[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
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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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Treating acute stress disorder following mild traumatic brain injury.
American Journal of Psychiatry, 160, 585-587.
3. Cohen BE, Marmar C, Ren L, Bertenthal D, Seal KH. Association
of cardiovascular risk factors with mental health diagnoses in Iraq and
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2009;302(5):489-492.
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Mental health diagnoses and utilization of VA non-mental health medical
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Intern Med. Jan 2010;25(1):18-24.
5. Foa, E., Hembree, E., & Rothbaum, B. (2007). Prolonged
exposure therapy for PTSD: Emotional processing of traumatic
experiences: Therapist guide. Oxford: Oxford University Press.
6. Frayne SM, Chiu VY, Iqbal S, et al. Medical Care Needs of
Returning Veterans with PTSD: Their Other Burden. J General Intern Med.
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7. Gawande, A. (2004). Casualties of war--Military care for the
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351, 2471-2475.
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Marmar CR, et al. Trauma and the Vietnam War Generation: Findings from
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14. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender
differences in mental health diagnoses among Iraq and Afghanistan
veterans enrolled in veterans affairs health care. Am J Public Health.
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15. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment
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16. Monson, C., Schnurr, P., Resick, P., Friedman, M., Young-Xu,
Y., & Stevens, S. (2006). Cognitive processing therapy for veterans
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Consulting and Clinical Psychology, 74, 898-907.
17. Possemato K, Ouimette P, Lantinga LJ, Wade M, Coolhart D,
Schohn M, Labbe A, Strutynski K. Treatment of Department of Veterans
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Psychol Services. 2011 Vol 8(2):82-93.
18. Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR.
Getting beyond ``Don't ask; don't tell'': an evaluation of U.S.
Veterans Administration postdeployment mental health screening of
veterans returning from Iraq and Afghanistan. Am J Public Health. Apr
2008;98(4):714-720.
19. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar
CR. Trends and risk factors for mental health diagnoses among Iraq and
Afghanistan veterans using Department of Veterans Affairs health care,
2002-2008. Am J Public Health. Sep 2009;99(9):1651-1658.
20. Seal KH, Cohen G, Waldrop A, Cohen B, Maguen S, Ren L.
Substance use disorders in Iraq and Afghanistan Veterans in VA health
care, 2001-2010: Implications for screening, diagnosis, and treatment.
Drug Alcohol Depend. 2011 Jul 1;116(1-3):93-101.
21. Seal KH, Cohen G, Bertenthal D, Cohen BE, Maguen S, Daley A.
Reducing Barriers to Mental Health and Social Services for Iraq and
Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic. In
Press. Journal of General Internal Medicine.
22. Solomon Z, Mikulincer M. Trajectories of PTSD: a 20-year
longitudinal study. Am J Psychiatry 2006;163(4):659-66.
23. Spoont MR, Murdoch M, Hodges J, Nugent S. Treatment receipt by
veterans after a PTSD diagnosis in PTSD, mental health, or general
medical clinics. Psychiatr Serv. 2010 Jan;61(1):58-63
24. Tanielian TL, Jaycox LH, eds. Invisible wounds of war:
Psychological and cognitive injuries, their consequences, and services
to assist recovery. Santa Monica, CA: RAND Corporation; 2008.
25. Wang, P., Berglund, P., Olfson, M., Pincus, H., Wells, K., &
Kessler, R. (2005). Failure and delay in initial treatment contact
after first onset of mental disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62, 603-613.
26. Zeiss, A., & Karlin, B. (2008). Integration of mental health
and primary care services in the Department of Veterans Affairs Health
Care System. Journal of Clinical Psychology in Medical Settings, 15,
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\
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\1\ Veterans' Disability Benefits Commission. Honoring the Call to
Duty: Veterans' Disability Benefits in the 21st Century, Oct. 2007 p.
3.
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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).
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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\
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\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.
---------------------------------------------------------------------------
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.
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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\
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\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.
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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.
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\25\ National Academy of Public Administration, ``After Yellow
Ribbons: Providing Veteran-Centered Services,'' October 2008, p. ix.
\26\ Ibids.
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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\
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\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.
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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.
