
you need assistance and actively seeking out the necessary resources 
shows a person to have great resiliency, strength and determination in 
wanting to better their life.
    AMVETS believes inadequate medical screenings of our servicemembers 
before they are released from active duty is unacceptable for a group 
that has selflessly sacrificed for our country. This is just as true 
for those seeking the care and resources of VA after their release from 
DoD. Given the enormous number of this Nation's returning war fighters 
who have sustained a psychological wound during their service, AMVETS 
believes it is time to stop this vicious cycle of reactionary care that 
has caused us to have to bury veterans who suffered in silence for so 
long they felt the only way out was to take their own life since they 
wholeheartedly believed they were an unnecessary burden to their 
families or communities any longer. AMVETS strongly believes that the 
men and women who have selflessly sacrificed to serve this Nation 
deserve much more than we are currently offering.
    Chairman Miller, Ranking Member Filner and distinguished Members of 
the Committee, AMVETS again thanks you for inviting us to share our 
concerns and recommendations regarding this critical issue. This 
concludes my testimony and I stand ready to address any questions you 
may have for me.

                                 
      Prepared Statement of Antonette Zeiss, Ph.D., Acting Deputy
       Patient Care Services Officer for Mental Health, Veterans
       Health Administration, U.S. Department of Veterans Affairs
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee: Thank you for the opportunity to appear and discuss the 
Department of Veterans Affairs' (VA) response to the mental health 
needs of America's Veterans. I am accompanied today by my colleagues, 
Dr. Matthew Friedman, Executive Director of VA's National Center for 
PTSD, Veterans Health Administration (VHA); Dr. Mary Schohn, Acting 
Director of the Office of Mental Health Operations in VHA, and Mr. Tom 
Murphy, Veterans Benefits Administration (VBA) Director of Compensation 
Service.
    VA has responded aggressively since fiscal year (FY) 2005 to 
address previously identified gaps in mental health care by expanding 
our mental health budgets significantly. In FY 2011, VA's budget for 
mental health services, not including Vet Centers, pharmacy, and 
primary care, reached over $5.7 billion, while the amount included in 
the President's budget for FY 2012 is $6.15 billion. Both of these 
figures represent dramatic increases from the $2.4 billion obligated in 
FY 2005.
    This funding has been used to greatly enhance mental health 
services for eligible Veterans. VA has increased the number of mental 
health staff in its system by more than 7,500 full time employees since 
FY 2005. During the past 3 years, VA has trained over 4,000 staff 
members to provide psychotherapies with the strongest evidence for 
successful outcomes for post-traumatic stress disorder (PTSD), 
depression, and other conditions. Furthermore, we require that all 
facilities make these therapies available to any eligible Veteran who 
may benefit. We also have expanded inpatient, residential, and 
outpatient mental health programs with an emphasis on integrating 
mental health services with primary and specialty care. These 
expansions also have increased the numbers of Veterans receiving mental 
health care in VA. In FY 2010, VA treated more than 1.25 million unique 
Veterans in a VA specialty mental health program within medical 
centers, clinics, inpatient settings, and residential rehabilitation 
programs; this was an increase from 905,684 treated in FY 2005. If 
including care delivered when mental health is an associated diagnosis 
in integrated care settings, such as primary care, VA treated almost 
1.9 million Veterans in FY 2010, an increase of almost a half a million 
Veterans since FY 2005.
    According to VHA guidelines, all new patients requesting or 
referred for mental health services must receive an initial evaluation 
within 24 hours, and a more comprehensive diagnostic and treatment 
planning evaluation within 14 days. These guidelines help support VA's 
Suicide Prevention Program which is based on the concept of ready 
access to high quality mental health care and other services, and is 
discussed in more detail later in this testimony. Data closely 
monitored by VA confirm that our established standards for access to 
mental health care are met. Over 95 percent of all Veterans referred 
for new mental health care receive an appointment leading to diagnosis, 
and when warranted a full treatment plan, within 14 days. Similarly, 
data confirm that over 95 percent of established mental health patients 
also receive appointments for continuing care within 14 days of the 
preferred date, based on the treatment plan. VA also participated from 
FY 2006 through FY 2010 in a Government Performance and Results Act 
review, which was recently submitted to Congress. That review, 
conducted by RAND/Altarum, concluded that VA mental health care was 
superior to other mental health care offered in the United States on 
almost all dimensions surveyed. These data speak to the great strides 
made in the mental health care VA provides since implementation of the 
Comprehensive Mental Health Strategic Plan began in FY 2005, 
culminating with the Uniform Mental Health Services Handbook that was 
disseminated at the end of FY 2008 as VA policy for comprehensive 
mental health services to be offered throughout our health care system.
    In this testimony, I will begin by describing PTSD and associated 
scientific evidence, with particular focus on two important findings 
from research: that recovery from PTSD is complicated by co-occurring 
disorders, and that even the most effective treatments do not guarantee 
recovery. I will then explain VBA's role in providing support and 
compensation to affected Veterans. Finally, I will review some 
highlights of VA's mental health care program, including a general 
description of the services and care provided, the recovery-oriented 
nature of our programs, our suicide prevention and crisis line, VA's 
Readjustment Counseling Service and Vet Centers, and PTSD-specific 
care.

Explanation of PTSD and Scientific Evidence on PTSD

    All VA clinicians, including those responsible for completing 
Compensation and Pension (C&P) evaluations, adhere to the American 
Psychiatric Association's Diagnostic and Statistical Manual of Mental 
Disorders Volume IV Text Revision (DSM-IV-TR), recognized as the 
authoritative source for mental health conditions. According to the 
DSM-IV-TR clinical criteria, PTSD can follow exposure to a severely 
traumatic stressor that involves personal experience of an event 
involving actual or threatened death or serious injury. It can also be 
triggered by witnessing an event that involves death, injury, or a 
threat to the physical integrity of another. The person's response to 
the event must involve intense fear, helplessness or horror. The 
symptoms characteristic of PTSD include persistent re-experiencing of 
the traumatic event, persistent avoidance of stimuli associated with 
the trauma, numbing of general responsiveness, and persistent symptoms 
of increased arousal. No single individual displays all these symptoms, 
and a diagnosis requires a combination of a sufficient number of 
symptoms, while recognizing that individual patterns will vary. PTSD 
can be experienced in many ways. Symptoms must last for more than 1 
month and the disturbance must cause clinically significant distress or 
impairment in social, occupational or other important areas of 
functioning. Military combat certainly creates situations that fit the 
DSM-IV-TR description of a severe stressor event that can result in 
PTSD. The likelihood of developing PTSD is known to increase as the 
proximity to, intensity of, and number of exposures to such stressors 
increases.
    PTSD is associated with increased rates of other mental health 
conditions, including Major Depressive Disorder, Substance-Related 
Disorders, Generalized Anxiety Disorder, and others. PTSD can directly 
or indirectly contribute to other medical conditions. Duration and 
intensity of symptoms can vary across individuals and within 
individuals over time. Symptoms may be brief or persistent; the course 
of PTSD may ebb and return over time, and PTSD can have delayed onset. 
Clinicians use these criteria and discussions with patients to identify 
cases of PTSD, sometimes in combination with additional psychological 
testing. VA adheres to the guidance of the DSM-IV-TR when it states, 
``Specific assessments of the traumatic experience and concomitant 
symptoms are needed for such individuals.'' VA seeks to ensure we offer 
the right diagnosis in all clinical settings, whether for C&P 
examinations or as part of a standard mental health assessment for 
clinical treatment planning.
    VA recognizes that many individuals with symptoms of combat stress 
or PTSD find it difficult to discuss the details of their experiences, 
although they can more easily describe their symptoms and level of 
distress. However, without their disclosing the source of the stress, 
it is impossible for a clinician to diagnose patients with PTSD 
according to the clinical criteria of the DSM-IV-TR. Clinicians must 
develop a sense of safety and trust with patients in order to make them 
feel comfortable enough to share their trauma in the clinical 
interview. The expertise and sensitivity required for such clinical 
evaluation is one of the reasons why only doctoral level psychiatry and 
psychology providers are allowed to conduct initial C&P exams for 
service-connected PTSD.
    The following evidence provides a brief overview of current 
scientific understanding of PTSD, particularly those findings related 
to VA decisions on care for Veterans with PTSD and determination of 
service-connected disability for PTSD. Research demonstrates that PTSD 
prevalence is directly related to the likelihood of traumatic exposure 
and is therefore greatest among individuals who are most likely to face 
life-threatening situations such as military personnel, police, 
firefighters, and emergency medical practitioners. Among deployed 
Servicemembers, PTSD prevalence varies with each different military 
engagement. Among Operation Enduring Freedom, Operation Iraqi Freedom, 
Operation New Dawn (OEF/OIF/OND) personnel, PTSD is estimated to affect 
approximately 15 percent of deployed Servicemembers. Data from a number 
of sources has shown increasing rates of PTSD with increasing numbers 
of deployments. Given the reality of PTSD as a diagnosis that has 
greater prevalence among Veterans, the following discussion offers some 
perspective on the challenges faced by those with a PTSD diagnosis and 
the challenges in conceptualizing and providing the most effective 
treatments.
    OEF/OIF/OND Veterans with PTSD exhibit significantly more problems 
with post-deployment readjustment, including homelessness, marital 
instability and divorce, family problems such as parenting, and poor 
occupational functioning. PTSD is associated with unemployment for 
Veterans of all eras. Data from the Bureau of Labor Statistics for 2008 
shows that unemployment for OEF/OIF-era Veterans was 7.3 percent as 
compared with the overall jobless rate of 4.6 percent for Veterans of 
all eras, and 5.6 percent for non-Veterans. A number of studies have 
documented more functional impairment and role limitations at work due 
to PTSD, more sick calls and missed days of work, more depression, 
poorer physical functioning, more divorce, poorer relationship 
functioning and more psychosocial difficulties.\1\ Veterans who 
screened positive for PTSD were more than four times as likely to 
indicate suicidal thoughts as Veterans without PTSD. This rate 
increases to 5.7 times more likely if there are two or more comorbid 
disorders associated with PTSD.
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    \1\  See, e.g., Paula P. Schnurr, et al., Posttraumatic Stress 
Disorder and Quality of Life: Extension of Findings to Veterans of the 
Wars in Iraq and Afghanistan, 29 CLINICAL PSYCHOLOGY REVIEW, 727 
(2009).

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Recovery From PTSD Is Complicated by Co-Occurring Disorders

    Recovery from PTSD is usually complicated by co-occurring 
disorders, since most Veterans with PTSD have at least one additional 
diagnosis such as traumatic brain injury (TBI), depression, substance 
use disorder (SUD), chronic pain, problems with aggression, insomnia 
and other medical problems. Treating Veterans with multiple conditions 
cannot be restricted to PTSD but must address the other problems 
concurrently. For example, a Veteran with PTSD and chronic pain as a 
result of his or her injuries will experience the pain as a traumatic 
trigger that will reactivate other reactions such as PTSD nightmares, 
avoidant symptoms, and hyperarousal. The pain must be treated along 
with the PTSD if clinical improvement can be expected realistically. 
Unfortunately, although VA has excellent treatments for PTSD alone, the 
development of evidence-based treatments for concurrent PTSD and 
chronic pain is still at an early stage.

Even the Most Effective Treatments Do Not Guarantee Recovery

    Not everyone with PTSD who receives evidence-based treatment is 
likely to have a favorable response. For example, a recent analysis 
(submitted for publication) of data from VA's large Cooperative Study 
(CSP#494) on prolonged exposure to the stress factors associated with 
and contributing to PTSD symptoms among female Veterans and active duty 
Servicewomen identified those factors that predict poor treatment 
outcome. This is the largest randomized clinical trial of Prolonged 
Exposure (PE) ever conducted, with 284 participants, and the first one 
focusing solely on Veterans and military personnel. While the results 
(overall) clearly showed the efficacy of PE treatment for women with a 
military history who have PTSD, our analysis shows that Veterans with 
the most severe PTSD are least likely to benefit from a standard course 
of treatment. Other factors that predicted poor response were 
unemployment, comorbid mood disorder, and lower education. In other 
words, those with the worst PTSD are least likely to achieve remission, 
as is true with any other medical problem.
    Even when Veterans are able to begin and sustain participation in 
treatment, timing, parenting, social, and community functions all 
matter a great deal. Treatment, especially treatment of severe PTSD, 
may take a long time. During this period, disabled Veterans with PTSD 
are at risk for many severe problems including family problems, 
parenting, inability to hold a job, inability to stay in school, social 
and community function. Further, evidence also shows that whereas a 
positive response to treatment may reduce symptom severity and increase 
functional status among severely affected Veterans, the magnitude of 
improvement may not always be enough to achieve clinical remissions or 
terminate disability. This is no different than what is found with 
other severe and chronic medical disorders (such as diabetes or heart 
disease) where effective treatment may make a difference in quality of 
life without eradicating the disease itself.

Compensation for PTSD

    VBA has taken a number of steps to improve the effectiveness, 
timeliness, and consistency of the PTSD claims adjudication process. 
These improvements have occurred within the general framework of PTSD 
regulations and the medical examination process. In October 2008, VA 
amended its regulations to relax the stressor verification requirements 
where PTSD is diagnosed while a member is on active duty. In July 2010, 
VA again amended its regulations to relax stressor verification 
requirements where the claimed stressor is related to fear of hostile 
military or terrorist activity and the stressor is consistent with the 
places, types, and circumstances of service. The adjudication process 
involves making a determination as to: (1) whether current symptoms are 
connected to service and, if so, (2) what level of compensation is 
appropriate.

Service-Connection

    Service-connection for PTSD is governed by 38 CFR Sec. 3.304(f) and 
requires:

          Medical evidence diagnosing the condition in 
        accordance with the American Psychiatric Association's DSM-IV 
        [Diagnostic and Statistical Manual of Mental Disorders];
          A link, established by medical evidence, between 
        current symptoms and an in-service stressor; and
          Credible supporting evidence that the claimed in-
        service stressor occurred.

    The regulation draws a distinction between different types of 
stressors and the evidence required to substantiate them. If the 
stressor relates to an in-service diagnosis of PTSD, participation in 
combat with the enemy, or being held as a prisoner of war, the 
Veteran's lay statement alone may be sufficient to establish occurrence 
of the stressor. For all other stressor types, except the new type 
described below, VBA must substantiate occurrence of the stressor with 
credible supporting evidence.
    As the wars in Iraq and Afghanistan progressed and Veterans 
returning from those areas of conflict filed more claims for PTSD, it 
became apparent that a modification to the PTSD regulations was 
necessary to facilitate a more effective adjudication process. Many 
claims were filed by Veterans who were not involved with direct combat, 
but who experienced stressors related to their war-zone service. In 
these cases, the Veteran's lay statement was not sufficient to 
establish occurrence of the stressor, and obtaining credible 
documentation of the stressor was difficult and time consuming. As a 
result, VBA modified the PTSD regulations to add section 3.304(f)(3) in 
July 2010. This section provides that the Veteran's lay testimony alone 
may establish occurrence of the claimed in-service stressor if:

          The Veteran's stressor is related to fear of hostile 
        military or terrorist activity;
          A VA psychiatrist or psychologist (or contract 
        equivalent) confirms the claimed stressor is adequate to 
        support a diagnosis of PTSD and symptoms are related to the 
        stressor;
          There is no clear and convincing evidence to the 
        contrary; and
          The claimed stressor is consistent with places, 
        types, and circumstances of service.

    This regulation change has allowed VBA to schedule a PTSD 
examination in ``fearbased'' stressor claims without the need to 
objectively document the occurrence of the stressor, as long as the 
Veteran served in an area of potential hostile military or terrorist 
activity. When the stressor is accepted by the medical examiner and 
associated with current PTSD symptoms, the occurrence of the stressor 
is established. This has improved effectiveness by reducing evidence-
development time and promoting an equitable and consistent approach to 
evaluating PTSD claims where stressor evidence is difficult to obtain.
    Military sexual trauma (MST) claims fall under the PTSD regulatory 
heading of personal assault, at section 3.304(f)(5). These claims 
receive special treatment because of the sensitive nature of the 
stressor and the difficulty with obtaining evidence to support its 
occurrence. Evidence is sought from multiple sources in addition to 
military records, and any evidence of the Veteran's behavioral change 
is among the different types of evidence that may provide credible 
evidence of the stressor. The examiner's assessment of the evidence may 
then lead to a finding of occurrence of the stressor. Because of an 
emerging focus on these MST claims, VBA recently incorporated tracking 
mechanisms into the computer programs used to produce and store 
adjudication decisions. This will allow VBA to monitor statistics on 
these cases and determine how to further improve processing 
effectiveness.

Compensation

    Once service-connection is established in a PTSD claim, a 
determination of the rate of disability compensation payable must be 
made. This involves comparing the medical evidence describing symptom 
severity with the rating criteria in the VA Schedule for Rating 
Disabilities, contained in 38 CFR Part 4. PTSD, along with all other 
mental disorders, is evaluated under a section that assigns various 
degrees of disability, in percentages ranging from 0 to 100 percent, to 
various levels of occupational and social functioning, from no 
impairment to total occupational and social impairment. The rate of 
compensation paid correlates to the degree of disability assigned. VBA 
employees who adjudicate these claims must often exercise a measure of 
judgment when medical evidence is less than consistent. As a means to 
improve effectiveness and reduce judgmental variation, VBA, in 
conjunction with the Veterans Health Administration (VHA), developed a 
revised worksheet for the PTSD examiners to use. This serves as the 
basis for the final examination report, which is reviewed by VBA 
adjudicators when making their decisions. The revised worksheet prompts 
the examiner to choose one of a range of options that most closely 
describes the scope of the Veteran's symptom severity. The wording of 
the options is consistent with the wording of symptom gradations 
described in the actual mental-disorder rating schedule. This provides 
adjudicators with a statement from a medical authority that matches the 
rating schedule and thereby provides the basis for more accurate and 
consistent ratings.
    To devise a more comprehensive means to improve effectiveness and 
consistency in PTSD and other mental-disorder claims adjudication, VBA 
and VHA are developing an entirely new rating schedule for mental 
disorders. This evolved from a national mental health conference in 
January 2010 and an acknowledged need to update the rating schedule in 
order to conform to current medical practice. This new version has not 
been finalized, but will shift the emphasis from disabling symptoms to 
a functional impairment model that focuses on work and income-related 
outcomes. When the final version of this new rating schedule is 
adopted, it will further the goal of increased effectiveness and 
consistency in PTSD rating decisions. The proposed revision has been 
drafted and is in concurrence. We anticipate publishing the final rule 
by December 2012.
    VA currently does everything possible to support Veterans with PTSD 
and offer care and benefits that will enable them to begin a course of 
effective treatment through its excellent mental health services. We 
understand that some Veterans advocates have recommended a program that 
would offer Veterans financial incentives to seek treatment and delay 
applications for compensation and pension. VA believes delaying 
compensation to severely affected Veterans until they have had a full 
course of treatment will leave them vulnerable and at risk of the 
consequences of PTSD, such as suicide, homelessness, incarceration, 
marital/family disruption and unemployment. In addition, because 
avoidance of stressful situations, especially those that may remind the 
person with PTSD of the original traumatizing experience, is inherent 
in the diagnosis of PTSD, many severely affected Veterans will be 
challenged in seeking VA exposure-based treatment or maintaining 
participation in such treatment, once started. Handling this issue is 
the essence of successful care for PTSD: trauma survivors are best 
treated by re-experiencing of the original situation, in a safe and 
supportive environment with clinical relearning opportunities; however, 
the nature of the disorder makes this intrinsically difficult. Forcing 
individuals to enter treatment before they are ready and have developed 
trust of their therapist and the clinical environment could not only 
lead to treatment failure but also to retraumatization.

VA Mental Health Services

    In addition to our compensation and pension programs, VA offers 
mental health services to eligible Veterans through medical facilities, 
community-based outpatient clinics (CBOC), and in VA's Vet Centers. As 
noted above, VA has been making significant advances in its mental 
health services since 2005, beginning with implementation of the VA 
Comprehensive Mental Health Strategic Plan utilizing special purpose 
funds available through the Mental Health Enhancement Initiative. In 
2008 implementation of the strategic plan culminated in development of 
the VHA Handbook on Uniform Mental Health Services in VA Medical 
Centers and Clinics, which defines what mental health services should 
be available to all enrolled Veterans who need them, no matter where 
they receive care. Current efforts focus on fully implementing the 
Handbook, and continuing progress made, emphasizing additional areas 
for development, and sustaining the enhancements made to date.
    VA's enhanced mental health activities include outreach to help 
those in need to access services, a comprehensive program of treatment 
and rehabilitation for those with mental health conditions, and 
programs established specifically to care for those at high risk of 
suicide. VA has a full range of sites of care, including inpatient 
acute mental health units, extended care Residential Rehabilitation 
Treatment Programs, outpatient specialty mental health care, mental 
health care in integrated physical health/mental health settings such 
as the Patient Aligned Care Team (PACT), geriatrics and extended care 
settings, and Home-Based Primary Care, which delivers mental health 
services to eligible home-bound Veterans and their caregivers in their 
own homes.
    For Veterans seen in VA, identifying and treating patients with 
PTSD and other mental health conditions is paramount. VA's efforts to 
facilitate treatment while removing the stigma associated with seeking 
mental health care are yielding valuable results. VA screens any 
patient seen in our facilities for depression, PTSD, problem drinking, 
and a history of military sexual trauma. Any positive screen must be 
followed by a full diagnostic evaluation; if the screening is positive 
for PTSD or depression, an additional suicide risk assessment is 
conducted. This screening and treatment have been incorporated into 
primary care settings, resulting in the identification of many Veterans 
who benefit from early treatment, before they may have reached the 
point of initiating discussion of mental health difficulties they are 
facing.
    VA also offers a full continuum of care, including our array of 
inpatient, residential rehabilitation, and outpatient services for 
Veterans with one or more of the following conditions (this list is 
illustrative, not exhaustive): serious mental illness (such as 
schizophrenia), PTSD, alcohol and substance abuse disorders, 
depression, and anxiety disorders. Special programs are offered for 
Veterans at risk of suicide, Veterans who are homeless, and Veterans 
who have experienced military sexual trauma with resulting development 
or exacerbation of mental health problems.
    VA ensures that treatment of mental health conditions includes 
attention to the benefits as well as the risks of the full range of 
effective interventions, with emphasis on all relevant, evidence-based 
modalities, including psychopharmacological care, psychotherapy, peer 
support, vocational rehabilitation, and crisis intervention. VA is 
focused on providing patient-centered, effective care by ensuring that 
when there is evidence for the effectiveness of a number of different 
treatment strategies, the choice of treatment should be based on the 
Veteran's values and preferences, in conjunction with the clinical 
judgment of the provider.
    To reduce the stigma of seeking care and to improve access, VA has 
integrated mental health into primary care settings to provide much of 
the care that is needed for those with the most common mental health 
conditions, when appropriate. Mental health services are incorporated 
in the evolution of VA primary care to PACT, an interdisciplinary model 
to organize a site for holistic care of the Veteran in a single primary 
health care location. In parallel with the implementation of these 
programs, VA has been modifying its specialty mental health care 
services to emphasize psychosocial as well as pharmacological 
treatments and to focus on principles of rehabilitation and recovery.

Recovery-Oriented Care

    With the publication and dissemination of VHA Directive 1160.01, 
Uniform Mental Health Services in VA Medical Centers and Clinics in 
September 2008, VHA required that all mental health services must be 
recovery-oriented, with special emphasis on those services provided to 
Veterans with serious mental illness. VA has adopted the definition of 
recovery as developed by the Substance Abuse and Mental Health Services 
Administration (SAMHSA), which states: ``Mental health recovery is a 
journey of healing and transformation enabling a person with a mental 
health problem to live a meaningful life in a community of his or her 
choice while striving to achieve his or her full potential.'' It is 
important to note that this definition does not refer to the individual 
being ``cured'' of mental illness. Rather, it is a functional 
definition that describes an improved quality of life--often while 
managing ongoing symptoms of mental illness--as a result of engaging in 
recovery-oriented services.
    Recovery-oriented services are strengths-based, individualized, and 
person-centered. These services strive to help the Veteran feel 
empowered to realize his or her goals and to engender hope that 
symptoms of mental illness can be managed and integration into the 
community can be achieved. They rely on support for the Veteran from 
clinical staff, family, and friends and allow the Veteran to take 
responsibility for directing his or her own treatment, within the range 
of viable, evidence-based approaches to care.
    Although reducing the symptoms of mental illness that the Veteran 
is experiencing is important, the goal of recovery-oriented treatment 
services does not focus solely on symptom reduction, as symptoms may 
wax and wane over the course of the individual's life. While reducing 
the symptoms of mental illness the Veteran is experiencing is 
important, the reduction of symptoms alone does not mean that the 
Veteran has the skills necessary to lead a meaningful life. The goal of 
recovery is to help Veterans with mental illness achieve personal life 
goals that will result in improved functioning, while managing the 
symptoms they experience to the extent possible. For some Veterans, 
recovery could mean that they are able to live independently and that 
they have meaningful interpersonal relationships. For others, it could 
mean that they are able to return to school or achieve meaningful 
employment. VA believes that all Veterans should be afforded the 
opportunity to work, and offers the Supported Employment program to 
Veterans whose mental health problems interfere with obtaining or 
sustaining employment. This program has been implemented as an 
important recovery-oriented tool to assist those Veterans with serious 
mental illness in gaining competitive employment and providing 
continuing coaching and other services to increase the chances of 
success at work.
    It is important to emphasize that the path to recovery is not 
necessarily linear. Periods of significant growth, improvement, and 
stability in functioning are sometimes interrupted by periods of 
increased difficulty that may be accompanied by a worsening of symptoms 
or other setbacks. Such setbacks may have a significant effect on 
Veterans' ability to reach their goals. Many Veterans, for example, 
value work and understand its importance in improving their self-esteem 
and helping their integration into the community. Advancing in 
employment to the degree the Veteran could have expected without a 
mental health problem is often difficult or impossible, however, given 
the impact of remaining symptoms. The other major concern for Veterans 
in a recovery-focused course of treatment is that maintaining 
employment may be difficult if the Veteran has to take time away from 
the job due to a worsening of symptoms. Veterans with serious mental 
illness often become concerned that they will lose their jobs and will 
not be able to provide for themselves or their family during times of 
such relapse. In addition, while life events or environmental stressors 
might cause a relapse, there are many times when there is no 
identifiable cause. Because experiencing a relapse can be significantly 
disruptive, and because relapses are often unpredictable, Veterans with 
serious mental illness are sometimes hesitant to engage in recovery-
oriented activities without assurance that their basic needs can be met 
during times when they are unable to work.

Suicide Prevention/Veterans Crisis Line

    As mentioned earlier in the testimony, the VA Suicide Prevention 
Program is based on the concept of ready access to high quality mental 
health care and other services. VHA has added Suicide Prevention 
Coordinators (SPCs) at every facility and large CBOC; these are an 
important component of our mental health staffing. The SPCs ensure 
local planning and coordination of mental health care of support 
Veterans who are high risk for suicide, they provide education and 
training for VA staff, they do outreach in the community to educate 
Veterans and health care groups about suicide risk and VA care, and 
they provide direct clinical care for Veterans at increased risk for 
suicide. One of the main mechanisms to access enhanced care provided to 
high risk patients is through the Veterans Crisis Line, and the 
linkages between the Crisis Line and the local SPCs. The Crisis Line is 
located in Canandaigua, New York, and partners with the Substance Abuse 
and Mental Health Services Administration National Suicide Prevention 
Lifeline. All calls from Veterans, Servicemembers, families and friends 
calling about Veterans or Servicemembers are routed to the Veterans 
Crisis Line. The Crisis Line started in July 2007, and the Veterans 
Chat Service was started in July 2009. To date the Crisis Line has:

          Received over 400,000 calls;
          Initiated over 15,000 rescues;
          Referred over 55,000 Veterans to local VA SPCs, who 
        are available in every VA facility and many large CBOCs, for 
        same day or next day services;
          Answered calls from over 5,000 Active Duty 
        Servicemembers; and
          Responded to over 16,000 chats.

