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




                         [H.A.S.C. No. 112-62]

                     THE CURRENT STATUS OF SUICIDE

                  PREVENTION PROGRAMS IN THE MILITARY

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                           SEPTEMBER 9, 2011











                                  _____

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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                  JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
MIKE COFFMAN, Colorado               ROBERT A. BRADY, Pennsylvania
TOM ROONEY, Florida                  MADELEINE Z. BORDALLO, Guam
JOE HECK, Nevada                     DAVE LOEBSACK, Iowa
ALLEN B. WEST, Florida               NIKI TSONGAS, Massachusetts
AUSTIN SCOTT, Georgia                CHELLIE PINGREE, Maine
VICKY HARTZLER, Missouri
               Jeanette James, Professional Staff Member
                 Debra Wada, Professional Staff Member
                      James Weiss, Staff Assistant












                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2011

                                                                   Page

Hearing:

Friday, September 9, 2011, The Current Status of Suicide 
  Prevention Programs in the Military............................     1

Appendix:

Friday, September 9, 2011........................................    29
                              ----------                              

                       FRIDAY, SEPTEMBER 9, 2011
   THE CURRENT STATUS OF SUICIDE PREVENTION PROGRAMS IN THE MILITARY
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2
Wilson, Hon. Joe, a Representative from South Carolina, Chairman, 
  Subcommittee on Military Personnel.............................     1

                               WITNESSES

Bostick, LTG Thomas P., USA, Deputy Chief of Staff, G-1, U.S. 
  Army...........................................................     5
Jones, Lt. Gen. Darrell D., USAF, Deputy Chief of Staff for 
  Manpower and Personnel, U.S. Air Force.........................     7
Kurta, RADM Anthony M., USN, Director, Military Personnel, Plans, 
  and Policy, U.S. Navy..........................................     6
Milstead, Lt. Gen. Robert E., Jr., USMC, Deputy Commandant for 
  Manpower and Reserve Affairs, U.S. Marine Corps................     7
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for 
  Health Affairs.................................................     3

                                APPENDIX

Prepared Statements:

    Bostick, LTG Thomas P........................................    41
    Davis, Hon. Susan A..........................................    35
    Jones, Lt. Gen. Darrell D....................................    74
    Kurta, RADM Anthony M........................................    54
    Milstead, Lt. Gen. Robert E., Jr.............................    65
    Wilson, Hon. Joe.............................................    33
    Woodson, Hon. Jonathan.......................................    36

Documents Submitted for the Record:

    ``PTSD Cases Grow as Combat Continues for Fort Drum 
      Soldiers,'' by Daniel Woolfolk, Watertown Daily Times, 
      September 8, 2011..........................................    83

Witness Responses to Questions Asked During the Hearing:

    Mr. Coffman..................................................    89
    Mr. Jones....................................................    89
    Ms. Tsongas..................................................    89

Questions Submitted by Members Post Hearing:

    Ms. Bordallo.................................................   112
    Mrs. Davis...................................................    93
    Mr. Jones....................................................   103
    Ms. Tsongas..................................................   105
 
   THE CURRENT STATUS OF SUICIDE PREVENTION PROGRAMS IN THE MILITARY

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                         Washington, DC, Friday, September 9, 2011.
    The subcommittee met, pursuant to call, at 9:03 a.m. in 
room 2212, Rayburn House Office Building, Hon. Joe Wilson 
(chairman of the subcommittee) presiding.

  OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 
  SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mr. Wilson. Ladies and gentlemen, good morning.
    Today the subcommittee meets to hear testimony on the 
efforts by the Department of Defense and the military services 
to prevent suicide by service members, family members, and 
civilian employees.
    I want to preface my statement by recognizing the 
tremendous work the Department of Defense and the service 
leadership has done to respond to the disturbing trend of 
suicide in our Armed Forces. I understand this has not been an 
easy task, and I thank you for your hard work.
    I particularly see military service as an opportunity to be 
all that you can be. And I want service members to know they 
are talented people who are important and appreciated by the 
American people. They can overcome challenges.
    I am also grateful for Ranking Member Susan Davis' work she 
did as chairman of the Military Personnel Subcommittee to bring 
attention to the psychological stress in the military and the 
behavioral health needs of service members.
    With that said, clearly there is more work to be done. 
Suicide is a difficult topic to discuss. Every suicide is a 
tragedy, but suicide by members of our military is even more 
difficult because they have given so much to this Nation. 
Ultimately, it is an individual decision to take one's own 
life. But we must make sure every opportunity to redirect or 
change that decision is available before it is too late.
    Suicide is a multifaceted phenomenon that is not unique to 
the military. Unfortunately, in addition to the unique 
hardships of military service, our military members are subject 
to the same pressures that plague the rest of society. They are 
exposed to the same stressors, such as the current unemployment 
and economic situation, that may lead to suicide by their 
civilian counterparts. I am very concerned those stressors will 
only get worse in the coming months, as debate regarding cuts 
to the Department of Defense budget intensifies.
    Each of the military services and the Department of Defense 
has adopted strategies to reduce suicide by our troops. I would 
like to hear from our witnesses whether those strategies are 
working. What are your benchmarks for success? How do you 
determine whether your programs incorporate the latest research 
and information on suicide prevention? I am also interested to 
know how Congress can further help and support your efforts.
    With that said, I want to welcome our witnesses, and I look 
forward to your testimony.
    Before I introduce our panel, let me offer Congresswoman 
Susan Davis from San Diego an opportunity to make her opening 
remarks.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 33.]