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\29\ Social Security Administration. ``Benefit Offset Pilot
Demonstration--Connecticut Final Report.'' September 2009, Accessed at:
http://www.ssa.gov/disabilityresearch/offsetpilot.htm.
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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).
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\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].
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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\
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\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.
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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\
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\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
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II-G19. NUCLEAR MEDICINE TECHNOLOGIST II-G19-1
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II-G20. DIETITIAN II-G20-1
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II-G21. KINESIOTHERAPIST II-G21-1
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II-G22. OCCUPATIONAL THERAPY ASSISTANT II-G22-1
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II-G23 PHYSICAL THERAPY ASSISTANT II-G23-1
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II-G24. MEDICAL TECHNOLOGIST II-G24-1
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II-G25. DIAGNOSTIC RADIOLOGIC TECHNOLOGIST II-G25-1
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II-G26. THERAPEUTIC RADIOLOGIC TECHNOLOGIST II-G26-1
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II-G27. MEDICAL INSTRUMENT TECHNICIAN II-G27-1
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II-G28. PHARMACY TECHNICIAN II-G28-1
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II-G29. AUDIOLOGIST II-G29-1
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II-G30. SPEECH LANGUAGE PATHOLOGIST II-G30-1
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II-G31. AUDIOLOGIST/SPEECH LANGUAGE II-G31-1
PATHOLOGIST
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II-G32. ORTHOTIST-PROSTHETIST II-G32-1
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II-G33. MEDICAL RECORD ADMINISTRATOR II-G33-1
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II-G34 PROSTHETIC REPRESENTATIVE II-G34-1
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II-G35. MEDICAL RECORD TECHNICIAN II-G35-1
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II-G36. DENTAL ASSISTANT II-G36-1
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II-G37. DENTAL HYGIENIST II-G37-1
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II-G38. BIOMEDICAL ENGINEER II-G38-1
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II-G39. SOCIAL WORKER II-G39-1
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II-G40. BLIND REHABILITATION SPECIALIST II-G40-1
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II-G41. BLIND REHABILITATION OUTPATIENT II-G41-1
SPECIALIST
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[II-G42. MARRIAGE AND FAMILY THERAPIST II-G42-1
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II-G43. LICENSED PROFESSIONAL MENTAL HEALTH II-G43-1]
COUNSELOR
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II-H APPOINTMENT PROCEDURES BY OCCUPATION/
ASSIGNMENT
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II-H1. PROCEDURES FOR APPOINTING PHYSICIANS II-H1-1
TO SERVICE CHIEF AND COMPARABLE
POSITIONS
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II-H2. PROCEDURES FOR APPOINTING DENTISTS II-H2-1
AND EFDAS
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II-H3. PROCEDURES FOR APPOINTING PODIATRISTS II-H3-1
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II-H4. PROCEDURES FOR APPOINTING II-H4-1
OPTOMETRISTS
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II-H5. RECRUITMENT, APPOINTMENT, II-H5-1
ADVANCEMENT, CHANGE IN ASSIGNMENT
AND REASSIGNMENT OF REGISTERED
NURSES (RNs) IN GRADES IV AND V
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II-H6. PROCEDURES FOR APPOINTING NURSE II-H6-1
ANESTHETISTS TO SECTION CHIEF
POSITIONS
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II-H7. PROCEDURES FOR APPOINTING PHYSICIAN II-H7-1
ASSISTANTS AT CHIEF GRADE
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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
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II-H9. PROCEDURES FOR APPOINTING II-H9-1
OCCUPATIONAL AND PHYSICAL THERAPISTS
AS SECTION CHIEF
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II-H10. PROCEDURES FOR APPOINTING DOCTORS OF II-H10-1
CHIROPRACTIC
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II-I. ENGLISH LANGUAGE PROFICIENCY II-HI-1
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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
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II-K. RCVL (RESIDENT/TRAINEE CREDENTIALS II-K-1
VERIFICATION LETTER)
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II-L. CREDENTIALING CHECKLIST II-L-1
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II-M. SAMPLE CONSULTANT CERTIFICATE II-M-1
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II-N. CAREER INTERN PROGRAM II-N-1
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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).