    VA also has put in place sensitive procedures to enhance care for 
Veterans who are known to be at high risk for suicide. Whenever 
Veterans are identified as surviving an attempt or is otherwise 
identified as being at high risk, they are placed on the facility high-
risk list and their chart is flagged such that local providers are 
alerted to the suicide risk for this Veteran. In addition, the SPC will 
contact the Veteran's primary care and mental health provider to ensure 
that all components of an enhanced care mental health package are 
implemented. These include a review of the current care plan, addition 
of possible treatment elements known to reduce suicide risk, ongoing 
monitoring and specific processes of follow-up for missed appointments, 
individualized discussion about means reduction, identification of a 
family member or friend (either to be involved in care or to be 
contacted, if necessary), and collaborative development with the 
Veteran of a written safety plan to be included in the medical record 
and provided to the Veteran. In addition, pursuant to VA policy, SPCs 
are responsible for, among other things, training of all VA Staff who 
have contact with patients, including clerks, schedulers, and those who 
are in telephone contact with veterans, so they know how to get 
immediate help when veterans express any suicide plan or intent.
    All VA Suicide Prevention Program elements are shared regularly 
with the Department of Defense (DoD), and a joint conference is held 
annually to encourage use of all effective strategies across both 
Departments, including educational products and materials.

Readjustment Counseling Service: Vet Centers

    Vet Centers provide community outreach, professional readjustment 
counseling for war-related readjustment problems, and case management 
referrals for combat Veterans. Vet Centers also provide bereavement 
counseling for families of Servicemembers who died while on Active 
Duty. Through March 31, 2011, Vet Centers have cumulatively provided 
face-to-face readjustment services to more than 525,000 OEF/OIF/OND 
Veterans and their families. As required by Section 401 of Public Law 
111-163, VA is currently drafting regulations to expand Vet Center 
eligibility to include members of the Active Duty Armed Forces who 
served in OEF/OIF/OND (including Members of the National Guard and 
Reserve who are on Active Duty).
    In addition to the 300 Vet Centers that will be operational by the 
end of 2011, the Readjustment Counseling Service program will also have 
70 Mobile Vet Centers operational by the end of 2011 to provide 
outreach services to separating Servicemembers and Veterans in rural 
areas. The Mobile Vet Centers provide outreach and direct readjustment 
counseling at active military, Reserve, and National Guard 
demobilization activities. To better serve eligible Veterans with 
military-related family problems, VA is adding licensed family 
counselors to over 200 Vet Center sites that do not currently have a 
family counselor on staff.

PTSD Care in VA

    VA is nationally recognized for its outstanding PTSD treatment and 
research programs, and the quality of VA health care in this area also 
is outstanding, with continual enhancements as more is learned. For 
example, VA's National Center for PTSD advances the clinical care and 
social welfare of Veterans through research, education and training on 
PTSD and stress-related disorders. They also lead a national mentoring 
program throughout the VA system that provides continuous training to 
guide programs to consistently delivering recommended care based on 
Clinical Practice Guidelines and recognized best practices. They 
recently added a clinical consultation program to supplement the 
ongoing mentoring educational offerings. Their advances are used to 
guide clinical program policy development and implementation.
    In FY 2010, VA treated more than 408,000 unique Veterans for PTSD 
in VA specialty mental health programs within medical centers, clinics, 
inpatient settings, and residential rehabilitation programs; this was 
an increase from 235,639 treated in FY 2005. If we include care 
delivered in integrated care settings, such as primary care, VA treated 
a cumulative total of more than 438,000 in FY 2010, an increase from 
approximately 250,000 in FY 2005. Given the increasing numbers of 
Veterans seeking VA care for PTSD, VA is monitoring parameters to 
ensure prompt and efficient services for PTSD and other mental 
disorders, using indicators such as ``time to first appointment'' for 
Veterans of all service eras who present with new mental health 
problems.
    It is essential that mental health professionals across our system 
provide the most effective treatment for PTSD, once the diagnosis has 
been identified. In addition to use of effective psychoactive 
medications, VA supports use of evidence-based psychotherapies. VA has 
conducted national training initiatives to educate therapists in two 
particular exposure-based psychotherapies for PTSD that have especially 
strong research support, as confirmed by the Institute of Medicine in 
their 2008 report, Treatment of Posttraumatic Stress Disorder: 
Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). To 
date, VA has trained over 3,400 VA clinicians in the use of CPT and PE. 
For both of these psychotherapies, following didactic training, 
clinicians participate in clinical consultations to attain full 
competency in the therapy. VA is also using new CPT and PE treatment 
manuals developed for VA, with inclusion of material on the treatment 
of unique issues arising from combat trauma during military service.

Conclusion

    Thank you again for this opportunity to speak about VA's diagnosis 
and treatment of mental health concerns of eligible Veterans who use 
VA's health care system, with particular emphasis on PTSD. PTSD is a 
diagnosis of central importance in our work with Veterans, both in 
providing health care and when Veterans submit mental health service-
connection claims to VBA. It is imperative that VA provide a system of 
mental health care and benefits that is driven by evidence and is fully 
responsive to the mental health challenges that Veterans face. My 
colleagues and I are prepared to answer any questions you may have.

                                 
    Joint Statement of American Association for Marriage and Family 
                                Therapy,
   National Board for Certified Counselors, California Association of
    Marriage and Family Therapists, American Counseling Association,
           and American Mental Health Counselors Association
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee, our groups represent more than 160,000 Professional 
Counselors and Marriage and Family Therapists (MFTs), who are licensed 
in every State to provide behavioral-health services such as 
psychotherapy.
    This Committee is well aware of the large and rapidly growing 
number of veterans with long-term behavioral health needs, as current 
conflicts have produced ``signature wounds'' of Post-Traumatic Stress 
Disorder as well as Traumatic Brain Injury, which also has major 
behavioral symptoms. Repeated deployments, including of Guard and 
Reserve forces, also have increased the prevalence of separation 
anxiety and depression. Several hearing witnesses have detailed the 
extent and severity of these needs.
    Indeed, in 2006, Congress enacted Public Law 109-461 establishing 
38 U.S.C. Sec. 7401(3) to permit VA to hire MFTs and Counselors to help 
address veterans' mental-health needs. It took until September 30, 2010 
for the VA to issue Counselor and MFT Job Specifications (VA Handbook 
5005/41 for MFTs and 5005/42 for Counselors) implementing the law.
    Meanwhile, on May 10, 2011, the 9th Circuit Court of Appeals 
(Veterans for Common Sense v. Shinseki) ruled that ``unchecked 
incompetence'' by the VA has led to inadequate mental health care. 
According to the panel, ``(M)any veterans with severe depression or 
post-traumatic stress disorder are forced to wait weeks for mental 
health referrals and are given no opportunity to request or demonstrate 
their need for expedited care . . . . The delays have worsened in 
recent years, as the influx of injured troops . . . has placed an 
unprecedented strain on the VA, and has overwhelmed the system that it 
employs to provide medical care to veterans . . .''
    While we are pleased that the VA is finally taking steps to 
implement the 2006 statute, we are concerned with the pace and extent 
of implementation. We understand that most VA postings for MFTs and 
Counselors are for Readjustment Counseling Center (``Vet Center'') 
jobs, rather than at clinical facilities. We appreciate the integration 
of our professions into these facilities, but do not believe that they 
reflect the full intent of the law, which was to employ MFTs and 
Counselors throughout the health system. The nominal employment 
opportunities for MFTs and Counselors in the medical facilities since 
the release of the Standards, while hundreds of Social Work positions 
are advertised, shows a systemic failure to implement.
    As an example of the problem, the VA's testimony at this hearing 
stated ``VA is adding licensed family counselors to over 200 Vet 
Centers that do not currently have a family counselor on staff.'' The 
fact that the VA incorrectly characterized these professionals as 
``family counselors,'' thereby combining the two distinct professions 
into one inaccurate title, does not inspire confidence that the VA 
understands how either MFTs or Professional Counselors can aid its 
mission. Further, the VA only references the use of these professionals 
in Vet Centers, reinforcing our concerns that they are not considered 
for positions throughout the system. This language demonstrates a lack 
of understanding about who these professions are and why Congress 
passed the law. It is clear that more education needs to be done at all 
levels of the VA and a proactive integration plan needs to be 
developed. The VA national office needs to spearhead this effort and 
ensure that it is adopted by local facilities. We urge Congress to 
recommend such action.
    In addition to our concerns with the pace and extent of 
implementation, we have concerns with the rigidity of the eligibility 
criteria. Specifically, the fact that the new Qualification Standards 
for both professions exclude a significant portion of qualified MFTs 
and Professional Counselors from VA employment. While we appreciate the 
need for high standards, the lack of flexibility in the standards 
restrict access to many MFTs and Counselors who have been practicing 
effectively for decades. We estimate that roughly 80,000 Counselors and 
MFTs nationwide, including up to 95 percent of California MFTs, are 
barred from VA jobs by these requirements. We believe this severely 
undermines the VA's ability to hire qualified behavioral-health 
personnel.
    These requirements provide that job candidates must hold an 
advanced degree awarded by an academic program that, when the degree 
was granted, was accredited by a specialty accrediting body. (For 
Counselors, this is the Council for Accreditation of Counseling and 
Related Educational Programs, and for MFTs, it is the Commission on 
Accreditation for Marriage and Family Therapy Education.) This fails to 
recognize that there was a time when accreditation by these specialized 
bodies was not a widespread practice, even though the degree-granting 
institutions themselves were accredited by a Regional accrediting body. 
There are some professionals who may have graduated prior to the 
creation of these accrediting bodies and many who may have had limited 
or no accessible accredited programs. These MFTs and Counselors have 
been practicing for many years and should not be excluded from 
employment by the VA.
    In response to this concern, we formally requested that the VA 
establish an alternate means to recognize qualified MFTs and Counselors 
with strong credentials and significant clinical experience who may not 
otherwise meet the Qualification Standards. The VA denied this request 
to Counselors and a response is pending for MFTs. We believe that this 
flexibility will increase the number of qualified professionals 
available to serve our veterans and help address the access problems 
identified by the 9th Circuit Court of Appeals. We ask Congress to urge 
the VA to develop alternatives to the existing standards that allow for 
employment of experienced and qualified MFTs and Counselors.
    Finally, we agree with several hearing witnesses that the Committee 
should question why VA has not implemented Public Law 111-163, Section 
304, regarding mental-health and support services for OEF/OIF veterans 
and their families.
    We would be pleased to work with this Committee and VA to address 
these challenges, and to respond to any questions this Committee may 
have.

                                 
               Statement of the California Association of
                     Marriage and Family Therapists
    Mr. Chairman, Members of the Committee, the California Association 
of Marriage and Family Therapists (CAMFT), with over 29,000 members, is 
an independent professional organization representing the interests of 
licensed marriage and family therapists (MFTs) in the State of 
California. With its membership, CAMFT represents more than half of the 
54,000 licensed MFTs in the United States. CAMFT is dedicated to 
advancing the profession as an art and a science, to maintaining high 
standards of professional ethics, to upholding the qualifications for 
the profession, and to expanding the recognition and awareness of the 
profession.
    We are all painfully aware of the multitude of mental health 
problems that a number of veterans are dealing with today. The Congress 
has recognized that part of the solution to dealing with this problem 
is to make more mental health professionals available to treat these 
conditions being experienced by our veterans. With the passage of the 
Veterans Benefits, Health Care, and Information Technology Act of 2006, 
P.L. 109-461 and the Veterans' Mental Health and Other Care 
Improvements Act of 2008, P.L. 110-387, Marriage and Family Therapists 
are now recognized by the Department of Veterans Affairs as a provider 
of mental health services to both veterans and their family members. In 
order to implement the law, the Department of Veterans Affairs (VA) had 
to create employment standards by which their individual facilities 
could hire qualified MFTs. (Copy attached as Appendix A) From the 
outset, we believe that the VA has been seriously misinformed about how 
MFTs practice. Consequently, the qualification standard needs to be 
significantly reworked to reflect the actual way MFTs practice 
throughout the United States.

Education Requirements

    Standard 2(b) sets forth the education requirement for MFTs who 
wish to work for the VA. This standard requires MFTs to have graduated 
from master's programs approved by the Commission on Accreditation for 
Marriage and Family Therapy Education (COAMFTE), or programs accredited 
by a ``nationally accredited program conferring a comparable mental 
health degree as specified in the qualification standard of those 
disciplines (Social Work, Psychiatric Nursing, Psychology, and 
Psychiatry).'' CAMFT believes that these requirements are much too 
limiting. (Additionally, we are informed that MFTs in other States such 
as New York, Florida, and Texas as well are graduates of non-COAMFTE 
approved schools.) In actuality, very few MFT programs are approved by 
COAMFTE or accredited by national organizations. It is anticipated that 
90 percent of California MFT graduates are from programs that are NOT 
COAMFTE accredited. Further, COAMFTE accredits only those degree 
programs that are already accredited by a regionally accepted 
accrediting body. Given that there are 99 Veteran's Facilities in 
California, eliminating 90 percent of the pool of potential VA MFTs, 
who are licensed by the State of California in the profession, is a 
disservice to our veterans. Moreover, we are puzzled by the naming of 
the other disciplines (Social Work, Psychiatric Nursing, Psychology, 
and Psychiatry) for comparison purposes. MFTs are a separate and 
distinct discipline licensed to provide mental health services for 
individuals, adults, couples, '!,'; families, children, and 
adolescents, and groups. In California, MFTs may have master's or 
doctoral degrees in marriage and family therapy; marriage and family 
child counseling; 'psychology; counseling psychology; or, counseling 
with an emphasis in' marriage, faruily, and child counseling. The 
education of MFTs is comparable to what is required for licensed 
professional counselors with additional content required to work with 
couples, families, and children. In California, an MFT can earn the 
underlying master's or doctor's degree from a school, college, or 
university that is accredited by a regional accrediting agency 
recognized by the United States Department of Education, or by a 
school, college, or university approved by the Bureau of Private Post 
Secondary Education (see California Business & Professions Code 
Sec. 4980.37(b), Copy attached as Appendix B). CAMFT believes that 
regional accreditation should be the standard required by the VA.

Ability to Diagnose and Treat

    Standard 2 (c) sets forth the licensure requirement for MFTs who 
wish to work for the VA. This section needs to recognize that MFTs do 
diagnose and treat individuals with mental illness. In California, by 
law, the master's or doctor's program leading to licensure as an MFT 
must train students to diagnose, assess, and treat mental disorders 
(see California Business & Professions Code Sec. 4980.37 (e)(1), Copy 
attached as Appendix C).
    Moreover, MFTs diagnose and treat mental disorders in government 
agencies, nonprofit counseling agencies, and private practices. And, 
MFTs are reimbursed by public mental health programs, TRICARE, and 
private insurance companies for providing such work. MFTs, like other 
mental health professionals, diagnose and treat mental disorders. They 
are trained to do such work; they are tested by licensing boards on 
their ability to do such work; and, they get paid by public and private 
sources to do such work. CAMFT believes that this reality needs to be 
reflected by the VA in the MFT qualification standard.
    Every week a new study or report emphasizes the growing mental 
health needs of our veterans and the. shortage of mental health 
providers to minister to them. The members of CAMFT are anxious and 
willing to be added to the staff of VA facilities to provide for the 
needs of this patient population. Unless the standards are changed, a 
vast resource of mental health professionals in California and other 
parts of the country will be unavailable to care for our veterans. 
Thank you.

                               __________
                               APPENDIX A
                                               VA Transmittal Sheet
Department of Veterans Affairs
Handbook 5005/
Washington, DC 20420
                                STAFFING
    1.  REASON FOR ISSUE: To establish a Department of Veterans Affairs 
(VA) qualification standard for Marriage and Family Therapist, GS-I0l, 
appointed under 38 U.S.C. Sec. 7401(3).
    2.  SUMMARY OF CONTENTS/MAJOR CHANGES: This handbook contains 
mandatory procedures on staffing. This revision establishes the 
Marriage and Family Therapist occupation under VA's Title 38 Hybrid 
excepted service employment system in accordance with the ``Veterans 
Benefits, Health Care, and Information Technology Act of 2006'' 
(Public. Law 109-461). Authority is given to the Secretary of the VA 
under 38 U.S.C. Sec. 7402 to prescribe qualifications for occupations 
identified in 38 U.S.C. Sec. 7401(3). The pages in this policy are to 
be inserted in part II of VA Handbook 5005. This new qualification 
standard will be incorporated into the electronic version of VA 
Handbook 5005 that is maintained on the Office of Human Resources 
Management
    3.  RESPONSIBLE OFFICE: The Recruitment and Placement Policy 
Service. (059), Office of the Deputy Assistant Secretary for Human 
Resources Management.
    4.  RELATED DIRECTIVE: VA Directive 5005, Staffing.
    5.  RESCISSIONS: None.


                                               CONTENTS--CONTINUED               PARAGRAPH                                                             PAGEAPPENDICES-Continued
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
II-G14.                                 OCCUPATIONAL THERAPIST QUALIFICATION   II-G14-1
                                         STANDARD
----------------------------------------------------------------------------------------------------------------
II-G15.                                 LICENSED PHARMACIST QUALIFICATION      II-G-15-1
                                         STANDARD
----------------------------------------------------------------------------------------------------------------
II-G16.                                 DOCTOR OF CHIROPRACTIC QUALIFICATIONS  II-G16-1
                                         STANDARD
----------------------------------------------------------------------------------------------------------------
II-G17.                                 DEVELOPMENT OF QUALIFICATION           II-G17-1
                                         STANDARDS FOR VETERANS HEALTH
                                         ADMINISTRATION (VHA) POSITIONS
                                         FILLED UNDER 38 U.S.C.Sec.  7401(3)
----------------------------------------------------------------------------------------------------------------
II-G18.                                 PSYCHOLOGIST                           II-G18-1
----------------------------------------------------------------------------------------------------------------
II-G19.                                 NUCLEAR MEDICINE TECHNOLOGIST          II-G19-1
----------------------------------------------------------------------------------------------------------------
II-G20.                                 DIETITIAN                              II-G20-1
----------------------------------------------------------------------------------------------------------------
II-G21.                                 KINESIOTHERAPIST                       II-G21-1
----------------------------------------------------------------------------------------------------------------
II-G22.                                 OCCUPATIONAL THERAPY ASSISTANT         II-G22-1
----------------------------------------------------------------------------------------------------------------
II-G23                                  PHYSICAL THERAPY ASSISTANT             II-G23-1
----------------------------------------------------------------------------------------------------------------
II-G24.                                 MEDICAL TECHNOLOGIST                   II-G24-1
----------------------------------------------------------------------------------------------------------------
II-G25.                                 DIAGNOSTIC RADIOLOGIC TECHNOLOGIST     II-G25-1
----------------------------------------------------------------------------------------------------------------
II-G26.                                 THERAPEUTIC RADIOLOGIC TECHNOLOGIST    II-G26-1
----------------------------------------------------------------------------------------------------------------
II-G27.                                 MEDICAL INSTRUMENT TECHNICIAN          II-G27-1
----------------------------------------------------------------------------------------------------------------
II-G28.                                 PHARMACY TECHNICIAN                    II-G28-1
----------------------------------------------------------------------------------------------------------------
II-G29.                                 AUDIOLOGIST                            II-G29-1
----------------------------------------------------------------------------------------------------------------
II-G30.                                 SPEECH LANGUAGE PATHOLOGIST            II-G30-1
----------------------------------------------------------------------------------------------------------------
II-G31.                                 AUDIOLOGIST/SPEECH LANGUAGE            II-G31-1
                                         PATHOLOGIST
----------------------------------------------------------------------------------------------------------------
II-G32.                                 ORTHOTIST-PROSTHETIST                  II-G32-1
----------------------------------------------------------------------------------------------------------------
II-G33.                                 MEDICAL RECORD ADMINISTRATOR           II-G33-1
----------------------------------------------------------------------------------------------------------------
II-G34                                  PROSTHETIC REPRESENTATIVE              II-G34-1
----------------------------------------------------------------------------------------------------------------
II-G35.                                 MEDICAL RECORD TECHNICIAN              II-G35-1
----------------------------------------------------------------------------------------------------------------
II-G36.                                 DENTAL ASSISTANT                       II-G36-1
----------------------------------------------------------------------------------------------------------------
II-G37.                                 DENTAL HYGIENIST                       II-G37-1
----------------------------------------------------------------------------------------------------------------
II-G38.                                 BIOMEDICAL ENGINEER                    II-G38-1
----------------------------------------------------------------------------------------------------------------
II-G39.                                 SOCIAL WORKER                          II-G39-1
----------------------------------------------------------------------------------------------------------------
II-G40.                                 BLIND REHABILITATION SPECIALIST        II-G40-1
----------------------------------------------------------------------------------------------------------------
II-G41.                                 BLIND REHABILITATION OUTPATIENT        II-G41-1
                                         SPECIALIST
----------------------------------------------------------------------------------------------------------------
[II-G42.                                MARRIAGE AND FAMILY THERAPIST          II-G42-1
----------------------------------------------------------------------------------------------------------------
II-G43.                                 LICENSED PROFESSIONAL MENTAL HEALTH    II-G43-1]
                                         COUNSELOR
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
II-H                                    APPOINTMENT PROCEDURES BY OCCUPATION/
                                         ASSIGNMENT
----------------------------------------------------------------------------------------------------------------
II-H1.                                  PROCEDURES FOR APPOINTING PHYSICIANS   II-H1-1
                                         TO SERVICE CHIEF AND COMPARABLE
                                         POSITIONS
----------------------------------------------------------------------------------------------------------------
II-H2.                                  PROCEDURES FOR APPOINTING DENTISTS     II-H2-1
                                         AND EFDAS
----------------------------------------------------------------------------------------------------------------
II-H3.                                  PROCEDURES FOR APPOINTING PODIATRISTS  II-H3-1
----------------------------------------------------------------------------------------------------------------
II-H4.                                  PROCEDURES FOR APPOINTING              II-H4-1
                                         OPTOMETRISTS
----------------------------------------------------------------------------------------------------------------
II-H5.                                  RECRUITMENT, APPOINTMENT,              II-H5-1
                                         ADVANCEMENT, CHANGE IN ASSIGNMENT
                                         AND REASSIGNMENT OF REGISTERED
                                         NURSES (RNs) IN GRADES IV AND V
----------------------------------------------------------------------------------------------------------------
II-H6.                                  PROCEDURES FOR APPOINTING NURSE        II-H6-1
                                         ANESTHETISTS TO SECTION CHIEF
                                         POSITIONS
----------------------------------------------------------------------------------------------------------------
II-H7.                                  PROCEDURES FOR APPOINTING PHYSICIAN    II-H7-1
                                         ASSISTANTS AT CHIEF GRADE
----------------------------------------------------------------------------------------------------------------
II-H8.                                  PROCEDURES FOR APPOINTING CHIEF OF     II-H8-1
                                         PHARMACY SERVICE (ALL GRADES),
                                         CLINICAL/PHARMACY SPECIALISTS, AND
                                         PROGRAM SPECIALISTS, AND PROGRAM
                                         SPECIALISTS AT GRADES GS-13 AND
                                         ABOVE
----------------------------------------------------------------------------------------------------------------
II-H9.                                  PROCEDURES FOR APPOINTING              II-H9-1
                                         OCCUPATIONAL AND PHYSICAL THERAPISTS
                                         AS SECTION CHIEF
----------------------------------------------------------------------------------------------------------------
II-H10.                                 PROCEDURES FOR APPOINTING DOCTORS OF   II-H10-1
                                         CHIROPRACTIC
----------------------------------------------------------------------------------------------------------------
II-I.                                   ENGLISH LANGUAGE PROFICIENCY           II-HI-1
----------------------------------------------------------------------------------------------------------------
II-J.                                   REQUESTS FOR APPROVAL TO PETITION THE  II-J-1
                                         UNTIED STATES DEPARTMENT OF STATE
                                         (DOS) FOR SUPPORT OF A WAIVER OF THE
                                         2-YEAR HOME RESIDENCE REQUIREMENT OF
                                         THE UNITED STATES EXCHANGE VISITOR
                                         PROGRAM
----------------------------------------------------------------------------------------------------------------
II-K.                                   RCVL (RESIDENT/TRAINEE CREDENTIALS     II-K-1
                                         VERIFICATION LETTER)
----------------------------------------------------------------------------------------------------------------
II-L.                                   CREDENTIALING CHECKLIST                II-L-1
----------------------------------------------------------------------------------------------------------------
II-M.                                   SAMPLE CONSULTANT CERTIFICATE          II-M-1
----------------------------------------------------------------------------------------------------------------
II-N.                                   CAREER INTERN PROGRAM                  II-N-1
----------------------------------------------------------------------------------------------------------------
II-O.                                   ORGANIZATIONAL LOCATION OF HYBRID      II-O-1
                                         TITLE 38 PROFESSIONAL STANDARDS
                                         BOARDS
----------------------------------------------------------------------------------------------------------------
II-P.                                   PROCEDURES FOR SELECTING HYBRID TITLE  II-P-1
                                         38 PROFESSIONAL STANDARDS BOARDS
                                         MEMBERS
----------------------------------------------------------------------------------------------------------------
II-Q.                                   PRESIDENTIAL MANAGEMENT FELLOWS        II-Q-1
                                         PROGRAM*Use in conjunction with the OPM Standard.


                               __________

                                                  VA HANDBOOK 5005/
                                                            PART II
                                                       APPENDIX G42
  [APPENDIX G42. MARRIAGE AND FAMILY THERAPIST QUALIFICATION STANDARD]
                                 GS-101
                     Veterans Health Administration
    1. COVERAGE. The following are requirements for appointment as a 
Marriage and Family Therapist (MFT) in the Veterans Health 
Administration (VHA). These requirements apply to all VHA MFTs in the 
GS-l0 I series, including those assigned to VA Medical Centers, 
Community-Based Outpatient Clinics (CBOCs), Vet Centers, Veterans 
Integrated Service Network (VISN) offices, and VHA Central Office.
    2. BASIC REQUIREMENTS. The basic requirements for employment as a 
VHA MFT are prescribed by statute in 38 U.S.C. 7402(b)(10), as amended 
by section 201 of Public Law 109-461, enacted December 22, 2006. To 
qualify for appointment as an MFT in VHA, all applicants must:

        a.  Citizenship. Be a citizen of the United States. (Non-
        citizens may be appointed when it is not possible to recruit 
        qualified citizens in accordance with chapter 3, section A, 
        paragraph 3g, this part.)
        b.  Education. Hold a master's degree in marriage and family 
        therapy from a program approved by the Commission on 
        Accreditation for Marriage and Family Therapy Education 
        (COAMFTE) or have graduated from a nationally accredited 
        program conferring a comparable mental health degree as . . . 
        specified in the qualification standards of those disciplines 
        (Social Work, Psychiatric Nursing, Psychology, and Psychiatry). 
        All additional course work taken to be accepted for MFT 
        licensure must come from a nationally accredited program in one 
        of the above areas.

    NOTE: .A doctoral degree in marriage and family therapy from a 
COAMFTE approved program is considered to be a comparable mental health 
degree. 

        c.  Licensure. Persons hired or reassigned to MFT positions in 
        the GS-l0 I series in VHA must hold a full, current, and 
        unrestricted license to independently practice marriage and 
        family therapy in a State.

    (1)  Exception. The appointing official may waive the licensure 
requirement for persons who are otherwise qualified, pending completion 
of state prerequisites for licensure examinations for a period not to 
exceed 2 years from the date of employment on the condition that MFTs 
appointed on this basis provide care only under the supervision of a 
fully licensed MFT. Non-licensed MFTs who otherwise meet the 
eligibility requirements may be given a temporary appointment as a 
graduate MFT under the authority of 38 U.S.C. 74057405(c)(2)(B) This 
exception only applies at the entry level (GS-9). For grades at or 
above the full performance level, the candidate must be licensed.
    (2)  Failure to Obtain License. In all cases, unlicensed MFTs must 
actively pursue meeting State prerequisites for licensure starting from 
the date of their temporary appointment. At the time of appointment, 
the supervisor will provide the unlicensed MFT with the written 
requirements for licensure, the time frame by which the license must be 
obtained, and the consequences for not becoming licensed by the 
deadline. Failure to obtain a license within the prescribed amount of 
time will result in removal from the GS-101 MFT series and may result 
in termination of employment.
    (3)  Loss of Licensure. Once licensed, MFTs must maintain a full, 
valid and unrestricted license to remain qualified for employment. Loss 
of licensure will result in removal from the GS-101 MFT series and may 
result in termination of employment.

        d.  Physical Requirements. See VA Directive and Handbook 5019.
        e.  English Language Proficiency. MFTs must be proficient in 
        spoken and written English in accordance with VA Handbook 5005, 
        part II, chapter 3, section A, paragraph 3j.

3. GRADE REQUIREMENTS

        a.  Creditable Experience

    (1)  Knowledge of Current Professional Marriage and Family Therapy 
Practices. To be creditable, the experience must have required the use 
of knowledge, skills, and abilities associated with current 
professional marriage and family therapy practice. The experience must 
be post-master's degree or above. Experience satisfying this 
requirement must be active professional practice, which is paid/non-
paid employment as a professional MFT, as defined by the appropriate 
State licensing board.
    (2)  Quality of Experience. Experience is only creditable if it is 
obtained following graduation with a master's degree in marriage and 
family therapy or comparable degree in mental health (Social Work, 
Psychiatric Nursing, Psychology, and Psychiatry) from an accredited 
training program and includes: work as a professional MFT directly 
related to the position to be filled. Qualifying experience must also 
be at a level comparable to. marriage and family therapy experience at 
the next lower grade level. For all assignments above the full 
performance level, the higher level duties must consist of significant 
scope, administrative:independence, complexity (difficulty) and range 
of variety as described in this standard at the specified grade level 
and be performed by the incumbent at least 25 percent of the time.
    (3)  Part-Time Experience. Part-time experience as a professional 
MFT is creditable according to its relationship to the full-time work 
week. For example, an MFT employed 20 hours a week, or on a \1/2\ time 
basis, would receive 1 full-time work week of credit for each 2 weeks 
of service.
    (4)  Fellowships or Post-Graduate Training. Fellowship and post-
graduate training programs are typically in a specialized area of 
clinical practice, e.g., group or family practice. Training as a fellow 
or post-graduate may be substituted for creditable experience on a 
year-for-year basis.
    (5)  Practicum in a VA Setting. A VHA practicum experience may not 
be substituted for experience, as the practicum (field placement) is 
completed prior to graduation with a master's degree in marriage and 
family therapy or comparable mental health degree.

        b.  Grade Determinations. In addition to the basic requirements 
        for employment, the following criteria must be met when 
        determining the grade of candidates.

    (1)  GS-9 Marriage and Family Therapist (Entry Level)

        (a)  Experience, Education and Licensure. GS-9 is the entry 
        level grade for the GS-101 Marriage and Family Therapist series 
        and is used for licensed MFTs with less than 1 year of 
        experience (postmaster's degree) or for MFTs (master's or 
        doctoral level) who are graduates not yet licensed at the 
        independent practice level. Unlicensed MFTs at the GS-9 level 
        have completed the required education listed in paragraph 2b 
        above, and are working toward completion of prerequisites for 
        licensure. In addition, the candidates must demonstrate the 
        KSAs in subparagraph (b) below.
        (b)  Demonstrated Knowledge, Skills, and Abilities

    1.  Basic knowledge of human development throughout the lifespan, 
including interventions based on research and theory, family and system 
interaction formal diagnostic criteria, risk assessment, evidence-based 
practice and assessment tools.
    2.  Ability to assess, with supervision, the psychosocial 
functioning and needs of patients and their family members, and the 
knowledge to formulate, implement, and re-evaluate a treatment plan 
through continuous assessment identifying the patient's problems, 
strengths, readiness to change, external influences and current events 
surrounding the origins and maintenance of the presenting issue, and 
interactional patterns within the client system. This includes the 
utilization of testing measures where appropriate.
    3.  Ability to provide counseling and/or psychotherapy services to 
individuals, groups, couples and families in a culturally competent 
manner that facilitates change through restructuring and reorganizing 
of the client system with supervision.
    4.  Ability to establish and maintain effective working 
relationships with clients, colleagues, and other professionals, with 
supervisory guidance as needed. This includes the ability to 
communicate effectively, both orally and in writing, with people from 
varied backgrounds, and to communicate the MFT perspective in 
interdisciplinary staff meetings while respecting the roles and 
responsibilities of other professionals.
    5.  Basic knowledge and understanding of existing relevant 
statutes, case law, ethical codes, and regulations affecting 
professional practice of marriage and family therapy. This includes the 
ability, under close supervision, to assist clients in making informed 
decisions relevant to treatment, including limits of confidentiality.
    6.  Ability to organize work, set personal priorities and meet 
multiple deadlines as assigned by the supervisor.
    7.  Ability to use computer software applications for drafting 
documents, data management, maintaining accurate, timely and thorough 
clinical documentation, and tracking quality improvements.

        (c)  Assignments. Individuals assigned, as GS-9 MFTs are 
        considered to be at the entry level and are closely supervised, 
        as they are not yet functioning at the independent practice 
        level conferred by independent licensure. MFTs at the GS-9 
        entry level are typically assigned to VHA program areas that do 
        not require specialized knowledge or experience. Since these 
        MFTs are not practicing at an independent level, they should 
        not be assigned to program areas where independent practice is 
        required, such as in a CBOC, unless there is a licensed MFT in 
        the program area who can provide supervision for practice. GS-9 
        MFTs provide mental health services under close supervision and 
        within the ethics and guidelines of the professional standards 
        set by AAMFT.

    (2)  GS-11 Marriage and Family Therapist (Full Performance Level)

        (a)  Experience, Education and Licensure. In addition to the 
        basic requirements, the GS-11 full performance level requires 
        completion of a minimum of 1 year of post-master' s degree 
        experience in the field of health care marriage and family 
        therapy work (VA or non-VA experience) and licensure in a state 
        at the independent practice level. In addition, the candidate 
        must be licensed to practice at the independent practice level 
        and must demonstrate the KSAs in subparagraph (b) below.
                                  OR,
    A doctoral degree in marriage and family therapy or comparable 
degree in mental health from an accredited training program (see page 
2.b. NOTE above) may be substituted for the required 1 year of 
professional marriage and family therapy experience in a clinical 
setting. In addition, the candidate must be licensed to practice at the 
independent practice level and must demonstrate the KSAs in 
subparagraph (b) below.

        (b)  Demonstrated Knowledge, Skills, and Abilities

    1.  Knowledge of human development throughout the lifespan, 
interventions based on research and theory, family and system 
interaction, formal diagnostic criteria, risk assessment, evidence-
based practice and assessment tools.
    2.  Ability to independently assess the psychosocial functioning 
and needs of patients and their family members, and the knowledge to 
formulate, implement, and re-evaluate a treatment plan through 
continuous assessment identifying the patient's problems, strengths, 
readiness to change, external influences and current events surrounding 
the origins and maintenance of the presenting issue, and interactional 
patterns within the client system. This includes the utilization of 
testing measures where appropriate.
    3.  Ability to provide counseling and/or psychotherapy services to 
individuals, groups, couples and families in a culturally competent 
manner that facilitates change through restructuring and reorganizing 
of the client system.
    4.  Ability to establish and maintain effective working 
relationships with clients, colleagues, and other professionals in 
collaboration throughout treatment regarding clinical, ethical and 
legal issues and concerns. This includes the ability to represent and 
educate others regarding the MFT perspective in interdisciplinary staff 
meetings while respecting the roles and responsibilities of other 
professionals working with the client.
    5.  Knowledge and understanding of existing relevant statutes, case 
law, ethical codes, and regulations affecting professional practice of 
marriage and family therapy. This includes the ability to assist 
clients in making informed decisions relevant to treatment to include 
limits of confidentiality.
    6.  Ability to provide orientation, training and consultation to 
new MFTs including clinical oversight of MFT graduate students, and/or 
provide supervision to pre-licensure MFTs.
    7.  Skill in the use of computer software applications for drafting 
documents, data management, maintaining accurate, timely and thorough 
clinical documentation, and tracking quality improvements.

        (c)  Assignments. This is the full performance level for MFTs. 
        GS-11 MFTs are licensed to independently practice marriage and 
        family therapy and to provide other mental health services 
        within the ethics and guidelines of the professional standards 
        set by AAMFT. They may be assigned to all program areas that 
        provide mental health services. MFTs at this level may also be 
        involved in program evaluation and/or research activities.

    (3)  GS-12 Marriage and Family Therapist Supervisor

        (a)  Experience, Education, and Licensure. In addition to the 
        basic requirements, completion of 1 year of progressively 
        responsible assignments and experience equivalent to the GS 11-
        level, which demonstrates knowledge, skills, and abilities that 
        are directly related to the specific assignment. In addition, 
        the candidate must demonstrate the professional KSAs in 
        subparagraph (b) below.

        (b)  Demonstrated Knowledge, Skills, and Abilities

    1.  Ability to assess qualifications and abilities of current and 
prospective employees to include staff performance evaluation.
    2.  Ability to identify professional development needs of other 
MFTs and guide them in current practice guidelines.
    3.  Ability to collaborate with members of other disciplines and 
supervisors and to represent the profession both in and outside of VHA. 
This includes knowledge of the roles, contributions, and 
interrelationships with other disciplines.
    4.  Ability to administratively supervise in areas related to the 
provision of marital and family services. This includes knowledge of VA 
policy and procedures as well as fair, principled, and decisive 
leadership practices.
    5.  Ability to clinically supervise in areas related to the 
provision of marital and family therapy services to accomplish 
organizational goals and objectives.

        (c)   Assignment. MFT Supervisors typically supervise MFT 
        professional staff, which may include experienced MFTs, and 
        program coordinators. Supervisory MFTs at this level may be 
        assigned to any program area and may be involved in program 
        evaluation and/or research activities. Supervisory MFTs are 
        licensed to independently provide marital and family therapy 
        services, which may include coordinator responsibilities and to 
        supervise for licensure other MFTs within the ethics and 
        guidelines of the professional standards set by AAMFT.

    (4)  GS-12 Marriage and Family Therapist Program Coordinator

        (a)  Experience, Education, and Licensure. In addition to the 
        basic requirements, completion of 1 year of progressively 
        responsible assignments and experience equivalent to the GS-11 
        level, which demonstrates knowledge, skills, and abilities that 
        are directly related to the specific assignment. In addition, 
        the candidate must demonstrate the professional KSAs in 
        subparagraph (b) below.

        (b)  Demonstrated Knowledge, Skills, and Abilities

    1.  Ability to organize work, set priorities, meet multiple 
deadlines, delegate tasks and facilitate team building.
    2.  Ability to manage and direct the work of others to accomplish 
program goals and objectives.
    3.  Ability to devise innovative ways to adapt work operations to 
new and changing programs, to develop staffing and budget requirements, 
and to translate management goals and objectives into well coordinated 
and controlled work operations and ensure compliance with pertinent VHA 
policies.
    4.  Ability to establish and monitor production and performance 
priorities and standards and program evaluation criteria.

        (c)  Assignment. MFT Program Coordinators are administratively 
        responsible for a clinical program providing treatment to 
        patients in a major specialty such as, but not limited to 
        homeless veterans program, and mental health intensive case 
        management (MHICM). They may be the sole mental health 
        practitioner in this specialty at the facility and typically 
        provide direct patient care services in the program area. They 
        manage the daily operations of the program, develop policies 
        and procedures for program operation and prepare reports and 
        statistics for facility, VISN and national use. They may be 
        responsible for the program's budget. At this level, GS-12 MFTs 
        are licensed to independently provide mental health services 
        and to supervise for licensure other MFTs within the ethics and 
        guidelines of the professional standards set by AAMFT. Other 
        assignments of equal complexity and responsibility may be 
        approved on an individual basis where warranted.

    (5)  GS-13 Marriage and Family Therapist Program Manager

        (a)  Experience, Education, and Licensure. In addition to the 
        basic requirements, completion of 1 year of progressively 
        responsible assignments and experience equivalent to that 
        obtained at the GS-12 level, which demonstrates knowledge, 
        skills, and abilities that are directly related to the specific 
        assignment.
        (b)  Demonstrated Knowledge, Skills, and Abilities

    1.  Skill in assessing qualifications and abilities of current and 
prospective employees to include staff performance evaluation.
    2.  Ability to facilitate professional development of other MFTs 
and guide them in current practice guidelines.
    3.  Ability to contribute to professional development of staff 
members across a variety of disciplines within program specific area.
    4.  Ability to collaborate with leaders of other disciplines within 
facilities, the community, VISN, and VACO.
    5.  Skill in managing and directing the work of others to 
accomplish program goals and objectives, reporting requirements and 
ability to devise ways to adapt work operations to new and changing 
programs, staffing and budget requirements. This includes knowledge of 
VA policy and procedures as well as fair, principled and decisive 
leadership practices.
    6.  Ability to analyze organizational and operational problems and 
to develop and implement solutions that result in sound operation of 
the program.
    7.  Ability to clinically supervise in areas related to the 
provision of marital and family therapy services to accomplish 
organizational goals and objectives.
    8.  Knowledge of the roles, contributions and interrelationships of 
other disciplines within the program.

        (c)  Assignment

    1.  MFT Program Managers have broad program management 
responsibilities, which include the operation and management of key 
clinical, training, or administrative programs. Responsibilities 
include development and implementation of programs, policies and 
procedures; oversight of administrative and programmatic resources; and 
monitoring of outcomes using a data driven quality assurance process. 
Decisions made affect staff and other resources associated with the 
programs managed and are made while exercising wide latitude and 
independent judgment. Such programs deliver specialized, complex, 
highly professional services that are important program components and 
significantly impact the health care provided to Veterans. They have 
responsibility for staffing, work assignments, budget, clinical 
services provided and admission criteria for the program, day-to-day 
program operations and all reporting requirements. Additionally, 
program managers at this grade generally have collateral assignments 
determined by the needs of the local facility, the VISN, and/or VACO.
    2.  Managers may also have full responsibility for oversight of the 
professional practice of MFTs to assure the highest quality of mental 
health care provided to veterans throughout the facility and affiliated 
clinics. This responsibility also includes insuring that all MFTs in 
the facility and its affiliated clinics meet the requirements of this 
qualification standard. At this advanced performance level, GS-13 MFTs 
are licensed to independently provide marital and family therapy 
services with program management responsibilities.

    (6)  GS-14 Marriage and Family Therapist Program Manager Leadership 
Assignments (Care Line Manager/VISN/National)

        (a)  Experience, Education, and Licensure. In addition to the 
        basic requirements, completion of I year of progressively 
        responsible assignments and experience at the GS-13 level, 
        which demonstrates knowledge, skills, and abilities that are 
        directly related to the specific assignment.
        (b)  Demonstrated Knowledge, Skills, and Abilities. In addition 
        to meeting the KSAs for GS-13 level, the candidate must 
        demonstrate the KSAs below:

    1.  Advanced knowledge and skill in management/administration of 
multidisciplinary mental health programs at complex facilities and/or 
across multiple sites, which includes supervision, consultation, 
negotiation, and monitoring.
    2.  Demonstrated global knowledge of mental health counseling 
practice to develop, maintain, and oversee programs in all settings.
    3.  Ability to provide consultation on policy implementation, 
qualification standards, counseling practice, and competency with 
medical center director, VISN, or national program managers that are 
consistent with organizational goals and objectives.
    4.  Advanced knowledge of evidence-based practices and mental 
health practice guidelines in multiple professional areas, and the 
ability to use these resources to guide the program staff in providing 
appropriate treatment interventions.
    5.  Ability to influence high level officials in adoption of, and 
conformance to, performance measures, monitors, and other policy 
guidelines.

        (c)  Assignment. Typical assignments include serving at a 
        facility as a care line manager or at the VISN/VACO level. A 
        care line manager is assigned to manage, direct, and oversee 
        complex treatment programs within the medical center. 
        Supervisory responsibilities cover multiple disciplines that 
        may be separated geographically or in multi-division 
        facilities. They have responsibility for staffing, work 
        assignments, budget, clinical services provided and admission 
        criteria for the program, day-to-day program operation, and all 
        reporting requirements. Leadership positions at the VISN or 
        national level are characterized by their scope, level of 
        complexity, significant impact on VHA mission, significant 
        importance to the VISN, etc. They direct a mental health, 
        behavioral science, other patient care program component at the 
        VISN or national level or direct organizational development at 
        the national level. Duties are exercised with wide latitude, 
        autonomy, and independence. They have delegated authority to 
        determine long range work plans and assure that implementation 
        of the goals and objectives are carried out. They may serve as 
        consultants to other management officials in the field, VISN, 
        or national level.

4. DEVIATIONS

    a.  The appointing official may, under unusual circumstances, 
approve reasonable deviations to the grade determination requirements 
for MFTs in VHA whose composite record of accomplishments, performance, 
and qualifications, as well as current assignments, warrant such action 
based on demonstrated competence to meet the requirements of the 
proposed grade.
    b.  Under no circumstances will the educational or licensure 
requirements be waived for grade levels GS-11 or above.
    c.  The placement of individuals in grade levels not described in 
this standard must be approved by the Under Secretary for Health, or 
designee, in VHA Central Office.

Authority 38 U.S.C. 7402, 7403

                               __________
                               Appendix B
    4980.37.

        (b)   To qualify for a license or registration, applicants 
        shall possess a doctor's or master's degree in marriage, 
        family, and child counseling, marriage and family therapy, 
        psychology, clinical psychology, counseling psychology, or 
        counseling with an emphasis in either marriage, family, and 
        child counseling or marriage and family therapy, obtained from 
        a school, college, or university accredited by a regional 
        accrediting agency recognized by the United States Department 
        of Education or approved by the Bureau for Private 
        Postsecondary and Vocational Education. The board has the 
        authority to make the final determination as to whether a 
        degree meets all requirements, including, but not limited to, 
        course requirements, regardless of accreditation or approval. 
        In order to qualify for licensure pursuant to this section, a 
        doctor's or master's degree program shall be a single, 
        integrated program primarily designed to train marriage and 
        family therapists and shall contain no less than 48 semester or 
        72 quarter units of instruction. This instruction shall include 
        no less than 12 semester units or 18 quarter units of 
        coursework in the areas of marriage, family, and child 
        counseling, and marital and family systems approaches to 
        treatment. The coursework shall include all of the following 
        areas:

    (1)  The salient theories of a variety of psychotherapeutic 
orientations directly related to marriage and family therapy, and 
marital and family systems approaches to treatment.
    (2)  Theories of marriage and family therapy and how they can be 
utilized in order to intervene therapeutically with couples, families, 
adults, children, and groups.
    (3)  Developmental issues and life events from infancy to old age 
and their effect on individuals, couples, and family relationships. 
This may include coursework that focuses on specific family life events 
and the psychological, psychotherapeutic, and health implications that 
arise within couples and families, including, but not limited to, 
childbirth, child rearing, childhood, adolescence, adulthood, marriage, 
divorce, blended families, stepparenting, abuse and neglect of older 
and dependent adults, and geropsychology.
    (4)  A variety of approaches to the treatment of children.

    The board shall, by regulation, set forth the subjects of 
instruction required in this subdivision.

                               __________
                               Appendix C
        (e)   In order to provide an integrated course of study and 
        appropriate professional training, while allowing for 
        innovation and individuality in the education of marriage and 
        family therapists, a degree program that meets the educational 
        qualifications for licensure or registration under this section 
        shall do all of the following:

    (1)  Provide an integrated course of study that trains students 
generally in the diagnosis, assessment, prognosis, and treatment of 
mental disorders.
    (2)  Prepare students to be familiar with the broad range of 
matters that may arise within marriage and family relationships.
    (3)  Train students specifically in the application of marriage and 
family relationship counseling principles and methods.
    (4)  Encourage students to develop those personal qualities that 
are intimately related to the counseling situation such as integrity, 
sensitivity, flexibility, insight, compassion, and personal presence.
    (5)  Teach students a variety of effective psychotherapeutic 
techniques and modalities that may be utilized to improve, restore, or 
maintain healthy individual, couple, and family relationships.
    (6)  Permit an emphasis or specialization that may address any one 
or more of the unique and complex array of human problems, symptoms, 
and needs of Californians served by marriage and family therapists.
    (7)  Prepare students to be familiar with cross cultural mores and 
values, including a familiarity with the wide range of racial and 
ethnic backgrounds common among California's population, including, but 
not limited to, Blacks, Hispanics, Asians, and Native Americans.

                                 
       Prepared Statement of Hon. Russ Carnahan, a Representative
                 in Congress from the State of Missouri
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee, thank you for hosting this hearing to discuss mental health 
care issues in the Department of Veterans Affairs. Mental health is 
crucial to being a productive member of society. Unfortunately, many of 
our veterans struggle upon their return home. Today's hearing provides 
a conversation between Congress and those with knowledge of what needs 
to be done to ensure our Nation's heroes are successful and healthy.
    Our veterans returning from Operation Iraqi Freedom and Operation 
Enduring Freedom are suffering a lasting mental health toll. They have 
witnessed urban guerilla warfare and have intimately experienced the 
stress of combat. Many have seen their friends lost. They then return 
home to begin the difficult reintegration into civilian life. According 
to the VA, only half of OIF and OEF veterans have been evaluated and 
seen as outpatients in health care facilities. Of those, one out of 
four veterans demonstrates Post-Traumatic Stress Disorder (PTSD).
    PTSD is a disabling mental health epidemic among veterans. It 
impedes all aspects of a veteran's life, from employment to social 
wellbeing and family relationships. It is staggering that over half of 
OIF and OEF veterans have not been seen in health care facilities. How 
can these men and women begin to cope if they have not received the 
proper mental health evaluation? In 2008, the VA began efforts to call 
all veterans who had not yet enrolled in a VA health clinic to 
encourage them to seek care. These are the kinds of concerted efforts 
we must continue to employ. If our veterans are to thrive, we have to 
actively close the gaps that hinder their recuperation.
    PTSD rates have been steadily growing since the overseas conflicts 
began. Depression diagnoses are up particularly among younger active 
duty veterans who have higher combat exposure. We need greater 
community outreach efforts to help these heroes. By connecting with 
veterans in their own communities, we can provide the necessary support 
and encouragement for recovery. Many veterans find it personally 
difficult to seek care, but we can't allow these men and women to fall 
through the cracks. We must expand the scope of VA Vet Centers to 
ensure that servicemembers make a smooth transition.
    I look forward to hearing from our witnesses on ways we can 
guarantee successful community reintegration and mental health services 
for all veterans.

                                 
      Prepared Statement of Andrea B. Sawyer, Colonial Heights, VA
              (Spouse of Sergeant Loyd Sawyer, USA (Ret.))
    Mr. Chairman, Ranking Member Filner, thank you having this hearing 
today and for allowing me to submit my testimony for the record.
    My name is Andrea Sawyer, caregiver and spouse of U.S. Army 
Sergeant Loyd Sawyer, retired. While I understand that this Committee 
does not have jurisdiction over the Department of Defense, it is 
important that you understand my husband's whole story to understand 
why we are so frustrated with his care.
    Loyd was a civilian funeral director and embalmer before joining 
the Army Mortuary Affairs team. As a mortuary affairs soldier, Loyd did 
a tour at Dover Port Mortuary where all deceased servicemembers 
returning from Iraq and Afghanistan re-enter the United States, and 
Loyd worked in the Army uniform shop (where paperwork is processed and 
final uniforms prepared for deceased servicemembers) and embalmed on 
the days he was not in the uniform shop. Loyd then served a tour in 
Iraq, first in Talil and then the Balaad mortuaries where he processed 
countless deceased civilians and servicemembers. While there, he began 
exhibiting signs of mental distress such as anger, hypervigilance, 
insomnia, etc.
    Upon his return home, I attempted to get him help for 11 months. 
There was a delay in getting help because we had only one psychiatrist 
on base and then the help he received was ineffective. Ultimately I sat 
in a room with an Army psychiatrist and my husband and watched Loyd 
pull a knife out of his pocket and describe his plan of slitting his 
throat. It was apparent that he was delusional and in great psychiatric 
distress. On December 19, 2007, Loyd was admitted to Portsmouth Naval 
Medical Center (PNMC). What followed was an initial crisis 
hospitalization of 5 weeks (3 exclusively inpatient and 2 intensive 
outpatient), a separate 1 week crisis hospitalization for homicidal 
ideations, 8 months in an Army Warrior Transition Unit (WTU), 
appointments 3 days a week at PNMC 2 hours away from our home Army base 
of Fort Lee, a medical and physical evaluation (MEB/PEB) process that 
resulted in a 70 percent permanent Department of Defense (DoD) 
retirement from active duty for post-traumatic stress disorder and a 
secondary diagnosis of major depressive disorder, and medical paperwork 
that said, ``The degree of industrial and military impairment is 
severe. The degree of civilian performance impairment is severe at 
present, though over time--likely measured in years (emphasis added)--
with intensive psychotherapy augmented by pharmacotherapy to control 
his anxiety and depressive symptoms--his prognosis MAY improve.'' In 
July 2008 while still on Active Duty, but with retirement paperwork in 
hand, we enrolled Loyd at our local VA, the Richmond polytrauma center, 
better known as Hunter Holmes McGuire VA Medical Center (HHM VAMC), for 
medical services in the Veterans Health Administration (VHA). In 
October, with help from Wounded Warrior Project (WWP), Loyd's VA 
disability claim declared him 100 percent permanent and totally 
disabled (this claim is done through Veterans Benefits Administration), 
thus giving him the highest priority status for VA care.
    Knowing that Loyd needed extensive help quickly, we tried getting 
him into the PTSD clinic immediately which was not available. The first 
available appointment was almost a 2-month wait. When the appointment 
came, Loyd presented his history, including that he had been seen two 
to three times weekly at PNMC for the last 8 months of active duty, 
that he remained suicidal, and that he needed intensive therapy. What 
was available at the VA in the PTSD clinic for him was a once every 
quarter medicine management appointment and a once a month to once 
every 6 weeks 1-hour therapy appointment. Knowing that this was leading 
to spiraling depression and an unchecked increase in his PTSD symptoms, 
we used our TRICARE and began treatment with a local civilian counselor 
who was trained at the VA's National Center for PTSD. The counselor was 
able to see Loyd once or twice a week depending on the severity of the 
symptoms. Throughout the winter of 2008 and the spring of 2009, I 
became increasingly concerned at the out of control depression I was 
witnessing and feared that suicide was an imminent possibility. After 
getting little response from VA mental health, his TRICARE counselor 
and I discussed sending him to a long-term inpatient treatment program 
for PTSD through the VA. I contacted Loyd's Federal Recovery 
Coordinator (FRC) for help in finding a program. We did eventually do 
phone interviews, made a site visit, and enrolled him in a PTSD program 
at the VA facility in Martinsburg, WV. I got little to no help from our 
local VA hospital in finding this program, but I received invaluable 
help from Loyd's Federal Recovery Coordinator.
    The hospitalization was a nightmare. The program delivered on none 
of its promises. His doctors there never coordinated with his local VA 
mental health clinician, his civilian counselor, or his FRC. At one 
point, his civilian counselor, his FRC, and I were calling the facility 
daily because we were concerned the medication change they had made was 
making him physically and verbally aggressive. Even more concerning was 
that this was a medicine that he had been removed from while on active 
duty for the same reasons. In 90 days of inpatient treatment at the VA 
facility, he received fewer than five individual therapy sessions. Upon 
his completion of the program, which I truly believe was just about 
marking time, he was released and told to follow up with his local 
VAMC. For my husband, who had already expressed suicidal ideations, 
there was no coordination or communication between any of his treatment 
providers. He came home and promptly discontinued ALL of his medication 
because he did not like the way it made him feel. (It is important to 
note that for the year and a half prior to this hospitalization at 
Martinsburg, he had been completely compliant with his medication 
plan.)
    I immediately called the Richmond PTSD clinic as soon as I realized 
that he had stopped taking his medication. I was told that it would be 
4 weeks before they could see him to re-evaluate his medications. I had 
the FRC try to intervene with the primary care provider (PCM), hoping 
the PCM could speed up the process, but he simply told me, ``I was 
wasting his time.'' Eventually with the help of the FRC, I was able to 
get him an appointment within the week with a VA psychiatrist in 
general psychiatry. This psychiatrist has done his medication 
management since then, as she very clearly listened to what symptoms 
needed to be controlled, and, even more importantly, listened to what 
he needed and wanted as a patient. At that time, we agreed with her, 
that for counseling Loyd was better off continuing with the civilian 
counselor because he could be seen once/twice a week and with her for 
medication. By involving Loyd, she made it much more likely that he 
would continue with his pharmacotherapy regimen. She also asked that 
neuropsych testing be redone and suggested that Loyd try the PTSD 
``Young Guns'' therapy group that met with a clinician in the Richmond 
PTSD clinic weekly.
    Loyd's repeat neuropysch testing in January 2010 showed that his 
PTSD symptoms were still severe. On the DAPS (a psychiatric scale test 
for symptoms of PTSD used frequently by the VA), Loyd scored all 20 out 
of 20 on all the indicators except for suicidality for which he scored 
a 16, meaning he still fell into the extremely high risk category and 
was actively suicidal. His authenticity score was a five which is as 
high as you can score. So after more than a year in the VA, a 90-day 
hospitalization, weekly therapy, Loyd was not really improving. Feeling 
rather hopeless, Loyd did decide to try the Young Guns group. He found 
great solace in this group in being able to relate with others who 
experienced the same symptoms but also because he saw people in 
different stages of recovery who, led by a clinician, were able to 
analyze their behaviors and suggest multiple positive coping strategies 
that they each found successful. Unfortunately, 4 months into the group 
and without consultation with the patients, it was announced that the 
VAMC was changing its treatment model and was disbanding the group by 
year's end. For those who wished to continue in a group setting, the VA 
would be turning them over to a yet untested regional division of a new 
community-based program which had only two employees for a twenty-three 
county region, neither of whom was trained in counseling. I immediately 
contacted the Wounded Warrior Project (WWP), and the resulting year 
long saga of trying to keep the group on campus with a clinician is in 
their testimony. Suffice it to say, despite all requests from the 
veterans in the group in a petition signed by 27 of them, and an on 
campus successful attendance of 40 members regularly, the VAMC moved 
the group off campus, renamed it a support group, but has yet to pull 
the clinician because the community organization has failed to show up 
for a single off campus meeting of the group. Attendance has fallen 
sharply (averaging 7-10 individuals) as working veterans can no longer 
leave work to go to a ``support group'' like they could leave work to 
go to therapy appointment. In addition, by moving the group off campus, 
the VA is no longer able to reimburse for mileage--a significant 
problem in today's economy.
    So my question to you, the Committee is this:

         My husband is a veteran with well-documented severe chronic 
        PTSD who uses one of the major VA polytrauma centers as his 
        VAMC. We have all the advantages that should guarantee him good 
        treatment--an excellent, caring Federal Recovery Coordinator, a 
        100 percent service-connected disability rating, a polytrauma 
        case manager, and a super VSO. Yet, he has had a difficult time 
        accessing appropriate mental health treatment in this VISN and 
        in the inpatient treatment program at which he received care 
        that was in another VISN. If that is the case for him, how can 
        any vet just enrolling without any of these advantages be 
        expected to get quality and accessible care?

    That question being asked, as a spouse who has been involved with 
this system for some time and after having spoken to a number of other 
wounded warriors and spouses in similar situations, I would like to 
make to following suggestions to encourage those with mental health 
issues to seek and continue with treatment:

        1.  Treatment must be timely and available.

    The new treatment model suggests that veterans should be seen/
complete a minimum of nine visits to VA PTSD clinicians for either 
group or individual therapy in 15 weeks. I do not see how this is even 
a realistic model. Currently in VA's all over the country, veterans are 
waiting months in between appointments and drive hours to these 
appointments.
    According to a caregiver of a South Dakota OIF veteran:

         Hubby went to the group meeting last night for their final 
        session with the VA provider. She told them during the meeting 
        that the VA is hiring a new provider who will continue with the 
        group in July or possibly the end of June. I'm skeptical that 
        it will actually happen as we are still waiting for a full-time 
        psychiatrist at our CBOC that was promised a year ago after 
        they let the contract provider go. I'm afraid it's another 
        story to keep everyone happy.

    A caregiver for an OIF Marine veteran from Washington State wrote:

         We have an AWESOME psychiatrist at the VA, and I am terrified 
        he will retire. . .The only bad thing is that he is more 
        popular than a single sat [satellite] phone in a deployed 
        battalion. He is about 2 hours away and about once every other 
        month or so we get into see him.

    Another caregiver wrote:

         My husband has PTSD also, he was not considered a priority for 
        care for his PTSD by the VA and they said he only needed to be 
        seen every 6 months. Then he had an episode and was tazed 6 
        times by police and sent to civilian psych hospital where he 
        was not given his meds, they tried to treat him like a 
        schizophrenic and wanted to have him committed. Luckily I was 
        able to talk to an intern who had half a brain who went to bat 
        for my husband to get him released to my care. Now that my 
        husband has been hospitalized in a mental hospital the VA 
        suddenly thinks oh, well lets see him once every 2-3 months. 
        Not to mention that when he goes in to see his psychiatrist he 
        doesn't tell him everything and tries to make everything look 
        great. I have to e-mail his psychiatrist just to keep him 
        properly updated on my husband's status. Then there is also the 
        issue of availability of appointments if something sooner is 
        needed. If you have an emergency or feel your husband needs to 
        be seen sooner they never have anything available.

    The mom of a Kentucky vet wrote:

         One of the biggest problems I have noticed is simply not being 
        able to get an appointment. Call for help. . .wait 6 weeks to 
        get in to talk to someone.

    While I understand that there is a shortage of mental health 
providers in this country, that does not mean that we can set 
unrealistic standards for treatment and then wonder why no one is 
completing said treatment. If there is a shortage of providers, we must 
use all means necessary to ensure timely, quality care and use 
mechanisms such as fee-basis more often to accommodate the needs of 
this growing population.

    2.  Treatment must be an appropriately time focused intervention 
and needs to address severity, chronicity, and provide multiple ongoing 
treatment options.







    (From VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF 
POST-TRAUMATIC STRESS)
    The clinical practice guidelines are joint guidelines between DoD 
and VA and deal with the range of diagnoses involving trauma exposure. 
The guidelines' beginning focuses on EARLY intervention, literally 
starting assessment and treatment within minutes of experiencing or 
witnessing the trauma. For VA, this is not even a remote possibility. 
VAMC's access to veterans is limited to their time of enrollment being 
in most cases months to years after the witnessing of the trauma. 
Because of this, veterans who enter VA have chronic PTSD which is 
defined as anyone experiencing clinically significant symptoms 6 months 
after the trauma. (ptsd--full core page 10). This just by nature of the 
delay in treatment suggests that more time than nine visits will be 
necessary. VA needs to ensure that guidelines it is following are 
appropriate to the diagnosis of the individual.
    The treatment modules, which are located within the clinical 
guidelines, includes the recovery model which focuses on mild to 
moderate PTSD. Veterans with severe PTSD need different options than 
veterans with mild post-traumatic stress. The recovery model as it is 
being implemented at our VAMC, at least, puts too much emphasis on 
addressing mild-to-moderate PTSD, and not addressing severe PTSD. This 
leaves veterans with severe PTSD feeling not understood. By doing away 
with long-term therapy groups on campus, it leaves little option for 
continuing therapy except individual therapy which as discussed above 
is not available, plus it pits vets with long-term chronic issues 
needing continual individual therapy against vets just entering the 
system needing to begin therapy. VA must ensure that a wide variety of 
treatment options for the veteran population with a wide degree in 
severity and chronicity of their PTSD exists.

    3.  Treatment must be practical.

    One focus of VA has been veteran unemployment. Currently the new VA 
Mental Health (MH) guidelines are not at all conducive to employment. 
Consider this scenario: VA wants a veteran to attend nine treatment 
sessions in a 15-week period. A veteran as illustrated in the examples 
above may have to drive hours away to get treatment, but we will use 
for purposes of our example an hour drive. So a veteran must tell his 
employer that he will miss 9\1/2\ days of work at his job within the 
first 15 weeks of work. Then if the veteran were at the Richmond VAMC 
PTSD clinic and probably others, he may be channeled into 10-week 
recovery group, 6 week mindfulness coping skills group, 6-week anger 
management coping skills group, and more individual therapy, IF he 
needed all parts of the new recovery model. Literally that would 
require that a veteran miss a 1/2 day of work once a week for the first 
6 months of a job, ONLY for mental health treatment purposes, that 
disregards any other physical health issue for which a veteran may need 
treatment. Few employers would hire or retain that individual. It is 
not practical. Eventually a veteran would have to choose between his 
job and his care. That is not a choice a veteran should have to make.
    To complicate matters, veterans nationwide are not allowed to 
choose their appointment times, leading to inconvenient and missed 
appointments and constant rescheduling requirements. Currently, the VA 
sets the appointment time, and veterans are simply expected to show up 
regardless of other obligations. This obviously prevents a veteran from 
scheduling appointments around employment needs or scheduling multiple 
appointments on the same day.
    In light of the intensive requirements of the MH guidelines and out 
of respect for the time of individual veterans, the VA needs to allow 
veterans to make their own appointments and have limited evening and 
weekend hours to accommodate working veterans with families. Currently 
our VA is saying it will implement evening hours, but I have little 
faith in that as I have heard the same statement for the entire 3 years 
we have been in the VA.

    4.  Treatment must be tailored to the individual and not a series 
of a completion of cookie cutter modules.

    Too often in VA, patients are channeled into programs where every 
veteran is given the same program regardless of their needs. For 
example, every veteran in the clinician led group therapy session was 
moved into the community-based group without individual evaluation of 
the veteran's preparedness for the move. The new model lends itself to 
the same thing happening. A veteran would simply be channeled into a 
series of cookie-cutter modules explaining what PTSD is, what changes 
it creates in the chemicals of the body, what changes it creates in 
thinking patterns, and then a series of modules on teaching coping 
skills. It lends itself to shuffling them through the modules without 
the quality assessment to see if veterans have mastered the skills. 
Once a module is completed it is checked off whether or not the veteran 
feels he has mastered the skill. Where is his remedy in this situation? 
Individual therapy? He will have to wait months for that appointment 
where he will probably be told he has already had that class. A veteran 
does not need to be told by PowerPoint or workbook what all his 
symptoms are or should be; he lives them daily. While some education is 
good, this model makes me fear that it is simply check the block and 
veterans will be pushed through or simply quit because they do not see 
it as quality, individually tailored, or making a difference, not to 
mention the time it takes away from the occupational arena.
    Along the same lines, what happens to a veteran who has had all of 
these modules while still on active duty? Will he be funneled through 
them again on the VA side of treatment? Loyd had all these modules over 
his 8 months of treatment at PNMC on active duty. He got them again 
during his 90-day hospitalization and he was frustrated at having to 
retake them because that was all that was available. He wanted 
something that he had not tried. Who is going to check to see that 
people are not being forced to repeat things just for the sake of 
checking the block for treatment? A repeat of a previous therapy is 
another reason people do not continue with treatment.
    To encourage a veteran to seek and complete treatment, VA must 
ensure that each individual veteran is not lost in a maze of completing 
treatment that is not relevant to him as an individual patient. PTSD 
veterans like all other veterans with health conditions needs to be 
seen as patients first and diagnoses second. The patient's individual 
symptoms should determine his type of treatment, not a predetermined 
course of treatment that does not account for individual variances.

    5.  Treatment must be culturally competent.

    Some, not all, VA clinicians seem out of touch with combat PTSD. 
Most of them seem familiar with PTSD as a clinical diagnosis, but many 
do not seem to understand the difference veterans experience with 
combat PTSD verses military sexual trauma (MST) verses a routine car 
accident. Veterans routinely get frustrated having to stop and explain 
language/command structure/nature of combat jobs/even basic military 
language to clinicians. In one instance with my husband as he was 
explaining damage done to a body by an IED, the clinician got a very 
puzzled look on her face and asked how a contraceptive device could 
have caused limbs to be blown off. We had to explain the difference 
between an IED--improvised explosive device--and an IUD--a female 
contraceptive device--to her. At that point, that clinician had lost 
all credibility. Therapy was over for the day, and we never saw her 
again.
    In another instance, a female veteran whose PTSD rating is in part 
due to an MST and who still experiences horrific flashbacks, was placed 
in an all-male PTSD coping skills group. She was in with older men, 
mostly Vietnam era, who had little respect for females who had served, 
and certainly no understanding of MST. Eventually she stopped going to 
the group as it caused her more trauma listening to the comments of her 
fellow group participants than the symptoms she already experienced.
    The VA should engage in a program a program similar to the Navy's 
Civilian Familiarization for all employees. This program allows members 
of the public to experience a small taste of a sailor's occupation. 
Also a continuing education class in military terms is necessary. This 
could be easily added to the required continuing education classes that 
already exist in the VA.

    6.  Community-based partnerships for treatment should be available 
options for veterans to seek treatment, but they should not be the only 
option.

    There is a trend in VA to form community partnerships for purposes 
of offering wider support for veterans and for expanding options for 
veterans. While I think this may be a good idea, when it comes to 
dissolving existing therapy groups to hand over to community groups to 
become support groups, it is necessary for there to be some kind of 
oversight process if compensation is going to be tied to therapy. In 
the case of Richmond changing the therapy groups to support groups and 
moving them off campus, the community group that the VA said was going 
to facilitate the group has never shown up. Even if it had shown up, 
the community group does not have the trained staff to lead a group. 
Also, in the instance of Richmond, veterans were not consulted about 
the change, it was simply dictated, without evaluation to ensure that 
each individual was ready for leaving a clinical therapeutic setting 
and transitioning to a non-clinical supportive setting.
    For purposes of treatment and compensation, administrative data 
collection to support the evidence that treatment is being provided 
must be worked out in advance. Support groups do not normally keep 
attendance records, so it would be difficult to prove that a veteran 
had been to treatment at a support group. Also, using community 
settings whether support groups or community clinicians, needs to be 
evidence-based treatment. It is not fair to do away with a treatment at 
the VA because it is not evidence-based only to send veterans out into 
the community to receive other non-evidence based treatments while 
leaving them no options at the VA.
    VA should use MOA's with community partners and fee-basis providers 
to ensure that veterans with PTSD may have the option, at the veteran's 
discretion, of receiving evidence-based treatment in their home 
communities. This scenario would make treatment for veterans more 
accessible geographically, more time sensitive to the onset of the 
symptoms, and more practical from a standpoint of the availability of 
evening and weekend hours. Using MOA's would allow VA to ensure that 
all treatment remains evidence-based and set a clear expectation about 
the administrative practices it requires to document a veteran's 
treatment regimen for purposes of compensation.

    7.  Communication between DoD and VA, in addition to communication 
between VHA and VBA, and intraVHA needs to be improved.

    A model that would tie an incentive to receive and complete 
treatment for PTSD rests heavily on communication between all elements 
of inter DoD/VA and intra VA (VHA and VBA.)
    In the matter of tying compensation to treatment, a vet would need 
DoD to clearly communicate what treatment for PTSD had been received on 
active duty and determine whether or not there was a prognosis for 
improvement. If a veteran has received DoD treatment, then VA and DoD 
must communicate whether or not the veteran has shown improvement or 
has a prognosis that suggests improvement. If there is a prognosis to 
suggest that treatment will improve the quality of life and decrease 
the functional impairment caused by PTSD, then a veteran should be 
incentivized to seek all treatment available to improve functionality, 
but that treatment should NOT be a repeat of what was done already on 
active duty or with a civilian provider outside of DoD and VA.
    The point of incentivizing treatment is where I need to clearly see 
details worked out. I see this as being a bureaucratic nightmare. VHA 
and VBA need to agree on what the severity of a veteran's PTSD was and 
what treatment is necessary. Currently these two systems do not 
interact which constantly leads to one system giving one diagnosis for 
compensation and the other system giving a different diagnosis for 
treatment purposes. In addition, once VBA assigned a temporary rating, 
and then presumably VHA would assign a treatment plan, who researches 
whether that treatment plan is feasible for the veteran, which upon 
completion would go back to VBA for a final rating? Assigning a working 
vet to 6 months of weekly therapy modules would not work. It would lead 
to the vet not completing treatment and then not receiving compensation 
for a condition which he has due to service but for which VA cannot 
accommodate his real life needs of working and treatment. Not to 
mention, the therapy has to be geographically available which in ever 
increasing instances it is not. The amount of appointments necessary 
would have to be available clinically. I worry that VBA would set a 
timeline for treatment that is unreasonable because the VHA clinic 
appointments are not available due to staff shortages at clinics. The 
only person who would be penalized is the vet.
    In Loyd's case, before even leaving DoD, he had done all of the 
treatment that has been offered at VA. There was simply no point, other 
than going for symptom maintenance, for him to even go to the VA for 
mental health treatment. He has gone over the last 3 years, but it has 
been an exercise in futility and frustration which at times has 
increased the depression. Despite the fact that he has repeatedly 
indicated that he thinks of suicide three to four times a week, we have 
never been contacted by the suicide prevention person, and at this 
point, it is mute. People with Loyd's severity and chronicity should 
not necessarily be incentivized as through 4 years of treatment, one 
DoD and three VA, there has been little improvement as was the 
prediction of DoD.
    In other cases, where there has been no treatment for a veteran 
with PTSD, certainly incentives should be tied to treatment. That 
treatment should be relevant to the health needs of that particular 
veteran and accessible to the veteran as determined by the VETERAN and 
his clinician, not just a clinician. Simply assigning a rating without 
any treatment is a situation that says to a veteran that his case is 
hopeless. The incentive to receive that treatment, a stipend that 
allows a veteran to go to treatment, must be appropriate to address the 
financial concerns that will arise while treatment is obtained. Simply 
giving a veteran $100 a month will not cover the cost of travel, missed 
work for appointments, or emotional distress that will be increased at 
the beginning phase of treatment.
    DoD and VA must communicate to ensure relevant treatment is 
obtained and not duplicated. VHA must communicate internally to see 
that treatment is relevant and appropriate, grouping together all 
elements of a veterans mental health team--counselor, psychiatrist, 
neuropsychiatrist, etc. VHA and VBA must develop a plan to address 
timeliness of treatment, what is appropriate treatment to incentivize a 
veteran to seek treatment, and that treatment required is actually 
available to a veteran (meaning that staff, location, and particular 
treatment model are at a location where a veteran has access.) I fear 
that this may become a plan where VBA sets a particular timeframe for 
treatment only for VHA not to have the treatment available in a 
location accessible or a timeframe accessible to the veteran in that 
frame of time--for example that VBA will set a stipend limitation of 6 
months to do all eight visit, but a veteran's CBOC will only have one 
appointment a month available. I think that is an extremely realistic 
concern.
    In conclusion, I understand that some of these matters are 
questions that are theoretical, however, I think in this matter, it is 
necessary for Congress to have answers to these questions and a 
practical model BEFORE any changes are made. Too often, laws are made, 
then policies are implemented that do not agree with the spirit of the 
law, and it takes years to address and fix the issues. In this case, 
changing the treatment and compensation models as they exist without 
these questions being firmly answered with a practical working plan may 
cost lives. Today there are almost 400,000 veterans receiving 
compensation for PTSD with numbers predicted to increase rapidly with 
the influx of veterans from OIF/OEF into the VA system. Veterans are 
dying from suicide at a rate of 18 a day. If we want veterans to feel 
that VA truly understands them and wants them to successfully seek 
treatment and lead mentally healthy lives, Congress must show veterans 
that legislators and the VA understand the true barriers to seeking VA 
mental health care and remove them so that our veteran population can 
continue to be strong and productive for years to come.
    Summary: I believe that every veteran who suffers from post-
traumatic stress would gladly give up any compensation check if they 
could get quality, timely, relevant treatment to end the daily 
nightmare that they live. While I think in theory the idea of tying 
compensation to receiving treatment is logical, I have grave concerns 
about the VA being able to do this correctly. I think this matter of 
tying compensation to continuous treatment that needs to be treated 
cautiously and needs to consider several matters concerning existing 
treatment need to be addressed. I have asked to be able to present my 
testimony to raise the concerns that I have.
    Main Points:

    1.  Treatment must be timely and available.
    2.  Treatment must be an appropriately time focused intervention 
and needs to address severity, chronicity, and provide multiple ongoing 
treatment options.
    3.  Treatment must be practical.
    4.  Treatment must be tailored to the individual veterans needs and 
symptoms not be a series of cookie-cutter modules.
    5.  Treatment must be culturally competent.
    6.  Community based partnerships for treatment should be available 
options for veterans to seek treatment, but they should not be the only 
option.
    7.  Communication between DoD and VA, in addition to communication 
between VHA and VBA, and intraVHA needs to be improved.

Conclusion:

    I understand that some of these matters are questions that are 
theoretical; however, I think in this matter, it is necessary for 
Congress to have answers to these questions and a practical model 
BEFORE any changes are made. Too often, laws are made, then policies 
are implemented that do not agree with the spirit of the law, and it 
takes years to address and fix the issues. In this case, changing the 
treatment and compensation models as they exist without these questions 
being firmly answered with a practical working plan may cost lives. 
Today there are almost 400,000 veterans receiving compensation for PTSD 
with numbers predicted to increase rapidly with the influx of veterans 
from OIF/OEF into the VA system. Veterans are dying from suicide at a 
rate of 18 a day. If we want veterans to feel that VA truly understands 
them, wants them to successfully seek treatment, and wants them lead 
mentally healthy lives, Congress must show veterans that legislators 
and the VA understand the true barriers to seeking VA mental health 
care and remove them so that our veteran population can continue to be 
strong and productive for years to come.

                                 
                   MATERIAL SUBMITTED FOR THE RECORD
                  Pre-Hearing Questions for the Record
                 for House Veterans' Affairs Committee
                            Chairman Miller
    Question 1: Please outline the growth in the budget for VA mental 
health care programs from 2002 to the present. Please outline what 
those resources have been used for, i.e., staffing increases, rural 
initiatives, etc.

    Response:
    Information included in the annual President's Budget submissions 
related to the growth in the VA mental health care program budget is 
shown in the table below. Major expenses within the categories shown 
are mental health staffing, training for mental health staff, and 
environmental improvement costs (including, for example, provision of 
telemental health equipment in both medical facilities and outpatient 
clinics).

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 History of Mental Health in the President's Budget ($Millions)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                      Actual Obligations                                                 Current Estimate
                                                             -----------------------------------------------------------------------------------------------------------------------------------
                                                               FY 2002    FY 2003    FY 2004    FY 2005    FY 2006    FY 2007    FY 2008    FY 2009    FY 2010    FY 2011    FY 2012    FY 2013
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Seriously Mentally Ill                                          $2,282     $2,393     $2,137
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PTSD                                                              $138       $154       $160
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Substance Abuse                                                   $426       $459       $353
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Psychiatric Inpatient                                                                            $1,022       $965       $973     $1,228     $1,323     $1,449     $1,575     $1,679     $1,770
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Psychiatric Outpatient                                                                           $1,238     $1,265     $1,421     $2,052     $2,445     $2,932     $3,295     $3,606     $3,778
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Psychiatric RRT*                                                                                   $170       $185       $196       $246       $264       $240       $250       $261       $272
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Domiciliary RRT*                                                                                                         $334       $353       $415       $540       $583       $607       $630
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mental Health Initiative                                                                                                 $326
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Total Mental Health                                             $2,846     $3,006     $2,650     $2,430     $2,415     $3,250     $3,879     $4,447     $5,161     $5,703     $6,153     $6,450
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*Residential Rehabilitation Treatment


    Question 2: How many veterans in receipt of compensation for mental 
illness utilize VA mental health care services? Please break the data 
down by war cohort.

    Response: The following data are based on interpretation of the 
request above, as follows:

          Compensation for mental illness, as well as treatment 
        for mental illness, is provided to a larger population of 
        veterans than that limited to PTSD, anxiety disorder, or 
        depression. For the purposes of this query we are responding to 
        these three diagnoses because they are specifically mentioned 
        in the request and they are the three diagnoses provided to the 
        Veterans Health Administration (VHA) by the Veterans Benefits 
        Administration (VBA), based on most recent complete VBA rolls 
        (through May 2011). For all veterans with a compensable, 
        service-connected mental health condition, these are the three 
        most prevalent mental health diagnoses.
          VBA provided data on service era for all compensated 
        veterans based on Congressionally-defined war cohorts.
          When reviewing the veteran population considered to 
        be ``diagnosed'' with any of the mental illnesses included, VA 
        usually includes a veteran in the population based on at least 
        two outpatient encounters or one inpatient admission for that 
        mental illness. This is done because mental illness diagnoses 
        are often coded on encounters where the visit is intended to 
        assess veterans for the disorder, and such patients may or may 
        not be meet criteria for a confirmed mental illness diagnosis. 
        However, for the purposes of this report, VA included in the 
        population all veterans with a coded entry of the mental 
        illness for which they have received service-connection, 
        regardless of the number of visits in the record. This more 
        inclusive methodology may result in a higher number of mental 
        illness diagnoses than in other reports.

    A total of 648,118 veterans are receiving compensation for PTSD, 
anxiety, or major depression and are service-connected as of May 2011. 
This includes veterans rated 0 percent for these conditions, but 
receiving compensation for other conditions; veterans rated zero 
percent for these conditions are not included in these counts unless 
they are receiving compensation for another disability. Of these, 
554,469 received some health care in VA and 381,334 received specialty 
mental health services in VA between April 1, 2010, and March 31, 2011. 
Thus 59 percent of all veterans receiving compensation for PTSD, 
anxiety, or major depression received specialty mental health treatment 
in VA during this time period and 69 percent of those receiving 
compensation for PTSD, anxiety, or major depression received some VA 
health care services during this time period, not limited to specialty 
mental health treatment. These data are broken out into populations 
defined by service era (war cohort).


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number of
                                              veterans
                                              receiving    Number of veterans receiving    Number of veterans receiving    Percent of veterans receiving   Percent of veterans receiving
                                            compensation     compensation and service-       compensation and service-       compensation and service-       compensation and service-
                                            and service-  connected for PTSD, anxiety or  connected for PTSD, anxiety or  connected for PTSD, anxiety or  connected for PTSD, anxiety or
  Period of Service (war cohort)      connected    major depression who received   major depression who received   major depression who received   major depression who received
                                              for PTSD,    any VA health care in Q3FY10-      specialty mental health         specialty mental health      any VA health care in Q3FY10-
                                             anxiety or       Q2FY11         services in Q3FY10-Q2FY11       services in Q3FY10-Q2FY11        Q2FY11 
                                                major                                                            
                                             depression
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Gulf War*                                      228,727                181,485                         134,922                             59%                             74%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Peacetime Era                                   40,720                 35,239                          25,871                             64%                             73%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Vietnam Era                                    325,476                295,195                         202,689                             62%                             69%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Korean Conflict                                 17,888                 15,624                           8,278                             46%                             53%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
WWII                                            35,307                 26,926                           9,584                             27%                             36%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Total                                          648,118                554,469                         381,344                             59%                             69%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Gulf War population is composed of both Pre- and Post-9/11 veterans. VA did not break out veterans of OEF/OIF vs. non-OEF/OIF because this is not an official war era in VBA records,
  and the veteran population included in this analysis was supplied by VBA.
In order to investigate recent VA specialty mental health service use in this population, we matched this cohort of compensated veterans with VA patients seen in the most
  recent 4 quarters (Q3FY10-Q2FY11). This time period was chosen to match a fiscal year in length, but provide the most updated information possible. FY 2010 was not used because it may not
  have included veterans added to VBA rolls between October 2010 and May 2011 who subsequently received VHA services.


    Question 3: How many veterans have completed the recommended, 
evidence-based treatments (EBT) VA acknowledges as effective? Please 
break down the data by war cohort.

    Response: VA is strongly committed to developing IT capabilities 
that will enable VA Central Office to track how many veterans have 
received evidence-based mental health treatments. Currently this 
information resides in the field. Described below are the processes we 
are putting in place to ensure needed data can be captured, as well as 
relevant data currently available on some specific populations being 
treated.

Evidence Based Psychotherapies (EBP)

    Current Procedural Terminology codes used for tracking health care 
services do not allow distinction of different types of psychotherapy, 
nor do they provide information about an individual's level of 
participation, such as the number of therapy sessions received as 
compared to the number recommended within a given therapy protocol. The 
VA Office of Mental Health Services has developed documentation 
templates for each of the EPBs being nationally disseminated; these 
templates will become part of the VA's electronic medical record. These 
templates will allow for precise tracking of EBP delivery and treatment 
completion, as well as facilitate documentation of session activity, 
promote fidelity to therapy protocols, and capture data elements to 
help track more detailed information about participation in EBP 
activities than is available through the standard encounter form data 
currently in use. The templates have been piloted at several facilities 
and are scheduled for national system deployment in fiscal year 2012.
    Pending these new informatics processes, VA has conducted surveys 
of the field to obtain information on the extent to which OEF/OIF/OND 
veterans with PTSD have been offered and provided Cognitive Processing 
Therapy (CPT) or Prolonged Exposure (PE) Therapy--two evidence-based 
psychotherapies for PTSD--as well as the extent to which the veterans 
participating in these therapies have completed a full course of at 
least one of these treatments. Responses to this survey indicate that 
all facilities are providing either CP Therapy or PE Therapy, as 
required by VHA Handbook 1160.01, Uniform Mental Health Services in VA 
Medical Centers and Clinics, and all but two facilities reported 
providing both CPT and PE Therapy. Further, the survey results reveal 
that, between October 1, 2009 and May 31, 2010, 8,484 OEF/OIF veterans 
initiated CPT or PE Therapy, and 4,314 of these veterans completed a 
full course of at least one of these therapies.
    It is important to note that these survey data are approximations 
reported by facilities based on locally available data collected by 
facility staff, since centralized administrative data for tracking 
specific types of psychotherapy are not available at this time. 
Furthermore, these data represent a subset of the total number of 
veterans who have received and completed a full course of EBPs for 
PTSD, as these data refer only to OEF/OIF/OND veterans. These therapies 
have also been implemented and shown to be effective with veterans of 
other service eras, including Vietnam veterans. Moreover, these data 
relate only to EBPs for PTSD. In addition to these therapies, VHA has 
been nationally implementing EBPs for depression, serious mental 
illness, relationship distress, insomnia, and other conditions.
    In addition to the survey data noted above, VA collects data on the 
number of veterans who have received a full course of EBP as 
participants in the VA national EBP training programs, which include as 
a core component of competency-based training, intensive, weekly 
consultation on actual cases with an expert in the EBP. As part of 
these centralized EBP training processes, approximately 2,500 
additional veterans have completed a full course of EBP. Thus, to date 
we can verify that 6,814 veterans have completed a course of EBP (4,314 
+ 2,500), but we are certain this is a subset of a larger group of 
veterans who have received treatment. When the treatment templates are 
in use throughout the system, we will be able to identify from that 
point forward, the entire population of veterans who have received EBP.
    Program evaluation data are also obtained on a subset of the 2,500 
veterans who have received EBP as participants in the training of VA 
mental health staff. These data indicate that the implementation of the 
EBPs has resulted in statistically significant positive treatment 
outcomes for many patients. Patient outcomes associated with VA's EBP 
training programs in CPT or PE Therapy for PTSD and Cognitive 
Behavioral Therapy and Acceptance and Commitment Therapy for depression 
are summarized below:

        1.  Both the PE Therapy Training Program and the CPT Training 
        programs collected clinical outcome data regarding pre- and 
        post-treatment PTSD scores using the PTSD Checklist (PCL) and 
        pre- and post-treatment depression scores using the Beck 
        Depression Inventory (BDI). PCL scores can range from 17 to 85 
        and a score of 50 or greater is suggestive of PTSD. BDI scores 
        can range from 0 to 63 and scores in the 20 to 28 range are 
        considered suggestive of moderately severe depression.

          a.  Prolonged Exposure Therapy Results: Veterans who 
        completed PE therapy decreased from an average pre-treatment 
        PCL score of 62.1 to an average post-treatment PCL of 42.1. 
        This reduction is statistically significant and indicates a 32 
        percent drop in self-reported PTSD symptoms. Improvement as a 
        result of treatment was similar across veteran cohorts. The 
        average pre-treatment BDI-2 score was 28.0, and the average 
        post-treatment BDI-2 was 17.3. This reduction is statistically 
        significant and indicates a 38 percent drop in self-reported 
        symptoms of depression.
          b.  CPT Results: Veterans who completed CPT decreased from an 
        average pre-treatment PCL score of 63.8 to an average post-
        treatment PCL of 45.5. This reduction is statistically 
        significant and indicates a 29 percent drop in self-reported 
        PTSD symptoms. Treatment gains were similar across veteran 
        cohorts. The average pre-treatment BDI-2 score was 30.4, and 
        the average post-treatment BDI-2 was 19.2. This reduction is 
        statistically significant and indicates a 37 percent drop in 
        self-reported symptoms of depression.

        2.  The Cognitive Behavioral Therapy for Depression (CBT-D) and 
        Acceptance and Commitment Therapy for Depression (ACT-D) 
        training programs have collected clinical outcome data 
        regarding pre- and post-treatment depression scores using the 
        Beck Depression Inventory--Version 2 (BDI-2).

          a.  CBT-D Results: Veterans who completed CBT-D decreased 
        from an average pre-treatment BDI-2 score of 27.5 to an average 
        post-treatment BDI-2 of 17.0. This reduction is statistically 
        significant and indicates a 38 percent drop in self-reported 
        symptoms of depression.
          b.  ACT-D Results: Veterans who completed ACT-D decreased 
        from an average pre-treatment BDI-2 score of 29.8 to an average 
        post-treatment BDI-2 of 18.7. This reduction is statistically 
        significant and indicates a 37 percent drop in self-reported 
        symptoms of depression.

Evidence Based Pharmacotherapy

    Evidence-based pharmacotherapy cannot be tracked with current 
information systems to determine who has received a full course. 
Evidence-based psychopharmacotherapy consists of guideline concordant 
medication treatment for a particular condition. VA can determine which 
veterans have received a prescription for a particular psychoactive 
medication, but cannot currently determine whether a full course of the 
treatment was completed.
    The first-line (Grade A) pharmacotherapy recommendation for PTSD in 
the new VA/DoD Clinical Practice Guideline for PTSD (released in 2010) 
is the use of selective serotonin reuptake inhibitors (SSRI) or 
selective norepinephrine uptake inhibitors (SNRI). Data from a VA-
sponsored research project examining the use of evidence-based 
medication practices for PTSD indicate that in fiscal year (FY) 2009, 
59 percent of all patients with a PTSD diagnosis received a SSRI or 
SNRI. This is up from 50 percent of veterans with a PTSD diagnosis in 
1999. Moreover, more than 80 percent of veterans with PTSD who received 
any psychotropic medication received a SSRI or SNRI. Medication use 
includes having at least one outpatient prescription fill of any 
quantity, day's supply, or dosage from within the selected therapeutic 
classes. These data do not allow VA to draw a conclusion as to whether 
a veteran completed a full course of prescribed treatment, but they do 
provide verification that a veteran presented for and received 
treatment at some point during the year.
    To promote best practices in pharmacological management of PTSD, 
the VA National Center for PTSD, in the Office of Mental Health 
Services developed a monthly telephone-based lecture series in the fall 
of 2008, which was widely promoted and has been well-received by VA 
providers. In this series, an expert discusses various aspects of 
pharmacotherapy for PTSD, reviews the research evidence and 
recommendations in the VA/DoD Clinical Practice Guideline for PTSD, and 
answers commonly posed questions. The series includes an overview 
presentation on PTSD pharmacotherapy and presentations on specific 
issues, including issues around prescribing in veterans with mild TBI 
or those who are aging. Moreover, a fact sheet for providers was 
developed and revised in 2011 to provide information to the field on 
recommendations for good prescribing practice and management of PTSD 
and is available on the National Center for PTSD's Web site. 
Educational products and lectures have also been developed, and are 
available on the Web site that allow clinicians to earn CEU's and CME's 
to learn these best practices.
    Likewise, Opioid Agonist therapy is considered first-line therapy 
for treatment of opioid dependence based on the 2009 VA/DoD Clinical 
Practice Guideline for Management of Substance Use Disorder. Opioid 
Agonist Treatment (OAT) is a highly effective, evidence-based treatment 
for opioid dependence, and opioid dependent patients receiving OAT are 
more likely to achieve and maintain illicit opioid abstinence, and less 
likely to contract infectious diseases such as HIV and engage in 
criminal activities. VHA has mandated that OAT be available to opioid 
dependent patients at all VA facilities either as 1) care in a licensed 
VA OAT clinic with methadone or buprenorphine, 2) office-based OAT with 
buprenorphine, or 3) OAT by contract with a community provider or 
clinic. VA continues to undertake initiatives to increase availability 
and improve quality of OAT delivery in VA, including development of a 
mentoring network, a clinical help-line, monthly newsletters with 
practice tips and summaries of new literature, and monitoring and 
feedback on performance. In FY 2010, VA treated 11,919 (33.4 percent) 
of the 35,713 patients diagnosed with opioid dependence with clinic, 
office, or contracted OAT, up from 7,724 (27.8 percent) of 27,840 
patients in FY 2002.

    Question 4: How many veterans who have received a diagnosis of 
mental illness (PTSD, anxiety disorder, or major depression) from VHA 
are not receiving compensation for that diagnosed condition? Please 
break the data down by war cohort.

    Response: The following data are based on interpretation of the 
request above, as follows:
    Compensation for mental illness, as well as treatment for mental 
illness, is provided to a larger population of veterans than that 
limited to PTSD, anxiety disorder, or depression. For the purposes of 
this query we are responding to these three diagnoses because they are 
specifically mentioned in the request and they are the three diagnoses 
provided to VHA by VBA, based on most recent complete VBA rolls 
(through May 2011). For all veterans with a compensable, service-
connected mental health condition, these are the three most prevalent 
mental health diagnoses.
    A total of 891,362 VA patients seen between April 1, 2010 and March 
31, 2011 were diagnosed with PTSD, anxiety disorder, or major 
depression. (Note: VHA data represents ICD9 codes. PTSD patients were 
included if PTSD was a ``possible'' diagnosis.) Of these patients 57 
percent or 510,345 were not receiving compensation for these diagnoses. 
VA patients diagnosed with these disorders who were veterans of the 
OIF/OEF conflicts were more likely to be receiving compensation for 
these diagnoses than those from other combat eras (55 percent OIF/OEF 
veterans receiving compensation versus 41 percent of non-OIF/OEF 
veterans receiving compensation). These numbers do not account for 
veterans with pending claims.


----------------------------------------------------------------------------------------------------------------
                                                               Number of VA  patients    Percent of VA  patients
                                                                with a  diagnosis of      with a  diagnosis of
                                     Number of VA  patients      PTSD,  anxiety, or        PTSD,  anxiety, or
                                      with a  diagnosis of      depression in Q3FY10-    depression in  Q3FY10-
        Period of  Service          PTSD,  anxiety disorder,    Q2FY2011  who are not     Q2FY2011  who are not
                                    or  depression in Q3FY10-  receiving compensation    receiving compensation
                                             Q2FY11            for PTSD,  anxiety, or    for PTSD,  anxiety, or
                                                                     depression                depression
----------------------------------------------------------------------------------------------------------------
All VA Patients                                     891,362                   510,345                       57%
----------------------------------------------------------------------------------------------------------------
OIF/OEF VA Patients                                 135,918                    61,638                       45%
----------------------------------------------------------------------------------------------------------------
Non-OIF/OEF VA Patients                             755,444                   448,707                       59%
----------------------------------------------------------------------------------------------------------------


    The majority of VA patients who were recently seen in VA for PTSD, 
anxiety, or depression and receive compensation for these disorders are 
veterans of the Gulf war era (including OEF/OIF) or the Vietnam war 
era. These numbers do not account for veterans with pending claims.


----------------------------------------------------------------------------------------------------------------
                                                                     Number of VA patients with a diagnosis of
                                                                      PTSD, anxiety, or depression in Q3FY10-
                        Period of Service                           Q2FY2011 who are receiving compensation and
                                                                    are service-connected for PTSD, anxiety, or
                                                                                     depression
----------------------------------------------------------------------------------------------------------------
Gulf War                                                                                                 123,288
----------------------------------------------------------------------------------------------------------------
Peacetime Era                                                                                             20,840
----------------------------------------------------------------------------------------------------------------
Vietnam Era                                                                                              215,845
----------------------------------------------------------------------------------------------------------------
Korean Conflict                                                                                            9,100
----------------------------------------------------------------------------------------------------------------
WWII                                                                                                      11,944
----------------------------------------------------------------------------------------------------------------
Total                                                                                                    381,017
----------------------------------------------------------------------------------------------------------------


    Question 5: How many veterans in receipt of compensation for mental 
illness utilize non-VA mental health care services? Please break the 
data down by war cohort.

    Response: Based on VA's response to Question 2 where a full count 
of who is service-connected for mental health is not implied by those 
numbers, a total of 648,118 veterans were receiving compensation for 
PTSD, anxiety, or major depression and are service-connected as of May 
2011. This includes veterans rated 0 percent for these conditions, but 
receiving compensation for other conditions; veterans rated zero 
percent for these conditions are not included in these counts unless 
they are receiving compensation for another disability. Of these 
veterans, 381,344 received specialty mental health services in VA 
between April 1, 2010, and March 31, 2011. Thus 59 percent of all 
veterans receiving compensation for PTSD, anxiety, or major depression 
received specialty mental health treatment in VA during this time 
period. We are not able to determine the number of these veterans who 
may have received this care in primary care or in general mental 
health.

    VA does not collect data on veterans who choose to utilize non-VA 
mental health care or receive mental health care in VHA non-specialty 
Clinics. Of the approximately 41 percent remaining veterans that 
receive compensation for PTSD, anxiety, or major depression, they 
either receive mental health care within VHA in non-specialty care, 
from non-VA providers, or are not receiving mental health treatment at 
all.

    Question 6: What measure exists to demonstrate that veterans who 
utilize VA mental health care services are on the road to recovery?

    Response: This is a complex question, since the mental health 
Recovery model relates to functioning at the highest possible level for 
an individual, despite a chronic illness, and recovery is not 
equivalent to ``cure'' nor is it equivalent to reaching a state where 
there is no disability, as discussed in VA's Testimony for this 
Hearing. Thus, being on the ``road to recovery'' is a multifaceted 
state and requires a battery of measures, not any single measure.

    One component is improvement in the presence or severity of 
symptoms leading to a mental health diagnosis; this is probably the 
easiest component to measure. For PTSD, for example, VA has evidence-
based psychotherapy protocols in place that incorporate weekly symptom 
monitoring with the PTSD Checklist (PCL) plus a single item on the 
impact of symptoms on level of function. In addition, current standards 
require the administration of the PCL (plus the item on personal 
function) every 90 days for all OEF/OIF veterans in active treatment 
for PTSD, as defined by at least 2 visits to an outpatient mental 
health clinic within the previous 6 months. Data on the PCL (plus the 
item on personal function) have recently been extracted into a national 
data base allowing for total population sampling for clinical review 
and aggregate analyses. Outcome measures for evaluation of symptom 
level during the course of treatment for substance abuse and depression 
are under development and will be available, dependent on availability 
of informatics tools, which are scheduled for deployment in FY 2012.
    A measure of veterans' self-reported perceptions of their recovery 
and current functional status versus their desired status is in 
development. While symptom monitoring is an important element in 
measuring treatment effectiveness, broader, systematic outcome 
evaluation of functioning and meeting personal life goals is also 
critical for evaluating program effectiveness.

    Question 7: Does VA have baseline measures to determine the status 
of a veteran's mental illness prior to treatment and after treatment?

    Response: Baseline, ongoing, and post-treatment administration of 
established symptom measures (e.g., PCL, Beck Depression Inventory-2) 
are routinely conducted as part of EBP protocols for PTSD, depression, 
and other mental health conditions implemented in VHA. Additional 
measures of well-being and the treatment process are also often 
administered during the course of these therapies. In addition, as 
noted in #6 above, current standards require the administration of the 
PCL plus a single item on the impact of symptoms on level of function 
every 90 days for all OEF/OIF veterans in any active treatment for 
PTSD, as defined by at least 2 visits to an outpatient mental health 
clinic within the previous 6 months. This will automatically ensure 
measurement at the end of treatment. Outcome measures for evaluation of 
symptom level during the course of treatment for substance abuse and 
depression are under development and will be available, dependent on 
availability of informatics tools which are scheduled for deployment in 
FY 2012.

    Question 8: Please provide data to the Committee on the following:

    Question 8(a): For each of the last 10 years, the net number of 
veterans who have a disability rating, broken down by war era, for 
PTSD, depression, or anxiety disorder.

    Response: Please see Enclosure 1 for the breakdown by period of 
service for veterans service-connected for PTSD, depression, or anxiety 
disorder and in receipt of disability compensation at the end of the 
past 10 fiscal years. Veterans rated zero percent for these conditions 
are not included in these counts unless they are receiving compensation 
for another disability.

    Question 8(b): For each of the last 10 years, the average 
disability rating for veterans (broken down by war era) with a mental 
illness (PTSD, depression, or anxiety disorder). Please make the 
average rating exclusive to the mental health conditions, e.g., exclude 
ratings associated with physical ailments and other non-mental health 
service-connected disabilities.

    Response: Please see Enclosure 1 for the average ratings 
exclusively for PTSD, depression, and anxiety disorder at the end of 
the past 10 fiscal years by period of service.

    Question 8(c): For Gulf War II veterans, please break out the 
distribution of ratings among those in receipt of compensation for 
mental health conditions over the last 10 years. For example, the 
number of Gulf War II veterans who have a disability rating. Veterans 
rated zero percent for these conditions are not included in these 
counts. Also, veterans that are service-connected for these conditions 
are not necessarily receiving compensation due to these conditions.

    Response: Please see Enclosure 2 for the breakout of Post-9/11 
veterans service-connected for PTSD, depression, or anxiety disorder 
and in receipt of disability compensation at the end of the past 10 
fiscal years by disability rating. These veterans are included as Gulf 
War era veterans in Enclosure 1.

    Question 9: For every veteran with a service-connected mental 
illness VA has the name, address, and specific condition for which the 
veteran is receiving compensation. After disability is established, 
what effort is made to proactively link those individuals to effective 
treatment?

    Response: VHA does not receive notification when a veteran is 
awarded compensation and/or pension for a mental health diagnosis. 
Lacking this notification, there is no current trigger that would alert 
VHA to conduct outreach following the C&P decision. C&P examiners are 
required to review medical records to assess what diagnoses have been 
made and any treatments received. C&P examiners often do encourage 
veterans to seek treatment at VA, or in some other site of their 
choosing, if a diagnosis is confirmed in the C&P interview and it does 
not appear that treatment is being received, but we do not have formal 
data on how frequently this occurs. There are no protocols that require 
C&P examiners to encourage veterans who are examined for service-
connection to engage in treatment. However, VHA and VBA are 
increasingly working on projects together, and will consider how best 
to ensure that all veterans with service-connected diagnoses are 
encouraged to enter treatment, with VA proactively engaged in reaching 
out to these veterans to offer and facilitate needed health care 
services.
    For all veterans there are a number of outreach functions where VA 
collaborates with DoD, e.g., the Yellow Ribbon Program and PHDRA 
events. Each medical center also provides at least one outreach 
function each year.

                               __________

                  U.S. Department of Veterans Affairs
                              Enclosure 1

----------------------------------------------------------------------------------------------------------------
                                                      2001
-----------------------------------------------------------------------------------------------------------------
                                        9400 Anxiety            9411 PTSD        9434 Major Depressive
                                          Disorder       -----------------------        Disorder
                                  -----------------------                       -----------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               2,277          22      7,479          42      7,287          33    17,043
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        6,822          30      6,524          50        219          53    13,565
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,580          27      5,626          51      3,526          45    15,732
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           16,779          27    106,801          59      2,268          51   125,848
----------------------------------------------------------------------------------------------------------------
World War II                          48,978          26     18,095          44        421          50    67,494
----------------------------------------------------------------------------------------------------------------
Grand Total                           81,436          26    144,525          44     13,721          50   239,682
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2002
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               2,563          23      8,833          44      9,540          34    20,936
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        6,438          31      7,682          51        291          52    14,411
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,482          28      6,429          52      4,600          45    17,511
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           16,504          28    121,863          60      3,283          50   141,650
----------------------------------------------------------------------------------------------------------------
World War II                          44,074          26     20,684          46        506          50    65,264
----------------------------------------------------------------------------------------------------------------
Grand Total                           76,061          27    165,491          57     18,220          40   259,772
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2003
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               3,020          24     10,942          46     12,602          34    26,564
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        6,130          31      8,994          52        368          51    15,492
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,342          29      7,390          54      5,986          46    19,718
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           16,275          29    142,865          61      4,781          50   163,921
----------------------------------------------------------------------------------------------------------------
World War II                          39,577          26     23,187          47        611          50    63,375
----------------------------------------------------------------------------------------------------------------
Grand Total                           71,344          28    193,378          57     24,348          41   289,070
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2004
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               3,569          25     13,524          47     15,882          35    32,975
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        5,758          32     10,016          53        442          51    16,216
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,236          31      8,261          56      7,302          46    21,799
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           16,025          30    161,023          61      6,256          49   183,304
----------------------------------------------------------------------------------------------------------------
World War II                          35,375          27     24,590          48        705          50    60,670
----------------------------------------------------------------------------------------------------------------
Grand Total                           66,963          28    217,414          58     30,587          41   314,964
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2005
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               4,371          26     19,358          47     20,214          36    43,943
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        5,422          32     10,944          53        531          51    16,897
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,173          32      9,088          57      8,522          47    23,783
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           15,773          31    179,735          61      7,756          49   203,264
----------------------------------------------------------------------------------------------------------------
World War II                          31,364          27     25,281          49        784          49    57,429
----------------------------------------------------------------------------------------------------------------
Grand Total                           63,103          29    244,406          58     37,807          41   345,316
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2006
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               5,291          26     28,392          45     25,035          36    58,718
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        5,128          33     11,423          53        594          50    17,145
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,071          32      9,796          57      9,582          47    25,449
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           15,571          32    194,438          61      9,224          49   219,233
----------------------------------------------------------------------------------------------------------------
World War II                          27,809          28     24,902          49        801          49    53,512
----------------------------------------------------------------------------------------------------------------
Grand Total                           59,870          29    268,951          58     45,236          41   374,057
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2007
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               6,600          26     44,445          44     30,629          36    81,674
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        4,849          33     11,940          52        665          49    17,454
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,005          33     10,586          58     10,727          47    27,318
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           15,390          33    210,432          61     10,759          49   236,581
----------------------------------------------------------------------------------------------------------------
World War II                          24,561          28     24,219          49        803          49    49,583
----------------------------------------------------------------------------------------------------------------
Grand Total                           57,405          30    301,622          57     53,583          41   412,610
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2008
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                               8,425          25     66,073          44     38,128          35   112,626
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        4,564          33     12,288          52        720          48    17,572
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,018          33     11,639          58     12,367          47    30,024
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           15,150          33    228,538          60     12,238          47   255,926
----------------------------------------------------------------------------------------------------------------
World War II                          21,223          28     23,373          49        814          48    45,410
----------------------------------------------------------------------------------------------------------------
Grand Total                           55,380          30    341,911          56     64,267          40   461,558
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2009
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                              10,412          25     91,648          44     46,168          36   148,228
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        4,267          33     12,360          52        800          48    17,427
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,013          34     12,869          59     14,304          47    33,186
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           14,987          33    247,426          60     13,971          47   276,384
----------------------------------------------------------------------------------------------------------------
World War II                          18,106          28     22,110          49        799          47    41,015
----------------------------------------------------------------------------------------------------------------
Grand Total                           53,785          30    386,413          55     76,042          40   516,240
----------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------
                                                      2010
-----------------------------------------------------------------------------------------------------------------
                                            9400                   9411                   9434
                                  ---------------------------------------------------------------------
        Period Of Service                       Average                Average                Average     Total
                                      Cnt     Disability     Cnt     Disability     Cnt     Disability
                                                   %                      %                      %
----------------------------------------------------------------------------------------------------------------
Gulf War                              12,598          26    120,449          45     54,609          37   187,656
----------------------------------------------------------------------------------------------------------------
Korean Conflict                        3,984          33     12,518          52        839          48    17,341
----------------------------------------------------------------------------------------------------------------
Peacetime Era                          6,025          34     14,578          59     16,580          48    37,183
----------------------------------------------------------------------------------------------------------------
Vietnam Era                           14,940          34    268,849          59     16,028          47   299,817
----------------------------------------------------------------------------------------------------------------
World War II                          15,274          28     20,534          49        788          47    36,596
----------------------------------------------------------------------------------------------------------------
Grand Total                           52,821          30    436,928          55     88,844          41   578,593
----------------------------------------------------------------------------------------------------------------


                                                                       Enclosure 2
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2001
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                               3        29                  19                   5                   1                   1        58
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                               5        29                  63                  36                  20                   2       155
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                              24       138         1       135                  70                  21                  14       403
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                       32       196         1       217                 111                  42                  17       616
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2002
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                              27       169                 117                  25                   8                   4       350
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                              19       178                 440                 262                 130                  62     1,091
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                              98       782         2       803         1       362                 131                  61     2,240
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                      144     1,129         2     1,360         1       649                 269                 127     3,681
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2003
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                              59       361         1       260                  59                  27                   6       773
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                              36       379         2       931                 597                 360                 200     2,505
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                             183     1,589         3     1,729         1       762                 293                 138     4,698
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                      278     2,329         6     2,920         1     1,418                 680                 344     7,976
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2004
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                              88       563         1       456                 121                  39                  14     1,282
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                              49       573         4     1,643         3     1,111         1       669                 410     4,463
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                             242     2,338         7     2,784         2     1,218         1       528                 233     7,353
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                      379     3,474        12     4,883         5     2,450         2     1,236                 657    13,098
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2005
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             105       865         4       753                 201                  64                  21     2,013
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                              91     1,193         7     3,666         5     2,382         2     1,357                 776     9,479
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                             333     3,321        14     4,293         7     1,871         2       825                 361    11,027
--------------------------------------------------------------------------------------------------------------------------------------------------------
GrandTotal                                       529     5,379        25     8,712        12     4,454         4     2,246               1,158    22,519
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2006
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             181     1,237         3     1,076                 277                  92                  32     2,898
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                             195     2,352         8     7,386         9     4,486         2     2,211               1,169    17,818
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                             439     4,435        15     6,059         6     2,544         6     1,158                 505    15,167
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                      815     8,024        26    14,521        15     7,307         8     3,461               1,706    35,883
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2007
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             305     1,673         7     1,595                 407         1       132                  51     4,171
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                             397     4,220        12    14,081         9     8,369         5     3,861               2,004    32,958
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                             639     5,679        23     8,137         9     3,429         8     1,564                 671    20,159
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                    1,341    11,572        42    23,813        18    12,205        14     5,557               2,726    57,288
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2008
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             529     2,372         8     2,157         1       589         2       194                  65     5,917
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                             680     6,646        14    21,942        11    14,064        11     6,557               3,395    53,320
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                           1,073     7,320        34    10,605        10     4,565         4     2,148                 937    26,696
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                    2,282    16,338        56    34,704        22    19,218        17     8,899               4,397    85,933
--------------------------------------------------------------------------------------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2009
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             704     2,954        14     2,964         3       799         2       269                  91     7,800
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                             865     8,548        16    31,143        18    21,107         9    10,412               4,959    77,077
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                           1,337     8,849        48    13,307        19     5,968         5     2,922               1,224    33,679
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                    2,906    20,351        78    47,414        40    27,874        16    13,603               6,274   118,556
--------------------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          2010
---------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             PERCENTAGE
                                           -------------------------------------------------------------------------------------------------------------
                 DIAGNOSIS                                                                                                                        Grand
                                                0        10        20        30        40        50        60        70        80        100      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
9400                                             903     3,467        14     3,903         3     1,092         2       401                 117     9,902
--------------------------------------------------------------------------------------------------------------------------------------------------------
9411                                           1,072    10,243        23    40,926        21    29,020        11    15,838               6,689   103,843
--------------------------------------------------------------------------------------------------------------------------------------------------------
9434                                           1,530     9,916        47    16,256        26     7,741         8     3,899               1,563    40,986
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total                                    3,505    23,626        84    61,085        50    37,853        21    20,138               8,369   154,731
--------------------------------------------------------------------------------------------------------------------------------------------------------

                     Committee on Veterans' Affairs
                     U.S. House of Representatives
          Post-Hearing Questions for Karen H. Seal, M.D., MPH
                     From the Honorable Bob Filner
              Mental Health: Bridging the Gap between Care
                     and Compensation for Veterans
                             June 14, 2011
    1.  One of your recommendations is to provide greater access to 
specialty mental health treatment through primary care which includes 
restructuring VA services such that specialty mental health providers 
are collocated and fully integrated within primary care. Can you 
describe how this differs from the current configuration of providing 
mental health services in the primary care setting?
    2.  One of the key findings of your study regarding the prevalence 
of mental health disorders is that age and component type mattered. 
Active duty veterans less than age 25 years had 2 to 5 times higher 
rates of PTSD, alcohol and drug use disorder diagnoses compared to 
active duty veterans over age 40. In contrast, among National Guard/
Reserve veterans, risk for PTSD and depression were significantly 
higher in veterans over age 40 compared to their younger counterparts 
less than age 25. What is your professional opinion on this finding and 
do you have any recommendations to address this issue?
    3.  How are OEF/OIF veterans different from older cohorts of 
veterans in terms of their mental health needs and the involvement of 
their families in their care?
    4.  In your testimony, you point out that older National Guard and 
Reserve Veterans are at higher risk for PTSD and depression.

          Can you speak to why members of the Guard and Reserve 
        face unique mental health challenges?
          What support and services do you feel the VA could 
        better provide to older veterans from OEF/OIF/OND as well as 
        older cohorts of veterans, such as Vietnam Veterans?

    5.  Do you have any specific recommendations to improve retention 
in mental health treatment?
    6.  How well prepared do you feel that VA medical facilities are in 
providing for the growing mental health needs of veterans?
    7.  With respect to the privacy concerns regarding Department of 
Defense's access to veterans' electronic medical records and how this 
has discouraged some veterans from coming forward and disclosing 
information about substance abuse, interpersonal violence, and sexual 
identity issues--How do you suggest VA best address these concerns?
    8.  Your testimony points to a need for more research to develop 
and test modified evidence-based treatments for PTSD and other mental 
health problems.

          What specific areas should the VA invest research 
        resources in order to close some of these research gaps on 
        effective treatments for PTSD?
          How can the VA work with other Federal research 
        organizations such as the National Institutes of Health (NIH) 
        to advance this area of research?

                               __________

                                U.S. Department of Veterans Affairs
                                                 San Francisco, CA.
                                               August 5, 2011, 2010
Chairman Bob Filner
Committee on Veterans' Affairs
U.S. House of Representatives
One Hundred Eleventh Congress
335 Cannon House Office Building
Washington, DC 20515

Dear Chairman Filner:

    Below please find my responses to the post-hearing questions 
following the June 14, 2011 Full Committee Hearing entitled, ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans''. 
Questions are paraphrased, followed by my responses.

        1. How does the recommendation to restructure VA primary care 
        services to collocate and more fully integrate specialty mental 
        health providers in primary care differ from the current system 
        of providing mental health services within VA primary care?

    Currently, even in model VA primary care clinics, embedded mental 
health providers (many of whom are social workers) typically provide 
very basic, time-limited mental health services such as further 
assessment of positive mental health screens, mental health referrals, 
medication management, and brief supportive therapies, but rarely 
provide evidence-based mental health treatments (Possemato et al., 
2011). In some cases, brief, time-limited treatment may be sufficient 
for conditions such as mild depression or re-adjustment stress. The 
majority of OEF/OIF veterans who present to VA, present with more 
complex mental health conditions however. The most common mental health 
condition in OEF/OIF veterans is PTSD, which is highly comorbid with 
depression and substance use disorders. Comorbid PTSD is most 
effectively treated with evidence-based trauma-focused therapies that 
are delivered by trained mental health professionals. Currently, in the 
majority of VA facilities across the country, this requires a referral 
to a specialty mental health clinic. Unfortunately, due to a myriad of 
barriers, many veterans fail to follow-up with specialty mental health 
referrals and thus fail to engage in and complete an adequate course of 
therapy. Thus, in order to enhance engagement in specialty mental 
health treatment, it may be prudent to restructure VA primary care such 
that specialty mental health providers, trained in evidence-based 
therapies, are available to meet patients where they present, i.e. in 
primary care (Hoge, 2011). Moreover, with the new Patient Aligned Care 
Team (PACT) model in VA primary care, PACT primary care nurses are also 
available to support patient adherence to and retention in specialty 
mental health services, especially if these services are delivered 
within primary care.

        2. Why, in your study, do you think that you found that mental 
        health disorders were more prevalent in older National Guard 
        and Reserve veterans (> age 40) compared to their younger 
        counterparts (< 25 years)?

    One explanation is that when called to arms, older Guard/Reserve 
members are more established in civilian life--are married, have 
children, jobs and community ties, and may be less well prepared for 
combat, making their transition to war zone and home again more 
stressful, mostly because of the disparity between their civilian life 
and life as a soldier. In addition, relatively older National Guard and 
Reserve veterans may return to family responsibilities, relationship 
and/or parenting stress, job pressures, or in this economy, 
unemployment, which may compound post-deployment stress. Thus, they may 
be more vulnerable to PTSD or other mental health problems after 
deployment. It is therefore important to carefully assess older 
National Guard and Reserve veterans for potential mental health 
problems after war and to provide targeted counseling services both in 
VA and in their communities.
    Younger veterans often access the GI Bill after returning home, 
attend school, and defer financial pressures, but older veterans must 
often return to work immediately after returning from war. Perhaps, 
some time-limited financial support for older National Guard and 
Reserve veterans who are not accessing the GI Bill could alleviate some 
financial pressure and allow them to de-compress for a couple of months 
after returning home. Unlike active duty military personnel who return 
home to a military base with other military personnel and their 
families, older National Guard and Reserve members may find themselves 
relatively isolated in their communities. Education and support for 
families of National Guard and Reserve veterans regarding the unique 
stressors older veterans face upon their return home may prove helpful. 
Adding a component of professional or peer support during National 
Guard and Reserve monthly trainings could also be very useful for some.

        3. How are OEF/OIF veterans different from other era-veterans 
        in terms of their mental health needs and the involvement of 
        their families in their care?

    I would argue that OEF/OIF veterans are not significantly different 
from other era-veterans in terms of their mental health concerns and 
needs and the importance of family in their care. I think the main 
difference between this generation of veterans and prior generations is 
that we now have a substantial body of literature and clinical 
experience to guide us in the care of these veterans. We know 
substantially more than we did when Vietnam veterans returned home 
about the diagnosis of PTSD and prevention of chronic PTSD. For 
instance, evidence-based treatments for PTSD have been developed, 
tested, and have been proven effective. We now face different 
challenges than before in that we know how to diagnose PTSD and have 
effective therapies, but we are still struggling to figure out how to 
get these therapies to the veterans who most need them. Here, family 
education and support are invaluable in that family members are often 
the ones who rally around the veteran to help them access and stay in 
treatment.

        4. Why do National Guard and Reserve members face unique 
        challenges on returning home and what support services would be 
        beneficial to this group and to Vietnam-era veterans?

    The answer to this question is largely addressed in my response to 
question 2 above. Vietnam veterans can indirectly benefit from 
increased VA mental health and support services for OEF/OIF veterans 
because in VA, these enhanced services are generally not limited to 
OEF/OIF veterans. Indeed, OEF/OIF veterans often comment that they 
appreciate the participation of Vietnam veterans in their treatment 
programs because these older veterans provide peer support for younger 
veterans. Being able to reach out and help the younger veterans is also 
proving therapeutic for many older Vietnam veterans.

        5. What are some specific recommendations to improve retention 
        in mental health service?

    As mentioned in response to question 1 above, providing specialty 
mental health care in primary care could improve retention in mental 
health treatment. Our own data show that OEF/OIF veterans with mental 
health problems are significantly more likely to utilize primary care 
medical services than OEF/OIF veterans without mental health problems. 
Moreover, those with mental health problems are also more likely to 
utilize primary care more frequently. Thus, in the spirit of meeting 
veterans where they are, we believe that these veterans would be more 
likely to be retained in mental health treatment if these services were 
provided in the context of primary care. In addition, many of the 
medical problems (e.g. alcohol abuse, smoking, obesity, hypertension 
etc . . . ) seen in OEF/OIF veterans are associated with mental health 
problems as demonstrated by our research. Addressing these related 
physical and mental health problems together in a coordinated and 
collaborative fashion, which would occur if specialty mental health 
providers practiced along side primary care colleagues, would likely 
reinforce retention in both mental health and primary care, as well as 
lead to improved behavioral health outcomes.
    There is no reason why primary care and mental health appointments 
could not be scheduled as sequential appointments on the same day, as 
we already do in our OEF/OIF Integrated Care Clinic at the San 
Francisco VA Medical Center. This is more convenient for patients, 
especially patients who live at a distance, increasing the likelihood 
that they will attend their mental health visit when they come for 
their primary care visit. Same-day, sequential visits also promote 
greater coordination and collaboration between primary care and mental 
health providers in delivering integrated care. Other recommendations 
to improve engagement and retention in mental health services involve 
the use of primary care nurses to call patients to remind and motivate 
them to follow-up with their primary care-mental health appointments, 
as well as increased use of the telephone and Internet to deliver 
mental health treatments to those patients who live too far to come to 
a VA facility for weekly treatment.

        6. How well prepared are VA medical facilities in providing for 
        the growing mental health needs of veterans?

    In my position as a researcher at one VA medical center, it is 
difficult for me to make generalizations about the adequacy of mental 
health treatment at all VA facilities across the country. I suspect 
that there is likely wide geographic variation. Our study on mental 
health utilization in OEF/OIF veterans based on national VA 
administrative data revealed that 50 percent or more of returning 
combat veterans with a new mental health diagnosis have attended at 
least one mental health session. Nevertheless, only a minority (10 
percent or less) of these veterans went on to complete what would be 
considered an adequate amount of therapy for most mental health 
disorders. As was discussed in this session, there are numerous 
barriers to veterans staying in and completing a course of mental 
health therapy, both patient-level barriers as well as VA system-level 
barriers. VA is working on several innovative solutions, such as 
telemental health, in an attempt to overcome system-level barriers to 
mental health treatment, but more work in this area is clearly needed.

        7. The DoD may access veterans electronic medical records and 
        this may inhibit some veterans from coming forward to disclose 
        sensitive concerns to their VA medical providers. How should VA 
        address these privacy concerns?

    There is potentially a great advantage to bi-directional sharing of 
de-identified data across the VA and DoD systems for research. 
Nevertheless, while there may be an advantage to the VA's being able to 
access prior medical information about a veteran from their military 
service in order to provide the best medical care in the post-
deployment period, there may be risks to the DoD being able to access 
veterans' medical records without a patient's consent once they have 
sought care at VA. Most veterans who seek care at VA have separated 
from active duty military service, and while some may remain in 
inactive status, most consider returning to military service a remote 
possibility. A notable exception are National Guard and Reserve 
veterans who are eligible to obtain VA health care services after each 
deployment and they may be re-deployed in the future.
    Most veterans who come to VA desire treatment for one or more 
medical or mental health conditions. Many of the conditions for which 
veterans seek care could potentially render them ineligible to pursue a 
career in the military, such as drug or alcohol dependence, illegal 
drug use, and severe mental health conditions. It is devastating to 
think that veterans would not disclose important, but sensitive medical 
and mental health concerns to their VA providers out of concern that 
the DoD might obtain access to these records without their consent. 
This may prohibit some veterans with serious problems from getting the 
help they need at VA facilities. Thus, while VA may have some of the 
best care available for combat-related conditions such as PTSD, some 
veterans may chose to receive their care elsewhere from less well-
trained community providers because DoD would not be able to have 
access or their medical records. This may very well represent a 
significant barrier to accessing care at VA for many veterans. Prior to 
making decisions about VA-DoD information sharing however, it is 
essential that this matter be evaluated more thoroughly and 
systematically.

        8. Your testimony points to a need for more research to develop 
        and test modified PTSD treatments. In what specific areas 
        should the VA invest research resources and how can the VA work 
        with other federally-funded research organizations, such as the 
        NIH, to advance this area of research?

    There is a need to develop and test PTSD treatments that are 
briefer and better suited for primary care settings. It is important to 
implement these treatments directly within primary care settings to 
better understand the specific barriers and facilitators to their 
effective delivery. Since PTSD is highly comorbid with other mental and 
physical health problems, there is a need to develop and test 
integrated treatments for PTSD that simultaneously address substance 
abuse or other behavioral (e.g., smoking) or physical health problems 
(e.g., chronic pain) in the context of PTSD treatment. It is also 
important to test novel delivery techniques for PTSD treatment 
especially designed to meet the needs of rural or remote veterans, such 
as the use of the telephone or the Internet to deliver these 
treatments. VA facilities and clinics often represent the best and most 
natural settings in which to conduct this research.
    VA, in its historical affiliation with universities and academic 
medical centers, has a long-standing tradition of excellence in 
research. Nevertheless, VA cannot be expected to fund all research 
studies that occur in VA settings, especially when the research 
findings could easily generalize to other health care systems. It is 
hoped that NIH will consider funding more research that is based at VA 
because veterans' concerns are important to American public health, VA 
provides ideal clinical settings in which to conduct research, and 
information gleaned from these studies may inform needed improvements 
in other health care systems in the United States.
    Thank you for giving me the opportunity to respond to these follow-
up questions. Should additional questions arise, or you would like 
additional clarification about any of my responses, please feel free to 
contact me at 415-732-9131 or via email [email protected] or 
[email protected].
            Sincerely,

                                                Karen Seal, MD, MPH
                     Associate Professor of Medicine and Psychiatry
                            University of California, San Francisco
                        Co-Director, OEF/OIF Integrated Care Clinic
                                    San Francisco VA Medical Center

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      June 23, 2011
LTG James Terry Scott, USA (Ret.)
Chairman
Advisory Committee on Disability Compensation
P.O. Box 893
Coleman, TX 76834

Dear General Scott:

    In reference to our full Committee hearing entitled ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans,'' 
that took place on June 14, 2011, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 5, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by faxing your responses to Debbie at 202-225-2034. If you 
have any questions, please call 202-225-9756.
            Sincerely,

                                                         BOB FILNER
                                          Ranking Democratic Member
    CW:ds

                               __________

        Prepared Statement of LTG James Terry Scott, USA (Ret.)
        Chairman, Advisory Committee on Disability Compensation
                              P.O. Box 893
                           Coleman, TX 76834
August 10, 2011

Committee on Veterans' Affairs
U.S. House of Representatives
Post-Hearing Questions for LTG James Terry Scott, USA (Ret.)
From the Honorable Bob Filner

    Subject: Mental Health: Bridging the Gap between Care and 
Compensation for Veterans held on June 14, 2011.

    I am honored to respond to the questions and more than willing to 
elaborate subsequently if useful.

    Question 1: What do you think is the most important change the 
Department of Veterans Affairs can make to help bridge the gap between 
compensation and care for veterans?

    Answer: A significant component of the gap between compensation and 
care for veterans is division of responsibilities between VHA and VBA. 
VBA is focused on claims adjudication and VHA on patient care. Neither 
has any real responsibility for maximizing the disabled veteran's 
ability to function as a contributing member of society through follow 
up assessment and vocational rehabilitation. The argument can be made 
that we ``pay them to go away''. The magnitude of the case load and 
case backlog make it difficult to focus on follow up treatment and 
vocational rehabilitation. An argument can be made that to the extent 
that resources are a shortfall, VA should focus on the disabled 
veteran. It may be that we are asking VA (VHA) to treat more categories 
of patients than the resources allow. In a time of budget tightening, 
priorities may require a more focused approach.

    Question 2: The arguments against creating the linkage among 
compensation, treatment, vocational assessment/rehabilitation, and 
follow up examinations to determine efficacy of treatment include it 
could be used as a mechanism to reduce disability benefits. Do you 
agree with that argument?

    Answer: The perception is widely held among veterans and veterans' 
advocates, that linking compensation, treatment, vocational assessment/
rehabilitation, and follow up examinations places disability benefits 
at risk. A program that creates the linkage must protect the 
participant from arbitrary and dramatic reductions in compensation. 
Perhaps a pilot program combining a temporary disability rating and the 
previously mentioned linkages could be instituted. Current VA policy is 
to wait until the mentally disabled veteran presents himself/herself 
for treatment rather than requiring or rewarding veterans for seeking 
treatment.

    Question 3: Do you believe that mental disabilities should be 
addressed differently than physical disabilities by the Department of 
Veterans Affairs?

    Answer: Yes, for the reasons elaborated on in question 4. In 
particular, the reluctance of individuals with mental disabilities to 
seek treatment and the self destructive behavior that often accompanies 
the disability differentiate between physical and mental disabilities.

    Question 4: In your testimony you state there is significant 
evidence that individuals with mental disabilities are less likely to 
seek and maintain a treatment regimen than those with physical 
disabilities. What do you attribute that to?

    Answer: Individuals with a physical disability historically seek 
treatment and medical care in an attempt to be sure they are taking 
advantage of advances in medical science that may alleviate their pain, 
injuries, or disability. Among veterans with physical disabilities, 
there is little perceived risk of losing disability benefits because 
the nature of physical disabilities and the permanence associated with 
them. Physical disabilities tend to become more debilitating with age 
and virtually all physically disabled veterans want to maintain as high 
a level of functioning as possible for as long as possible.
    The literature available indicates that many individuals with 
mental disabilities, whether veterans or not, do not perceive 
themselves as needing or benefitting from treatment and therefore do 
not seek treatment or follow unsupervised treatment regimens. Lack of 
treatment may include manifestations of self destructive behavior such 
as substance or alcohol abuse, homelessness, and suicidal risk. The 
untreated mentally disabled veteran may be a risk to himself/herself, 
the family and/or society. At best, the opportunities for maximum 
improvement and integration into society are foregone.
                                                  James Terry Scott
                                                           Chairman
                      Advisory Committee on Disability Compensation

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      June 23, 2011
Sally Satel, M.D.
Resident Scholar
American Enterprise Institute
1150 Seventeenth Street, N.W.
Washington, DC 20036

Dear Sally:

    In reference to our full Committee hearing entitled ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans,'' 
that took place on June 14, 2011, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 5, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by faxing your responses to Debbie at 202-225-2034. If you 
have any questions, please call 202-225-9756.
            Sincerely,

                                                         BOB FILNER
                                          Ranking Democratic Member
    CW:ds

                               __________

                             August 5, 2011
                  Responses to Post-Hearing Questions
                from the Honorable Bob Filner regarding
   Mental Health: Bridging the Gap Between Care and Compensation for 
                        Veterans (June 14, 2011)
                           Sally Satel, M.D.
    Question 1: You recommended a living stipend for the veteran or his 
family during the course of care; can you explain how it would work?

    Response: My recommendation assumes what one might call a 
``treatment first'' approach. That approach is warranted, in my view, 
because VA psychiatrists and psychologists are not able to render an 
assessment of a veteran's potential for work in a 90-minute comp-and-
pension exam. The information derived from serious course of treatment/
rehabilitation is essential to making an intelligent determination of 
disability status.
    The basic idea of a ``stipend'' is that veterans who are too 
mentally impaired to work would be offered financial support to sustain 
them and their families while they are undergoing care for war-related 
depression, anxiety, or PTSD within a number of different treatment 
settings: inpatient hospitalization, residential care facility, 
intensive outpatient treatment, and/or intensive rehabilitation.\1\ 
Given that veterans would have no earning power during the time-limited 
and intensive treatment phase, the amount of temporary financial 
support offered could logically equal the ``full disability'' amount 
otherwise available to totally disabled veterans.
---------------------------------------------------------------------------
    \1\ The same general principles could apply to veterans with 
bipolar illness and schizophrenia taking into account that (1) these 
conditions, while service-connected (that is, they were temporally 
associated with service in a war-zone but not caused by the stress of 
serving) and (2) the high likelihood of chronicity of schizophrenia.
---------------------------------------------------------------------------
    These funds provided to veterans during the treatment-rehab phase 
could be considered a living stipend, a wellness benefit, or a 
treatment benefit. Other labels may be appropriate as long as the word 
``disability'' is not part of them. This is because the prognosis 
regarding a veteran's capacity to join the workforce is yet to be 
determined--and also because of the unfortunate consequence of 
prematurely labeling someone disabled.
    Consider this general outline:

         Veterans, mostly OIF/OIE veterans, who are not already 
        receiving disability payments from VBA, would present to the VA 
        for care, just as he or she does now. An assessment of clinical 
        need would be made, just as it is now. There would be no 
        special ``program'' for anyone. Veterans who are judged to 
        require intensive treatment and rehabilitation will receive it, 
        as is done now. The differences from the status quo are (1) 
        there would be no opportunity to apply for disability prior to 
        treatment for PTSD, anxiety, or depression; (2) veterans 
        referred to intensive care--their precise treatment regimen to 
        be determined by clinicians on a case by case basis--would meet 
        with a VA social worker to discuss the patients' need for 
        financial support for themselves and their families while they 
        are unable to work.

    Ideally, of course, veterans who receive excellent treatment/rehab 
will no longer be mentally impaired or believe they are unfit for the 
workplace. But, doubtless, some veterans will remain partially 
disabled--and a much smaller number will be totally and permanently 
incapable of competitive employment. If after a year or so of quality 
treatment, the VBA deems such veterans disabled, he or she would 
receive a standard rating and corresponding benefits and a reassessment 
of disability status within 3 to 5 years.
    At bottom: the VA should support veterans while they recover and 
ready themselves to enter the workforce. Meaningful disability 
assessments cannot be made by VBA unless the veteran first receives 
quality treatment/rehab first. (see C. W. Hoge editorial on 
Interventions for War-Related Posttraumatic Stress Disorder in Aug.3, 
2011 JAMA)

    Question 2: How do we change the stigma behind compensation 
suggesting that a veteran is beyond recovery?

    Response: One answer is to help veterans get better so that they do 
not need to apply for disability compensation in the first place--see 
answer to question #1 above. Another is to set an expectation for 
recovery by re-assessing veterans who are receiving disability every 1 
to 3 years (the frequency might depend upon the severity of rating.)
    Sadly, too many veterans are given the message that they are beyond 
recovery. Partly, this reflects the low expectations for improvement 
that many clinicians still harbor (i.e., based on a misimpression of 
what the diagnosis itself means). Failure to rejoin the workforce can 
also be attributed to the perverse incentives that accompany disability 
payments themselves. For example, even if a veteran wants very much to 
work, he understandably fears losing his financial safety net if he 
leaves the disability rolls to take a job that ends up proving too much 
for him. A practice of gradually decreasing benefits over a year or 
more as the veteran acclimates to the workforce is something to 
consider.
    Accordingly, the VA should emphasize some kind of productivity even 
if it is not in the competitive workforce. One strategy is to deploy 
more compensated work therapy programs for disabled veterans through 
the VA (see http://www.cwt.va.gov/veterans.asp) and to allow the VA to 
use financial incentives to as a contingency management strategy to 
combat co-morbid substance abuse (see http://www.mirecc.va.gov/visn1/
brief/brief_money.asp but substitute VA compensation for SSI 
compensation).
    At bottom: The best way to alter impressions is to change the 
reality behind them. The foregoing are some suggestions to weaken the 
existing link between veterans' compensation and the all-too-common 
failure to recover or at least to assume productivity of some kind.

    Question 3: How can VA do a better job at integrating occupational 
therapists into treatment teams?

    Response: This is an important logistical question that is best 
addressed by someone who works daily at a VA and understands the 
organization of specialty care there. My fellow panelist, Karen Seal, 
MD, for example, would be in a good position to answer.
    Thank you very much for your interest in my June 14, 2011 
testimony.

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      June 23, 2011
Ralph Ibson
National Policy Director
Wounded Warrior Project
1120 G Street, NW, Suite 700
Washington, DC 20005

Dear Ralph:

    In reference to our full Committee hearing entitled ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans,'' 
that took place on June 14, 2011, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 5, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by faxing your responses to Debbie at 202-225-2034. If you 
have any questions, please call 202-225-9756.
            Sincerely,
                                                         BOB FILNER
                                          Ranking Democratic Member
    CW:ds

                               __________
                     HVAC: Questions for the Record
                         Ranking Member Filner
             June 14, 2011--Mental Health: Bridging the Gap
                     between Care and Compensation
                  Ralph Ibson, Wounded Warrior Project
    Question 1: Of the pieces not yet fully implemented in VA Mental 
Health Strategic Plan, what piece would be considered WWP's priority?

    Answer: VA's Mental Health Strategic Plan recognizes the importance 
of early detection and early intervention of war-related mental health 
conditions, but it has only partially realized that critical goal. 
While VA has established a system for routine screening of OEF/OIF 
veterans for PTSD, it has no mechanism to assess veterans who do not 
seek VA care but may be at risk of PTSD. For those veterans who are 
deemed to need further evaluation and treatment for possible PTSD, VA 
has had only mixed success at sustaining those veterans in treatment 
and achieving positive outcomes. A system that sets its own performance 
goal at only 20 percent evidence based treatment completion, and then 
fails that standard by almost half, can hardly be considered successful 
in supporting veterans' treatment goals. As discussed in our testimony, 
there are many dimensions to that problem associated with gaps in VA 
mental health care. Of those, the Mental Health Strategic Plan 
discusses the importance of ``community mental health''--outreach to 
OEF/OIF veterans in the community and coordination and partnership with 
mental health services that already exist in that space. This aspect of 
the strategic plan remains largely unrealized.

    Question 2: Do you have any ideas about how VA can be more 
effective in providing reintegration services for veterans and their 
families?

    Answer: Successful community reintegration is of the utmost 
importance to this generation of young veterans. Many return home eager 
to pursue civilian employment, begin their education, and resume family 
life, yet still need assistance in making a successful transition into 
the civilian world. VA offers an array of benefits and services that 
can be helpful in that process, but it lacks a holistic coordinated 
approach that could make a profound difference in a veteran and 
family's efforts to reintegrate. The Department should be moving toward 
the goal of ``One VA'' that provides ``wraparound'' services that 
seamlessly and effectively integrate Veterans Health Administration 
(VHA) services and Veterans Benefits Administration (VBA) benefits, as 
proposed by a panel of the National Academy of Public 
Administration.\1\ As emphasized in our testimony, recognizing and 
meeting warriors' mental health needs is an important aspect of 
successful reintegration. But VA must work to close the formidable gaps 
cited in our testimony if it is to be more effective in reintegrating 
veterans with war-related mental health problems, and their families.
---------------------------------------------------------------------------
    \1\ National Academy of Public Administration, ``After Yellow 
Ribbons: Providing Veteran-Centered Services,'' October 2008.
---------------------------------------------------------------------------
    In that regard, we believe it is important for VA to harness the 
power of peer-networking to engage OEF/OIF veterans who may be at risk 
of war-related mental health issues. One important step would involve 
implementing section 301 of the Caregivers and Veterans Omnibus Health 
Act of 2010, which requires VA to conduct a peer-outreach program 
through VA medical centers as it pertains to OEF/OIF mental health. As 
demonstrated by the success of the Vet Centers' approach, peers can 
draw veterans into the system and connect them to resources, as well as 
keeping them engaged in services and their treatment when things are 
difficult.
    VA must also work to improve access to effective mental health 
care. A system that can offer only one mental health appointment every 
6 weeks for a veteran in severe psychological distress is not 
structured to meet the reintegration needs of this generation of 
warriors. While VA has increased mental health staffing over the past 
few years, there are still inadequate human resources in many 
communities to meet the demand for mental health services. Another 
concern is that VA facilities do not effectively accommodate the needs 
of a young, working population. Veterans must be able to access 
services at times and locations that allow them to continue with other 
activities of daily living--their jobs, schooling, and family 
responsibilities. Where VA facilities are unable to provide needed 
services like mental health treatment, they must partner with community 
entities to provide timely, needed services. In many instances, 
successful reintegration will require the collective efforts of the VA 
medical center, Vet Centers and local community partners--all playing a 
coordinated role. VA must take a more proactive role in fostering VA-
community partnerships, given that there are relatively few communities 
that are effectively organized and have existing partnerships with VA 
to assist in this process of community reintegration.

    Question 3: How great is the need for family access to VA mental 
health care?

    Answer: WWP staff who work with warriors and families have used 
terms like ``huge'' to describe the need for mental health services for 
family members. Another estimated that ``70 percent of the warriors 
that I have counseled have expressed the need for access to mental 
health care for their families.'' Recent work done by RAND confirms our 
staff's experience. RAND has documented, for example, that children of 
deployed parents experience behavioral and emotional difficulties at 
rates above national averages, with anxiety being a specific 
problem.\2\ These issues seldom dissipate upon the servicemember's 
return or after separation from service.
---------------------------------------------------------------------------
    \2\ James Hosek, ``How Is Deployment to Iraq and Afghanistan 
Affecting U.S. Servicemembers and Their Families?,'' RAND (2011), 
accessed at http://www.rand.org/pubs/occasional_papers/OP316.html.

    Question 4: Do you have any recommendations about what types of 
---------------------------------------------------------------------------
mental health services for families that VA might provide?

    Answer: Given the experience of coping with multiple deployments, 
separation, fears of death or injury of a loved one, and subsequent 
readjustment challenges, it is not surprising to find that family 
members can experience a range of different mental health problems of 
varying severity. One would expect that needed interventions might 
range from individual or group counseling to more intense psychotherapy 
and/or psychopharmacotherapy to family-focused mental health services. 
In some instances, particularly where children might need mental health 
care, such services would best be furnished through fee-basis or other 
community-based arrangements.

    Question 5: You indicate that VA compensation exams for PTSD are 
``brief'' and ``superficial.'' How can VA improve on these exams to 
ensure that veterans are properly rated for PTSD?

    Answer: A recent WWP survey of wounded warriors found that some 20 
percent of these exams are 30 minutes or less in duration. Prior 
testimony before this Committee regarding an Institute of Medicine 
study on PTSD compensation underscored the gravity of this concern:

         ``Testimony presented to our Committee indicated that 
        clinicians often feel pressured to severely constrain the time 
        that they devote to conducting a PTSD Compensation and Pension 
        (``C&P'') examination--sometimes as little as 20 minutes--even 
        though the protocol suggested in a best practice manual 
        developed by the VA National Center for PTSD can take 3 hours 
        or more to properly complete.'' \3\
---------------------------------------------------------------------------
    \3\ Dean G. Kilpatrick, Ph.D., Committee on Veterans' Compensation 
for Posttraumatic Stress Disorder, Institute of Medicine, Testimony 
before House Veterans' Affairs Committee Hearing on ``The U.S. 
Department of Veterans Affairs Schedule for Rating Disabilities,'' Feb. 
6, 2008, accessed at: http://veterans.house.gov/hearings/
Testimony.aspx?TID=638&Newsid=
2075&Name=%20Dean%20G.%20Kilpatrick,%20Ph.D.

    VA can take many steps to improve this process. It can require as a 
matter of standard practice that the examiners be provided the hours of 
time needed to conduct a thorough examination consistent with the 
protocol suggested in the best-practice manual. It can require 
examiners to review the veteran's medical treatment records prior to an 
exam or obtain information from the veteran's treating psychologist or 
psychiatrist. It can institute a policy that recognizes that a veteran 
with a mental health condition often will have difficulty in discussing 
sensitive or difficult psychiatric or psychological issues with a 
stranger, that is, with a C&P examiner. As such, a C&P examination is 
often the least revealing and least reliable source on which to base VA 
decisions regarding service-connection for a mental health condition. 
VA policy should be revised to give greater weight to the findings of 
clinicians who have or are treating the veteran and are necessarily far 
more knowledgeable about his or her circumstances. To the extent that 
VA must still rely on C&P exams, measures should be instituted to 
achieve more thorough exams. For example, cases are sometimes remanded 
because of inadequate examinations. Such remands are costly to the 
veteran and to the VA; VA could certainly take steps to hold the 
examiner (or contractors) responsible and institute appropriate 
---------------------------------------------------------------------------
disciplinary measure or penalties.

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      June 23, 2011
Christina Roof
National Acting Legislative Director
AMVETS
4647 Forbes Blvd.
Lanham, MD 20706-4380

Dear Christina:

    In reference to our Full Committee hearing entitled ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans,'' 
that took place on June 14, 2011, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 5, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by faxing your responses to Debbie at 202-225-2034. If you 
have any questions, please call 202-225-9756.
            Sincerely,

                                                         BOB FILNER
                                          Ranking Democratic Member
    CW:ds

                               __________
                     Committee on Veterans' Affairs
                     U.S. House of Representatives
              Post-Hearing Questions for Christina M. Roof
                     From the Honorable Bob Filner
              Mental Health: Bridging the Gap between Care
                     and Compensation for Veterans
                             June 14, 2011
    Question 1: Do you have any ideas about how the VA can be more 
effective in providing re-integration services for veterans and their 
families?

    Answer: AMVETS believes in order to provide a successful transition 
and re-integration for a servicemember/veteran VA must have a stronger 
presence in TAP classes and a greater presence on DoD installations. 
Transitioning servicemembers and eligible family members must be armed 
with the understanding of all of the post-service resources VA has to 
offer. By taking a more ``pro-active'' approach to re-integration, 
AMVETS believes many of the issues and/or problems many veterans and 
their families face can be avoided all together. DoD and VA must build 
upon their relationship if we are to truly offer a seamless transition 
to all of today's returning war fighters and their families.

    Question 2: Do you have any recommendations about what types of 
mental health services for families that VA might provide?

    Answer: In order to provide the highest quality of mental health 
care available to our veterans community we must start treating the 
entire veteran, including support for their families, instead of the 
reactionary approach of treating individual symptoms and illnesses as 
if they are exclusive of one another. VA has several programs aimed at 
providing mental health resources to the families of veterans, such as 
VetCenters counseling programs. However, AMVETS believes these programs 
are not often offered to family members and that the programs are too 
widespread to be utilized by the number of families that actually need 
them. It is going to be critical to the treatment and care of today's 
veterans to remember that mental health issues not only affect the 
veteran, but can also affect, and have devastating impacts if 
incorrectly treated, on the veteran's spouse, children and/or other 
immediate family members. Often we see a large disconnect between the 
families of veterans and veterans themselves. Often families are not 
aware of the possibility that the person that may have left for war, 
just may not be the same person that returns. This is not say that the 
person will never return to their pre-deployment self, but the odds are 
very slim. We need to provide support services to the families of 
veterans and servicemembers to help better educate them on what to 
expect when their loved one returns and/or what to expect and how to 
cope with a loved one who may need mental health care when they return. 
VA and DoD both need to provide strong pre- and post-deployment mental 
health services to the entire family. The way a child will react to a 
parent suffering from a mental health disorder, compared to that of a 
spouse will be very different. VA and DoD mental health services need 
to be designed to address this fact. Recovery from either physical or 
mental wounds is a process the entire family will endure and until we 
start addressing this issue we will not be able to offer the best care 
and services available to all veterans seeking VA care.

    Question 3: How great of a need is there amongst your members for 
family access to VA mental health care?

    Answer: Given the fact that AMVETS membership is composed of 
veterans, active duty military personnel, as well as members of the 
National Guard and Reserve, there is a very large need for improved 
availability and care for mental health care among our membership's 
families.

    Question 4: You indicate that the VA compensation exams for PTSD 
are ``brief'' and ``superficial.'' How can VA improve upon these exams 
to ensure that veterans are properly rated for PTSD?

    Answer: When discussing the claims process as it related to 
benefits and care for psychological wounds, AMVETS strongly recommends 
a focus on quality instead of quantity when processing claims. This is 
especially true for mental health claims, such as those for PTSD. 
AMVETS believes that the Rater Veteran Service Representative's (RVSR) 
must be better trained in mental health care issues. For example, a 
rater may need to address issues that the veteran is not even prepared 
to address in a therapeutic setting, let alone a claims review. This 
means the veteran will most likely internally shut themselves down and 
provide little to no assistance to the RVSR. This is not a good outcome 
for any party involved. What will occur is that the rater will deny the 
claim due to lack of information and the veteran will then be left with 
a negative opinion of VA and will most likely appeal their denial, thus 
putting the claim into the growing claims appeals system. If we were to 
better educate the veteran on what to expect and better train the 
raters on the same, we will start seeing better outcomes and claims 
processed correctly the first time.

    Question 5: In what ways might the implementation of the Uniform 
Mental Health Services Handbook contribute to reducing the barrier that 
stigma plays in keeping veterans from seeking mental health and 
substance use services?

    Answer: AMVETS cannot speculate on how the proper implementation of 
VHA Handbook 1160.01 would reduce the stigmas attached to mental health 
care, however AMVETS strongly believes that the handbooks full 
implementation, as required by law, full would help ensure uniform care 
and availability resources for veterans in the areas of:

          Suicide Prevention
          Specialized PTSD Services
          Gender-Specific Care and Military Sexual Trauma
          24/7 Emergency Mental Health Care
          Seriously Mentally Ill and Rehabilitation/Recovery 
        Services
          Inpatient Care
          Care Transitions (discharge from medical care with 
        instructions)
          Substance Abuse Disorders
          Homeless Programs
          Incarcerated Veterans Programs
          Elder Care (integration of mental health into medical 
        care)
          Access to Trained Mental Health Staff

    As well as in several other key areas directly relating to mental 
health care and treatments.

    Question 6: In terms of the initiatives set forth in the Mental 
Health Strategic Plan, which action item is of top priority for AMVETS?

    Answer: AMVETS believes that every initiative, policy and procedure 
laid out by VHA 1160.01 are equally important in ensuring our veterans 
receive only the highest quality of care and availability of resources 
VA has to offer.

    Question 7: What can VA do to provide better outreach to OEF/OIF 
veterans regarding the availability of PTSD treatment?

    Answer: AMVETS believes VA must start taking a more proactive 
approach in ensuring our veterans are receiving all the necessary 
mental health care. Until we stop taking a ``reactionary'' approach to 
bettering the VA system of mental health we are destined to be playing 
``catch up'' in meeting the needs of today's returning war fighters. 
Veterans and their families must be educated on all of the resources 
available to them. This should be done through more affective outreach 
campaigns on television, through social media and through education 
provided to veterans and their families by VA personnel.

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      June 23, 2011
The Honorable Eric K. Shinseki
The Secretary
U.S. Department of Veterans' Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our full Committee hearing entitled ``Mental 
Health: Bridging the Gap between Care and Compensation for Veterans,'' 
that took place on June 14, 2011, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 5, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax your responses to Debbie at 202-225-2034. If you 
have any questions, please call 202-225-9756.
            Sincerely,

                                                         BOB FILNER
                                          Ranking Democratic Member
    CW:ds

                               __________

                     Committee on Veterans' Affairs
                     U.S. House of Representatives
           Post-Hearing Questions for Antonette Zeiss, Ph.D.
                     From the Honorable Bob Filner
              Mental Health: Bridging the Gap between Care
                     and Compensation for Veterans
                             June 14, 2011
    Question 1: Can any veteran who needs VA care for acute PTSD 
receive that care immediately? Can you give the Committee staff an 
update on the average waiting time for starting specialized therapy or 
counseling once it is requested?

    Response: According to Veterans Health Administration (VHA) 
guidelines, all patients newly requesting or referred for mental health 
services must receive an initial evaluation within 24 hours and a more 
comprehensive diagnostic and treatment planning evaluation within 14 
days. The rationale for initial evaluation within 24 hours of first 
contact with a Veteran is to identify urgent care needs and to initiate 
treatment in a timely manner. Over 95 percent of all Veterans referred 
for new mental health care receive an appointment leading to diagnosis, 
and when warranted a full treatment plan, within 14 days. Similarly, 
data confirm that over 95 percent of established mental health patients 
also receive appointments for continuing care within 14 days of the 
preferred date, based on the treatment plan. The average wait times for 
Veterans needing specialized outpatient PTSD care are 0 to 5.9 days 
from their desired date, depending on the clinic.

    Question 2: In regards to Mr. Hanson's testimony, what are the 
follow-up procedures after a veteran is released from psychiatric 
treatment?

    Response: VHA Mental Health services are provided in inpatient, 
residential rehabilitation treatment, and outpatient settings. During 
his testimony, Mr. Hanson indicated that he received VHA inpatient 
psychiatric care, residential care, and outpatient follow-up. We are 
not sure what you are referencing in regard to ``released from 
psychiatric treatment'', but will assume that you are referring to 
discharge from acute inpatient care.
    All VHA facilities are required to ensure that there is continuity 
of care during transitions from acute inpatient mental health care to 
outpatient or residential care. VHA has a monitor that requires that 
Veterans being discharged from an inpatient mental health program must 
be followed-up by an outpatient treatment program within 7 days of the 
date of discharge. This initial contact can be face-to-face, 
telephonic, or using telemental health services. If the contact is 
telephonic, a face-to-face appointment must take place within 14 days 
of the date of discharge from the inpatient program. Based on VHA data, 
in May 2011, 66 percent of Veterans discharged from inpatient 
psychiatric care received an outpatient mental health follow up within 
7 days (the target for this measure is 75 percent of Veterans in FY13). 
While data indicate that in May 2011, 66 percent of Veterans received 
mental health follow-up within 7 days, this does not imply that the 
other 34 percent of Veterans have not received mental health follow-up. 
Many Veterans choose not to receive mental health follow-up care during 
the first 7 days after discharge despite medical recommendations. VHA 
providers continue to attempt to engage these Veterans in treatment 
after the initial 7-day period after discharge. Specifically, Veterans 
who are released from inpatient hospitalizations and are considered to 
be at high risk for suicide receive regular follow-up from the Suicide 
Prevention program. All Veterans who are discharged from inpatient 
psychiatry are given information about how to access emergency mental 
health treatment and provided with the VA Crisis line telephone number.

    Question 3: Does the VA offer inpatient treatment programs spanning 
more than 90 days?

    Response: VA offers a full continuum of mental health care and 
programs, including inpatient mental health services and residential 
rehabilitation treatment programs. Both inpatient mental health 
services and residential rehabilitation treatment programs serve 
Veterans whose length of stay is greater than 90 days. The decision 
regarding length of stay is based on clinical need. Inpatient services 
are provided for patients with acute mental health problems, such as 
suicidality; behavior due to mental illness that can put the Veteran or 
others in danger; severe symptoms of depression, post-traumatic stress 
disorder, bipolar disorder or psychosis; or other symptoms requiring 
close monitoring and stabilization. Given the focus on stabilization of 
acute symptoms, the average length of stay in an inpatient setting is 
11.1 days, though patients may remain in the hospital for longer 
periods of time when clinically indicated. Once stabilized, patients 
are discharged to a lower level of care, depending on their clinical 
needs. As examples, patients may be discharged home or to transitional 
housing through the Homeless Program, with follow-up outpatient mental 
health care including possible participation in a Psychosocial 
Rehabilitation and Recovery Center (PRRC), or to a Mental Health 
Residential Rehabilitation and Treatment Program (MHRRTP).
    MHRRTPs provide residential rehabilitative and clinical care to 
eligible Veterans who have a wide range of problems, illnesses, or 
rehabilitative care needs which can be mental health, substance use, 
homelessness, vocational, educational, or social; Veterans also may 
have comorbid medical problems. The programs provide a 24-hours-per-
day, 7 days-per-week (\24/7\) structured and supportive residential 
environment as a part of the rehabilitative treatment regime. In 
addition to specialized treatment for mental health, substance use and 
co-morbid medical conditions, MHRRTPs provide a strong emphasis on 
psychosocial rehabilitation and recovery services that instill personal 
responsibility to achieve an optimal level of independence upon 
discharge to independent or supportive community living. In fiscal year 
(FY) 2010, the average length of stay in an MHRRTP was 62.8 days, 
although there is significant variation around that average.
    In FY 2010 there were 62 Substance Abuse Residential Rehabilitation 
and Treatment Programs (SARRTP) and Domiciliary Substance Abuse (DOM-
SA) programs in VA. These programs provide initial specialized 
Substance Use Disorder (SUD) services to Veterans in a residential 
setting. Average length of stay in the SARRTP and DOMSA programs was 
36.4 days, with significant variation around that average. VHA policy 
does not provide a specific length of stay recommendation for SARRTP 
and DOM-SA programs. Rather, policy (VHA Handbook 1162.02) requires 
that length of stay should be individualized based on the needs of the 
Veteran, as outlined in the treatment plan, with evolving attention to 
the length of time required to meet the Veteran's identified treatment 
goals and objectives. While participating in the initial specialized 
SUD care in the SARRTP or DOM-SA program, the Veteran's discharge 
planning is based on continued engagement in recovery services. Based 
on individual need, the Veteran may transition to additional levels of 
residential care, transitional, or permanent housing with continued 
engagement in community and VA outpatient treatment supports following 
discharge. Current VHA policy and treatment approaches are consistent 
with the available literature which demonstrates that a longer length 
of stay is not associated with better treatment outcomes.\1\
---------------------------------------------------------------------------
    \1\ Harris, A. H. S., Kivlahan, D., Barnett, P. G., & Finney, J. W. 
(2011). Longer Length of Stay is Not Associated with Better Outcomes in 
VHA's Substance Abuse Residential Treatment Programs, Manuscript 
submitted for publication.

    Question 4: Are there mechanisms to track when veterans miss 
appointments or just stopped calling all together and if so, what steps 
---------------------------------------------------------------------------
does the VA take to reengage these veterans?

    Response: Local VA facilities are required to make at least three 
attempts to contact Veterans who miss mental health treatment 
appointments after any missed appointment. Contacts are typically made 
by telephone, and the goals of these contacts are to determine if the 
Veteran is in need of urgent care and to address any concerns the 
Veterans may have about their condition or the quality of care they 
have been receiving. The results of these attempts are documented in 
the Veteran's medical record.
    In addition, the Office of Mental Health Services (OMHS) is 
implementing a program designed to locate and re-engage in treatment 
any Veterans with serious mental illness who have been lost to follow-
up care. This program is based on a project conducted by the Office of 
the Medical Inspector (OMI), which found that re-engaging Veterans with 
serious mental illness in treatment could significantly decrease the 
mortality rate of this population of Veterans. Using lists provided by 
the Serious Mental Illness Treatment Resource and Evaluation Center, 
the Local Recovery Coordinators at each facility attempt to locate 
these Veterans, assess their need for health care services, and re-
engage them in treatment. This program is currently being piloted at 
five VA medical centers and will be implemented nationally during the 
fourth quarter of FY 2011.

    Question 5: What are the VA's views on Mr. Hanson's suggestions to 
withhold compensation until treatment is complete as an incentive for 
veterans to seek care?

    Response: VHA and the Veterans Benefits Administration (VBA) are 
working very closely to facilitate appropriate treatment and disability 
compensation. Both parts of the organization have the goal of 
facilitating independence and the best possible health. For many 
Veterans, this is achieved through appropriate health care and 
treatment.
    However, VA does not support this suggestion to link benefits and 
treatment for the following reasons. Congress has mandated in 38 U.S.C. 
Sec. Sec. 1110 and 1131 that VA pay compensation to Veterans discharged 
or released under conditions other than dishonorable for disability 
resulting from personal injury or disease incurred or aggravated in 
line of duty. This requirement to pay compensation is mandatory and is 
not predicated upon any requirement that the Veteran undergo medical 
treatment as a condition of receiving compensation. The statutory and 
regulatory framework for rating disabilities is based on the premise 
that payments for service-connected disability are intended to 
compensate Veterans for ``reductions in earning capacity'' resulting 
from injury or disease.
    VA's statutes and regulatory scheme are clear that compensation 
payments are intended to make up for loss of earnings incurred 
throughout the course of a disability, including those periods while 
the disability is at its most severe, prior to completion of any 
necessary treatment, and when it has stabilized. Withholding 
compensation from Veterans with the most severe disabilities until all 
treatment modalities are completed would cause great harm to these 
Veterans and their families at a time when compensation is most needed, 
when the reduction in earning capacity is at its highest level.

    Question 6: Does VA have enough resources to admit veterans to 
treatment at the point of compensation evaluation?

    Response: VA currently has sufficient resources to engage eligible 
Veterans who desire or need mental health treatment at the point of 
their compensation evaluation as evidenced by current VHA data. VHA 
data from May 2011, indicates that 95 percent of new mental health 
patients are seen for a mental health evaluation within 14 days 
following their first mental health encounter and that 96 percent of 
established mental health patients are seen for a follow-up mental 
health appointment within 30 days (if a follow-up mental health 
appointment is required/desired). Thus Veterans have been able to 
access both initial and follow-up mental health care.
    VHA and VBA are currently collaborating to determine the best 
processes to provide targeted mental health outreach to those Veterans 
who receive new service-connected status for a mental health disability 
and who are not currently accessing VHA mental health care. VA has the 
capacity to provide such services, so only the administrative actions 
to ensure information flow from VBA to VHA are needed to accomplish 
this goal.

    Question 6(b): Does VA have the resources to conduct periodic re-
evaluations at 2 to 5 year intervals to assess progress and continued 
applicability of disability status, as discussed by the American 
Enterprise Institute?

    Response: VA regulations provide that, generally, a reexamination 
is required if it is likely that a disability has improved or if 
evidence indicates a material change in a disability or that the 
current rating may be incorrect. VA's current policy is to conduct 
routine reexaminations at 5 year intervals unless a different interval 
is required by regulation. According to 38 CFR Sec. 3.327(b), VA rating 
boards may schedule, when necessary, reexaminations after 2 years but 
no later than 5 years, unless another time period is elsewhere 
specified. VA does not schedule reexaminations when, among other 
things, the disability is determined to be static, has persisted 
without improvement for over 5 years, or is permanent and not likely to 
improve or in Veterans over 55 years of age.

    Question 7: What are the VA's views on providing treatment to a 
veteran before making a determination about their future functional 
capacity?

    Response: The question has two relevant contexts. The first relates 
to how clinicians evaluate and plan for treatment of Veterans who are 
using VHA health care. The second relates to policies that VA has been 
encouraged to consider regarding requiring a course of treatment for a 
mental illness prior to being considered for compensation due to a 
mental illness. VA can respond to the first based on clinical 
experiences and policies, and that information follows (No. 1 below). 
The second issue depends in many ways on the first, but also involves 
additional policy issues as discussed below, in No. 2.

        1.  Clinician evaluation and planning for treatment of 
        Veterans: Clinical determination of future functional capacity 
        cannot be established without full assessment and engagement of 
        the Veteran in treatment. When a Veteran is referred for or 
        requests mental health treatment, immediate needs are first 
        evaluated and addressed. Subsequently, the Veteran works with 
        his or her treatment team to set goals designed to maximize 
        recovery and help the Veteran meaningfully integrate into the 
        community. Only after the Veteran has begun to achieve his or 
        her treatment plan goals can a reliable assessment of future 
        functional capacity be conducted. Any clinical determination of 
        future functional capacity must take into account that 
        individuals in the process of recovery from mental illness 
        sometimes encounter setbacks that affect the course of their 
        recovery. Throughout these processes, OMHS is committed to 
        providing Veteran-centered, recovery-oriented mental health 
        service, as codified in a variety of Directives and memoranda 
        to the field (e.g., VHA Handbook 1160.01, Uniform Mental Health 
        Services in VA Medical Centers and Clinics).
        2.  Requiring a course of treatment for a mental illness prior 
        to being considered for compensation: As noted above, it is 
        never clear when first beginning to treat a Veteran what the 
        response to treatment will be and over what time course that 
        response will occur. Thus, requiring treatment before a claim 
        can be submitted leaves the Veteran in an uncertain status for 
        a potentially lengthy period. Such uncertainty is especially 
        difficult for those with a mental illness to tolerate and this 
        added stress may, in fact, reduce the likelihood that treatment 
        will be successful.

    As noted in our testimony, there are other concerns about 
establishing such a requirement. These are the relevant sections of the 
Testimony, prepared specifically to provide background information 
regarding the suggestion that treatment should precede claim submission 
(pages 5-7 of submitted Testimony). While these sections specifically 
focus on PTSD, the issues are very similar for other mental illnesses:

        ``Recovery from PTSD Is Complicated By Co-Occurring Disorders

        Recovery from PTSD is usually complicated by co-occurring 
        disorders, since most Veterans with PTSD have at least one 
        additional diagnosis such as traumatic brain injury (TBI), 
        depression, substance use disorder (SUD), chronic pain, 
        problems with aggression, insomnia and other medical problems. 
        Treating Veterans with multiple conditions cannot be restricted 
        to PTSD but must address the other problems concurrently. For 
        example, a Veteran with PTSD and chronic pain as a result of 
        his or her injuries will experience the pain as a traumatic 
        trigger that will reactivate other reactions such as PTSD 
        nightmares, avoidant symptoms, and hyperarousal. The pain must 
        be treated along with the PTSD if clinical improvement can be 
        expected realistically. Unfortunately, although VA has 
        excellent treatments for PTSD alone, the development of 
        evidence-based treatments for concurrent PTSD and chronic pain 
        is still at an early stage.

        Even the Most Effective Treatments Do Not Guarantee Recovery

        Not everyone with PTSD who receives evidence-based treatment is 
        likely to have a favorable response. For example, a recent 
        analysis (submitted for publication) of data from VA's large 
        Cooperative Study (CSP#494) on prolonged exposure to the stress 
        factors associated with and contributing to PTSD symptoms among 
        female Veterans and active duty Servicewomen identified those 
        factors that predict poor treatment outcome. This is the 
        largest randomized clinical trial of Prolonged Exposure (PE) 
        ever conducted, with 284 participants, and the first one 
        focusing solely on Veterans and military personnel. While the 
        results (overall) clearly showed the efficacy of PE treatment 
        for women with a military history who have PTSD, our analysis 
        shows that Veterans with the most severe PTSD are least likely 
        to benefit from a standard course of treatment. Other factors 
        that predicted poor response were unemployment, comorbid mood 
        disorder, and lower education. In other words, those with the 
        worst PTSD are least likely to achieve remission, as is true 
        with any other medical problem.
        Even when Veterans are able to begin and sustain participation 
        in treatment, timing, parenting, social, and community 
        functions all matter a great deal. Treatment, especially 
        treatment of severe PTSD, may take a long time. During this 
        period, disabled Veterans with PTSD are at risk for many severe 
        problems including family problems, parenting, inability to 
        hold a job, inability to stay in school, social and community 
        function. Further, evidence also shows that whereas a positive 
        response to treatment may reduce symptom severity and increase 
        functional status among severely affected Veterans, the 
        magnitude of improvement may not always be enough to achieve 
        clinical remissions or terminate disability. This is no 
        different than what is found with other severe and chronic 
        medical disorders (such as diabetes or heart disease) where 
        effective treatment may make a difference in quality of life 
        without eradicating the disease itself.''
        In summary, VA does not support the concept that treatment 
        should be required before a Veteran may submit a claim for 
        compensation due to a mental illness incurred or aggravated as 
        a consequence of military service. Placing such a restriction 
        on Veterans is inconsistent with the mandate in 38 U.S.C. 
        Sec. Sec. 1110 and 1131. This requirement to pay compensation 
        is mandatory and is not predicated upon any requirement that 
        the Veteran undergo medical treatment as a condition of 
        receiving compensation. In addition, the added stress of 
        uncertainty and concern about every setback in treatment, and 
        how that may prolong the course of improvement in treatment--
        thus prolonging the period before a claim can be submitted, may 
        in fact render treatments that could be very effective much 
        less successful. That would be the greatest tragedy for 
        Veterans.
        VA needs to consider changes in its current system of 
        disability evaluation and determination of level of service-
        connected disability for those with a substantiated service-
        connected mental illness diagnosis. Those efforts are underway.

    Question 8: Currently, are Rater Veteran Service Representatives 
(RVSRs) required to train regularly on changes to current laws and 
regulations?

    Response: All Rating Veterans Service Representatives are required 
to undergo 85 hours of annual training. Technical training makes up 80 
hours of the annual requirement and topics involve policy, regulations 
and procedures. The training topics are reviewed throughout the year to 
ensure that current lessons are available on all emerging issues as 
well as refresher training on established topics.

    Question 9: Is there a shortage of trained staff to provide 
Intensive Outpatient Services for the treatment of substance use 
disorders?

    Response: At the national and regional level, VHA has adequate 
numbers of trained staff to provide intensive outpatient services for 
substance use disorders (SUD). Specifically, all VISNs have licensed 
psychologists or social workers assigned to provide specialty intensive 
outpatient treatment for SUD as well as physicians and/or advanced 
practice nurses to provide pharmacotherapies for SUD. All VISNs provide 
intensive SUD treatment to VA patients with SUD diagnoses who would 
benefit from such intensive services. All VISNs also provide 
pharmacotherapy for SUD, opioid agonist treatment and pharmacotherapy 
as a component of treatment for problem use of alcohol. We are 
confident that staff are trained to provide intensive outpatient 
services across all VISNs.
    To further ensure competence to deliver a full range of services in 
Intensive Outpatient Programs (IOP) for Substance Use Disorder, during 
FY 2011, OMHS also conducted trainings for leaders of all active IOP 
programs to promote standardization of this level of care and 
implementation of evidence-based recommendations from the VA/DoD 
Clinical Practice Guideline on Management of Substance Use Disorders, 
including addiction focused pharmacotherapy and encouraging abstinence 
in early recovery through systematic use of motivational incentives. 
Ongoing follow-up consultation and monitoring is supporting 
implementation of this initiative to assure adequate training of staff 
in this level of care.
    At the facility level, because of variation in the structure of 
mental health and substance use disorder treatment programming, 
determining whether an optimal level of trained staff are available is 
more complex. Intensive outpatient services are provided to patients 
with SUDs within a variety of staffing structures at VA facilities. 
Some facilities have a single set of staff that provide intensive 
services to residential and outpatient patients with SUDs; others 
structure their outpatient programs such that staffs provide both 
intensive treatment and less intensive after care to patients with SUD. 
Thus, it is impossible to break out ``staff that provide intensive 
outpatient services'' from other specialty SUD treatment providers, as 
the same staff member may provide different levels of service to 
various patients in their care. Moreover, at some facilities, 
prescribing staff, such as MDs and advance practice nurses, may be 
shared between specialty SUD programs and general mental health 
programs, which can be beneficial for integrating pharmacotherapy for 
the majority of patients with SUD who have co-occurring mental health 
conditions. Using as a guide staffing recommendations contained in a 
June 11, 2008 memorandum by the Deputy Under Secretary for Health 
Operations and Management when establishing 28 new IOPs, all 92 stand-
alone specialty SUD outpatient programs offering intensive services 
have a sufficiently large total number of clinical staff. Nevertheless, 
6 of these 92 programs have fewer clinical psychologists or social 
workers and 22 have fewer prescribers assigned directly to them than 
recommended in the new program staffing memo. We are following these 
programs to 1) ensure that they are not providing intensive SUD 
treatment at lower rates than other programs, and 2) to determine if 
they are using more integrated mental health programming structures to 
deliver effective care to patients with SUD.

    Question 10: Is there a shortage of 23-hour observation beds for 
patients at risk for harming themselves or others?

    Response: There is not a shortage of beds for the purpose stated in 
the question. Veterans who are a danger to themselves or others (as 
indicated in this question) should not be assigned to 23-hour 
observation beds; they require immediate admission to an acute 
inpatient psychiatry unit. Per the Mental Health Handbook, ``Inpatient 
care must be available to all Veterans who require hospital admissions 
for a mental disorder, either in the VA medical center where they are 
treated, a nearby facility, or by contract, sharing agreement, or non-
VA fee basis referral to a community facility.'' All sites in the VA 
system report meeting this standard.
    There are appropriate uses for such 23-hour observation beds. All 
medical centers with emergency departments must have resources to allow 
extended observations for up to 23 hours when clinically indicated. 
This is often used for patients presenting in states of intoxication to 
allow effective determination of the required level of care for ongoing 
treatment. Per the survey results of June 2010, 79 percent of 
facilities with emergency rooms had implemented this requirement. VA is 
conducting a follow up survey to determine the current level of 
compliance with this requirement. However, this requirement is often 
met through an admission to the inpatient psychiatry unit when an 
observation bed is unavailable and admission is indicated, leading to 
an even greater availability of appropriate resources. The Mental 
Health Operations Office will monitor availability to ensure adequate 
resources are available.

    Question 11: What sorts of substitution therapies are available for 
veterans with narcotic dependence?

    Response: Methadone and buprenorphine are the only FDA approved 
agonist (i.e., ``substitution'') therapies for opioid addiction and 
there are no FDA approved agonist therapies for other drugs classified 
by statute as narcotics (e.g., cocaine). Methadone can be used to treat 
addiction only in the setting of federally regulated Opioid Treatment 
Programs (OTP) that may also make buprenorphine available under the 
same regulations. Buprenorphine can also be used by specially qualified 
providers in regular office-based practice outside of OTPs, making 
opioid replacement therapy much more accessible.

          Are these substitution therapies treatment offered at 
        all VA medical facilities?

    Response: Opioid Agonist Treatment can be delivered in either or 
both of the following settings:

        1.  OTP. This setting of care involves a formally-approved and 
        regulated opioid substitution clinic within which patients 
        receive opioid agonist maintenance treatment using methadone or 
        buprenorphine.
        2.  Office-based Buprenorphine Treatment. Buprenorphine can be 
        prescribed as office-based treatment in non-specialty settings 
        (e.g., primary care), but only by a ``waivered'' physician. 
        Administration and prescription of buprenorphine are not 
        subject to all of the regulations required in officially 
        identified OTPs, but buprenorphine must be delivered in a 
        manner consistent with treatment guidelines and Pharmacy 
        Benefits Management criteria for use.

    OTPs are established on-site at 32 medical centers, largely in 
urban settings where there is a ``critical mass'' of opioid dependent 
Veterans to warrant these complex programs. An additional 22 facilities 
arrange methadone treatment via contract or on a fee basis with a 
community provider. Buprenorphine is offered at 116 facilities as well 
as at a number of community-based outpatient clinics for a total of 239 
distinct points of service. Nineteen facilities have yet to establish 
capacity for providing opioid agonist treatment on-site or in the 
community. Since the VHA Handbook on Uniform Mental Health Services 
requires that pharmacotherapy with approved, appropriately-regulated 
opioid agonists (e.g., buprenorphine or methadone) must be available to 
all patients diagnosed with opioid dependence for whom it is indicated 
and for whom it is not medically contraindicated, this is a continuing 
source of implementation effort through monitoring and consultation.

          If a substitution therapy is needed but is not 
        offered at a particular facility, is it possible for a veteran 
        to get the needed services from another VA medical facility? If 
        so, what is the process for doing so?

    Response: Opioid agonist treatment initiation involves frequent 
visits early in recovery and long-term maintenance visits; thus 
arranging time-limited care at remote facilities is not indicated 
clinically. However, some VA facilities lacking internal opioid agonist 
treatment capacity are located within reasonable driving distance from 
other VA facilities and referral to these nearby VA medical facilities 
is an option. In these cases, referral is typically made via clinical 
coordination between providers within the two VA facilities.

    Question 12: Does VA have a system to reliably track your own 
provisions and utilization of mental health therapies and policies?

    Response: VA has multiple processes to track provision and 
utilization of mental health therapies and policies. Some major 
components of this system include:

          To track compliance with the Uniform Mental Health 
        Services in VA Medical Centers and Clinics, VISNs (to include 
        all medical centers and associated CBOCs) are required to 
        report on the presence/absence of required services twice a 
        year. This requirement has recently been increased to require 
        reporting four times per year.
          The Mental Health Program Evaluation Centers: 
        Northeast Program Evaluation Center (NEPEC), Program Evaluation 
        and Resource Center (PERC), and Serious Mental Illness 
        Treatment Resource Evaluation Center (SMITREC) expand on this 
        basic dataset by analyzing VA administrative data sets to both 
        validate and quantify the self-report data.
          VA offices outside of mental health, such as Systems 
        Redesign, and the Office of Quality and Performance (OQP), are 
        responsible for collecting data on mental health processes such 
        as screening requirements and compliance with timeliness 
        standards.
          VA also participates actively in reviews of 
        compliance conducted by the IG, GAO, and other oversight 
        bodies. VA has monitored compliance with the Mental Health 
        Residential Rehabilitation and Treatment Programs (MHRRTP) 
        through both VISN self-report and through a contracted review 
        of all programs by Mathematica. Sites that have been found to 
        have serious deficiencies are required to submit action plans 
        and are subject to more intensive follow-up until the program 
        comes into compliance. All MH programs are also monitored by 
        the Joint Commission.

    Question 13: One issue that is particularly important is care for 
veterans of the Guard and Reserve. An issue that they face is that they 
go back and forth between the DoD and VA health care systems sometime 
making 'seamless transition' a less-than-seamless process. This can be 
particularly concerning for veterans as the continuity of their care, 
particularly mental health care, may be compromised.

    Response: VA partners with DoD through multiple programs to foster 
optimal transitions between their health care systems for Guard and 
Reserve component veterans, as well as other servicemembers. VA's 
Liaisons for Health Care are Masters Prepared Social Workers (MSWs) or 
Registered Nurses (RNs) who serve as essential resources for 
transitioning injured and ill OEF/OIF/OND veterans and servicemembers. 
VA now has 33 VA Liaisons for health care stationed at 18 military 
treatment facilities (MTF) to transition ill and injured Servicemembers 
from DoD to VA Medical Centers that have specialized services that 
their medical condition requires or that may be closer to that 
Servicemember's home. VA Liaisons for Health Care are co-located with 
DoD Case Managers at MTFs and provide onsite consultation and 
collaboration regarding VA resources and treatment options. They 
educate Servicemembers and their families about VA's system of care, 
coordinate the Servicemember's initial registration with VA, and secure 
outpatient appointments or inpatient transfer to a VA health care 
facility as appropriate. VA Liaisons for Health Care make early 
connections with Servicemembers and families to begin building a 
positive relationship with VA. VA Liaisons coordinated 7,150 referrals 
for health care and over 26,825 professional consultations in fiscal 
year (FY) 2010. In fiscal year 2011, VA Liaisons coordinated 4,686 
transitions for health care through June 2011.
    Continuity of care is also provided through the DoD InTransition 
program, which provides support and coaching as Servicemembers 
transition between health care systems or providers, including those 
who are transferring their care to the VA system. This program empowers 
Servicemembers to improve their psychological and overall wellness, 
promotes and encourages Servicemembers to consider healthy choices, and 
models positive coping and adapting strategies. InTransition Support 
Coaches answer questions about mental health treatment modalities and 
techniques and use motivational interviewing techniques to maintain the 
Servicemember's engagement in treatment and followup.

    Question 14: From your experience, do you have any examples of how 
this `back and forth' has been a problem for veterans and their 
families?

    Response: The major potential concerns about the `back and forth' 
between the DoD and VA health care systems for National Guard and 
Reservists who return from deployment are access to high quality care, 
continuity of care, and confidentiality. We are aware of anecdotal 
incidents where these issues have been of concern and are making every 
effort to address them, both as they occur individually as well as 
proactively addressing them on a national level.
    National Guard and Reservists often return to their home community 
and do not remain at their post or installation where support and 
medical care may be more readily available. Many return to rural 
community settings where there may only be distant access to DoD health 
care resources or tertiary VA medical centers. Through the network of 
VHA's Community Based Outpatient Clinics (CBOCs) and Vet Centers, 
including mobile Vet Center capability, VA continues efforts to improve 
access to high quality mental health care for these Veterans and their 
family members who live and work in rural communities. In addition, VA 
continues to implement telehealth strategies to improve access to care 
for Veterans in rural settings.
    Active Duty Servicemembers receive care from both DoD and VA 
sequentially, the usual pattern; or concurrently, for those who are 
seen at VA facilities while still on active duty; or--especially for 
Guard and Reserve--in an alternating pattern, with care from DoD while 
activated and from VA when between periods of activation. The VA/DoD 
Bi-directional Health Information Exchange was initiated in 2008 and is 
designed to ensure that providers from both systems have access to 
information related to current treatments, which aims to improve 
continuity of care for the Servicemember or Veteran.
    This bidirectional record system supports continuity of care, but 
can raise concerns about confidentiality. A joint DoD/VA task group is 
currently examining policies for health information sharing between DoD 
and VA in order to provide continuity and coordination of care while 
allowing Veterans and Servicemembers some measure of control over 
whether, how, and with whom their information will be shared. This is 
particularly relevant for National Guard and Reservists, for whom 
medical records serve not only the purpose of clinical care but also 
the purpose of determining fitness for duty.

    Question 15: Is VA currently able to work with DoD in any way to 
maintain some continuity of care for Guard and Reserve members?

    Response: There are several ways in which VA and DoD work together 
to maintain continuity of care for Guard and Reserve members. For 
example, a 2005 Memorandum of Agreement between the National Guard 
Bureau and VA helps provide assistance to National Guard and Reserve 
Members. In 2006, the National Guard placed 62 Transition Assistance 
Advisors (TAAs) in all 50 States, the District of Columbia, and the 
territories of Guam, Puerto Rico, and the Virgin Islands. VA staff 
provided in depth training for the initial TAAs and continues to 
provide updates via monthly conference calls. The TAAs serve as the 
statewide point of contact and coordinator to facilitate access to VA 
health care and benefits and to provide assistance in accessing the 
Military Health System (TRICARE). TAAs assist National Guard with 
access to care and enrollment at local VA health care facilities. While 
the program was set up primarily to take care of Guard members and 
their families, TAAs provide critical support and facilitate the 
delivery of VA and community services to all members of the active and 
reserve components.
    The DoD inTransition mental health coaching and support program 
provides counselors who are trained to assist and support 
Servicemembers making transitions from one location to another within 
DoD, as well as those who are transitioning from the DoD health care 
system to VA. Through telephone assistance, the Servicemember and 
family members work with a personal coach who provides advice, 
information about mental health care, location of resources, and 
assistance in connecting with new providers. The inTransition program 
operates 24-hours-a-day, 7-days-a-week, 365 days-a-year.
    The needs of the most severely injured Servicemembers and Veterans 
are also met through the Federal Recovery Coordination (FRC) Program. 
FRCs serve to ensure that severely injured Veterans and Servicemembers 
receive access to the benefits and care they need to recover. Since its 
creation in 2008, the FRC Program has helped Servicemembers and 
Veterans access Federal, State, and local programs, benefits and 
services, while supporting the families of these heroes through their 
recovery, rehabilitation, and reintegration into the community. 
Currently, 556 clients are enrolled and another 31 individuals are 
being evaluated for enrollment; an additional 497 have received 
assistance through FRC.
    Each VA medical center has an Operation Enduring Freedom/Operation 
Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Care Management team in 
place to coordinate patient care activities and ensure that 
Servicemembers and Veterans are receiving patient-centered, integrated 
care and benefits from the moment they begin receiving care in VA. 
Members of the OEF/OIF/OND Care Management team include a Program 
Manager, Clinical Case Managers, and a Transition Patient Advocate 
(TPA). The Program Manager, who is either a registered nurse or 
licensed social worker, has overall administrative and clinical 
responsibility for the team and ensure that all OEF/OIF/OND 
Servicemembers/Veterans are screened for case management. Those 
severely ill and/or injured are provided with a case manager and other 
OEF/OIF/OND Servicemembers and Veterans are assigned a case manager as 
indicated by a positive screening assessment or upon request. Clinical 
Case Managers, who are either registered nurses or licensed social 
workers, coordinate all patient care activities, using an integrated 
approach across all systems of care. The TPA helps the Veteran and 
family navigate VA's system by acting as a communicator, facilitator, 
and problem-solver.
    OEF/OIF/OND Care Management team members actively support outreach 
events in the community, such as annual `Welcome Home' events. OEF/OIF/
OND team members also participate in the demobilization process, the 
Yellow Ribbon Reintegration Program events, Post-Deployment Health 
Reassessment events, and Individual Ready Reserve musters. Local VAMC 
OEF/OIF/OND staff regularly make presentations to community partners, 
Veterans Service Organizations, colleges, employment agencies, and 
others to collaborate in providing services and connecting with 
returning Servicemembers and Veterans.
    Since many returning OEF/OIF/OND Veterans are connected to more 
than one specialty case manager, VA introduced a new concept of a 
``lead'' case manager. The lead case manager now serves as a central 
communication point for the patient and his or her family. Case 
managers maintain regular contact with Veterans and their families to 
provide support and assistance to address any health care and 
psychosocial needs that may arise. The OEF/OIF/OND Care Management 
program now serves almost 54,000 Servicemembers and Veterans, including 
6,400 who are severely injured.

    Question 16: The mission of the National Center for PTSD is to 
advance the clinical care and social welfare of America's Veterans 
through research, education, and training in the science, diagnosis, 
and treatment of PTSD and stress-related disorders. What are VA's 
future research priorities as they relate to the treatment of PTSD?

    Response: A major goal of all National Center for PTSD (NCPTSD) 
research is to develop and test the most effective treatments for PTSD. 
In order to design the best treatments, it is essential to conduct a 
broad array of research that advances the scientific understanding of 
PTSD. NCPTSD investigators also seek to improve accuracy and efficiency 
in the assessment and diagnosis of PTSD through development of the best 
assessment instruments. Finally, ongoing collaborations with the 
military seek to understand basic mechanisms underlying resilience in 
order to develop effective preventive strategies. Here is a list of the 
National Center's research priorities in these areas.

          Advancing knowledge concerning evidence-based 
        treatments through multi-site and single-site trials of 
        psychotherapy, pharmacotherapy and the combination. Utilizing 
        VA's Cooperative Studies Program, NCPTSD has carried out large-
        scale multisite clinical trials testing: Prolonged Exposure 
        Therapy (PE), group therapy, and risperidone augmentation of 
        first line (selective serotonin reuptake inhibitor, SSRI) 
        pharmacotherapy. A recent multisite trial also tested delivery 
        of PTSD treatment in primary care settings. Smaller, no less 
        rigorous, single-site trials have tested cognitive processing 
        therapy (CPT), telehealth delivery of evidence-based 
        psychotherapy, complementary and alternative medicine (CAM) 
        trials such as mindfulness and yoga, telephone-based care 
        monitoring, and Internet-based treatment and self-management 
        regimens for Veterans and military personnel. Since PTSD is 
        often accompanied by at least one other co-occurring disorder, 
        NCPTSD research has focused on clinical trials for various 
        comorbid conditions: PTSD and substance use disorders (SUD), 
        PTSD and traumatic brain injury (TBI), and PTSD and pain.
          Advancing our scientific understanding of the causes 
        and biobehavioral abnormalities associated with PTSD. Such 
        research has included structural and functional brain imaging 
        to understand abnormalities in neurocircuitry associated with 
        PTSD. Genetic research has focused on identification of genes 
        that confer either vulnerability or resilience among Veterans 
        with PTSD. Molecular research investigates PTSD-related 
        alterations in neuronal function and how they promote hormonal 
        and physiological abnormalities associated with the disorder. 
        Psychological and behavioral research focuses on how veterans 
        with PTSD change their appraisals of environmental stimuli and 
        how such misperceptions affect behavior and functional 
        capacity. Finally, research on cognitive deficits associated 
        with PTSD is not only important in its own right, but also 
        helps to understand how the combination of PTSD and TBI might 
        affect intellectual performance and memory.
          Developing reliable and valid assessment tools for 
        assessing PTSD diagnosis, symptom severity and response to 
        treatment as well as measurement of functional status. Such 
        tools are intended for use in clinical settings, research and 
        for evidence-based compensation and disability assessment. 
        NCPTSD has developed some of the major instruments currently 
        used in PTSD diagnosis, treatment and research such as the 
        Clinician Administered PTSD Scale (CAPS), generally 
        acknowledged as the gold standard in the field), the PTSD 
        Checklist (PCL used widely in VA and DoD clinical and research 
        settings) and the Primary Care PTSD Scale (PC-PTSD) used in all 
        VA (and many DoD) primary care settings. Currently, NCPTSD is 
        involved in a multisite trial to see whether utilization of the 
        CAPS for Compensation and Pension exams will improve the 
        quality of such exams. Preliminary efforts are underway to 
        modify current instruments in order to incorporate revisions in 
        the PTSD diagnostic criteria that will go into effect in 2013 
        when the American Psychiatric Association releases a new 
        revision of the Diagnostic and Statistical Manual of Mental 
        Disorders (DSM-5).
          The above research activities are currently being 
        extended to understand how gender, ethnocultural differences, 
        and advancing age might affect post-traumatic reactions as well 
        as influencing the validity of assessment and the response to 
        different treatments.
          In collaboration with military colleagues, ongoing 
        research is leading to a better understanding of resilience at 
        both the molecular and behavioral level. For example, NCPTSD 
        investigators have identified two molecules, produced by the 
        brain (Neuropeptide Y) and adrenal cortex 
        (dehydroepiandosterone, DHEA), respectively, which improve 
        performance under stress and appear to be related to 
        resilience.
          Finally, NCPTSD research is exploring the 
        relationship between PTSD and medical illnesses. Although not 
        directly related to PTSD treatment, per se, such research is 
        directly relevant to growing evidence that PTSD is an important 
        risk factor for medical illnesses. Conclusive findings, in this 
        regard, would have a major impact on strategies to screen and 
        treat Veterans with PTSD in the primary care setting where a 
        holistic approach to treatment is often most beneficial.

    Question 17: What progress has the VA made in implementing the 
Mental Health Strategic Plan (MHSP)?

          VSOs note that all action items have not been 
        implemented. What is the VA's response to these concerns?
          How does the VA know that MHSP was a success and 
        helped to improve mental health care for our veterans?

    Response: The Mental Health Strategic Plan is no longer an active 
document. It was originally developed in FY 2004, approved in FY 2005, 
and implemented from FY 2005 to FY 2008. By the end of FY 2008, 
implementation on the Mental Health Strategic Plan was complete and 
lessons learned in that process were incorporated into the development 
of VHA Handbook 1160.01--Uniform Mental Health Services inn VA Medical 
Centers and Clinics, which was released in 2008 and defined minimum 
clinical requirements for VHA Mental Health Services throughout the VA 
health care system. VA has made steady progress in implementation of 
the Uniform Mental Health Services Handbook. Specifically, 
implementation rates of the Handbook have increased 5.8 percent between 
August 2009 and June 2010. The current rate of implementation of the 
VHA Uniform Mental Health Services Handbook across networks is 92 
percent.
    You indicate that VSOs have noted that not all action items in the 
Mental Health Strategic Plan have been implemented, but that is not the 
case--the plan was fully implemented. We assume you mean that VSOs note 
that not all components of the Uniform Mental Health Services Handbook 
have been implemented, which is correct. To address this issue, the 
OMHS and the Office of Mental Health Operations are providing technical 
assistance to assure that all networks achieve at least 95 percent 
implementation by second quarter, fiscal year 2012. Currently, two 
VISNS have > 95 percent implementation, 16 VISNS are between 89-95 
percent implementation, and three VISNs are between 83-89 percent.
    While VA is still in the process of working towards 95 percent 
implementation in 100 percent of VISNs, VA believes that the Uniform 
Mental Health Services Handbook has been an effective document, as the 
increasing rates of implementation have translated to additional mental 
health services being offered to Veterans and more Veterans accessing 
these services. Some specific examples that demonstrate the increase of 
access to services are:

        1.  The number of Veterans with a confirmed mental illness who 
        utilized VHA health services increased by 17.1 percent between 
        2008 and 2010;
        2.  The proportion of Veterans with a confirmed mental illness 
        who received mental health services in any specialty mental 
        setting increased by 1.2 percent between 2008 and 2010;
        3.  The number of unique veterans treated in an outpatient 
        mental health setting increased by 17.6 percent between 2008 
        and 2010; and
        4.  The number of mental health outpatient encounters increased 
        by 25.7 percent between 2008 and 2010.

    Question 18: There have been concerns raised here today and 
recently with the Subcommittee on Health concerning the ongoing cost of 
implementation of the Uniformed Services Handbook.
          What roles do you anticipate VA's stakeholders (e.g. 
        veterans themselves, Veterans Service Organization, and mental 
        health professional associations) to play in the final 
        implementation stages of the plan?

    Response: VA has been working with stakeholders as part of the 
implementation of the Uniform Services Handbook. The Handbook requires 
that each VISN and facility appoint mental health staff to liaise with 
various levels of governmental and non-profit service agencies, to 
establish and work with Veteran Consumer Councils, Veteran Service 
Organizations, and other agencies who work with Veterans or provide 
care for mental illness. The purpose of this requirement is to ensure 
that each VA facility is an integral part of its surrounding 
communities in planning, developing, and providing service delivery for 
mental health. Since many Veterans do not seek care with VA, VA also 
works with groups outside of VA to serve either as referral sources or 
to provide education about Veterans' mental health needs, thus 
expanding the reach of VA. OMHS has implemented regular meetings with 
representatives from Veterans Service Organizations (VSOs); mental 
health agencies including the National Alliance on Mental Illness 
(NAMI), the Depression and Bipolar Support Alliance (DBSA), and Mental 
Heath American (MHA)-; and mental health professional agencies such as 
the American Psychiatric Association, the American Psychological 
Association, the American Association of Marriage and Family 
Therapists, the National Board for Certified Counselors and the 
National Association of Social Workers. The purpose of the meetings is 
to exchange information between OMHS and the stakeholder groups and to 
encourage continued positive relations with those groups.
    In addition, Veteran Mental Health Councils (VMHC), also known as 
Consumer Councils, are strongly encouraged in the Handbook. The purpose 
of a council is to provide input regarding local mental health 
structures and operations and to share information with veterans, 
family members, and community representatives about local VA mental 
health programs and initiatives. Councils also promote the 
understanding and use of VA mental health services by all Veterans and 
their families. The councils are encouraged to be established and run 
by Veterans, and members may include Veterans, family members and 
community and VSO representatives. Although councils are independent of 
VA management, a VA staff liaison to the council facilitates 
communication with mental health and medical center leadership, VMHCs 
and the local VA work in partnership with each other to the benefit of 
both. Currently, there are 93 facility level VMHCs.

          Can VA quantify the resource levels needed to fully 
        implement the outstanding action items?

    Response: VA currently cannot quantify the exact resource 
requirements to fully implement the Uniform Mental Health Services 
Handbook, since resources are organized at the VISN level and there is 
no national roll-up. However, VA has estimated that, given the 
extensive mental health enhancements in staff already completed prior 
to adoption of the Handbook, that resources generally should already be 
available in the field for implementation. As part of the recent VA 
reorganization, the Office of Mental Health Operations was developed. 
This Office (in conjunction with OMHS) will be actively working with 
the VISNs on monitoring compliance and actively working to remove 
barriers and to facilitate implementation. The Mental Health Operations 
office oversees the MH Program Evaluation Centers, which are in the 
process of developing a comprehensive monitoring system to bring 
together in one place much of the previously reported information as 
well as to expand on the depth of the information to evaluate progress 
of implementation. Mental Health Operations will be developing 
interventions to assist in ensuring field compliance. In this process, 
information may be obtained about additional resources needed, but full 
implementation also will include needs for basic education about 
program development in transformational areas. We have started to work 
with the VISNs on getting better information about the barriers to 
implementation that can inform any needs for additional resources or 
redistribution of available resources.

          Have equipment, space, and personnel office needs of 
        the outstanding action items been recalculated in terms of 
        budget? Have VISN and local authorities allocated those 
        resources?

    Response: Equipment, space, and office needs were addressed 
extensively during the period of implementation of the Mental Health 
Strategic Plan, when staff were most rapidly being added to enhance 
mental health services. At this time, we expect that the issues are 
less about new resource needs of these kinds, and more about most 
effective utilization of available resources.

          Will other sources of funding be required at the 
        VISN, medical center and local levels to fully implement the 
        plan? If so, how much will be required? Is the funding set-
        aside through the Mental Health Enhancement Initiative 
        sufficient?

    Response: At present, we do not have enough information, as 
mentioned above, to specify what additional funding will be required, 
though we do not expect that to be the major obstacle. If funding is 
needed, there are no longer Mental Health Enhancement Initiative set 
aside funds, except for some designated to sustain national training 
programs and other national level efforts. Since FY 2010, funding from 
the VA mental health budget is sent directly to VISNs/facilities 
proportionately as a component of the Veterans Equitable Resource 
Allocation (VERA) process, without specific designation for mental 
health funds, and these funds are not currently tracked separately. 
Current monitoring efforts, as noted in several places, track 
functional measures, not dollars per se: resource availability, such as 
staff; service delivery to Veterans; and increasingly, tracking of 
outcomes for those receiving mental health services

    Question 19: How many VA mental health providers have been trained 
to provide evidence-based PTSD treatments? What is the average timeline 
for completing staff training nationally, and what are its elements?

    Response: As part of its effort to nationally disseminate and 
implement evidence-based psychotherapies (EBPs) for PTSD, VA has 
developed and actively implemented national programs to train VA staff 
in the delivery of Cognitive Processing Therapy (CPT) and Prolonged 
Exposure Therapy (PE) for PTSD. CPT and PE are recommended in the VA/
Department of Defense (DoD) Clinical Practice Guidelines for PTSD at 
the highest level, indicating ``a strong recommendation that the 
intervention is always indicated and acceptable.'' Moreover, in 2007, 
the Institute of Medicine (IOM) conducted a review of the literature on 
pharmacological and psychological treatments for PTSD and concluded in 
its report, Treatment of Posttraumatic Stress Disorder: An Assessment 
of the Evidence, that there was sufficient evidence to support the 
efficacy of these therapies. As of July 1, 2011, VA has provided 
training to over 3,500 VA staff in the delivery of CPT or PE, and many 
of these staff have been trained in both therapies.
    VA's CPT and PE training programs are competency-based training 
programs that involve intensive, highly experiential learning. The 
training model for these initiatives involves two key components 
designed to build skill mastery and promote successful implementation 
and sustainability: (1) participation in an in-person, experientially-
based, workshop, followed by (2) ongoing telephone-based clinical 
consultation on actual therapy cases with a training program consultant 
who is an expert in the psychotherapy, lasting approximately 6 months. 
The average timeline for completion of the overall training is 7-9 
months.
    The CPT and PE training workshops provide didactic and experiential 
training on the theoretical basis of PTSD, the specific therapy, 
assessment of PTSD and trauma-related symptoms prior to and during 
treatment, implementation of therapy components and processes (e.g., 
imaginal and in-vivo exposure for PE, cognitive restructuring for CPT), 
session structure, and logistical and practical implementation issues. 
The consultation phase that follows the training workshop provides in-
depth training and experience on the application of the therapy with 
actual therapy cases with an expert in the treatment who serves as a 
training consultant. The consultation further provides an opportunity 
for training participants to receive extensive feedback on their 
implementation of the therapy. The consultation has been shown to be a 
critical component to this competency-based training. Initial program 
evaluation results indicate that the CPT and PE training and 
implementation of the therapies has resulted in significant positive 
outcomes for both therapists and patients (Karlin et al., 2010).

                                 
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