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mrs. Davis. Thank you. Thank you, Mr. Chairman.
    I am pleased that this subcommittee is maintaining its 
attention on suicides in the military. Over the past several 
years, as we have seen the number of suicides by service 
members grow, the subcommittee has been forward-leaning in 
attempting to support the services and the Department of 
Defense in their efforts to develop a strategy to reduce and 
prevent suicides in the force.
    Mr. Chairman, I want to acknowledge particularly your 
opening comments that this is a very difficult, a very 
emotional, and yet a very important issue for us all to deal 
with. Every suicide, as you said, is a tragedy. But I think for 
the families the pain of suicide doesn't go away, and we need 
to acknowledge how tremendously difficult that is for all 
involved.
    Suicide in the military has been a focal point for this 
subcommittee, but we are not the only ones focused on this 
issue. In 2007, suicide was the third leading cause of death 
for young people ages 15 to 24. While our forces share this 
demographic, it is important that we share what we learn and 
what is learned by others if our country is to be successful in 
addressing this societal issue.
    The subcommittee's efforts have included the establishment 
of the Department of Defense Task Force on the Prevention of 
Suicide by Members of the Armed Forces in the Duncan Hunter 
National Defense Authorization Act of Fiscal Year 2009. The 
task force, comprised of 14 individuals, civilians and 
military, with expertise in national suicide-prevention policy, 
military personnel policy, research in the field of suicide 
prevention, clinical care and mental health, and other similar 
backgrounds, submitted their final report in August of 2010.
    There were 76 recommendations made by the task force, the 
majority of which were directed at the Department of Defense 
and the Services. I am interested in learning from the 
Department and the Services where they are in implementing many 
of these recommendations.
    So I want to welcome our witnesses. I look forward to 
hearing from them.
    And I want to welcome all of the members of the committee, 
of course.
    Thank you, Mr. Chairman.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 35.]
    Mr. Wilson. Thank you, Ms. Davis.
    We are joined today by an outstanding panel. We would like 
to give each witness the opportunity to present his or her 
testimony and each Member an opportunity to question the 
witnesses. I would respectfully remind the witnesses that we 
desire that you summarize, to the greatest extent possible, the 
high points of your written testimony in 3 minutes. I assure 
you your written comments and statements will be made part of 
the record.
    Let me welcome our panel: the Honorable Jonathan Woodson, 
M.D., Assistant Secretary of Defense for Health Affairs; 
Lieutenant General Thomas P. Bostick, U.S. Army, Deputy Chief 
of Staff, G-1, U.S. Army; Rear Admiral Anthony M. Kurta, 
director of military personnel, plans, and policy, U.S. Navy; 
Lieutenant General Robert E. Milstead, Jr., USMC, deputy 
commandant for manpower and reserve affairs, U.S. Marine Corps; 
Lieutenant General Darrell D. Jones, U.S. Air Force, deputy 
chief of staff for manpower and personnel of the U.S. Air 
Force.
    Admiral Kurta, since this is your first time appearing 
before the subcommittee, I want to give you a special welcome. 
It is good to have you join us today on this very important 
issue.
    I now ask unanimous consent that Ms. Chu of California and 
other committee and non-committee members, if any, be allowed 
to participate in today's hearing after all subcommittee 
members have had an opportunity to ask questions. Is there any 
objection?
    Without objection, non-subcommittee members will be 
recognized at the appropriate time for 5 minutes.
    And we shall now proceed with Dr. Jonathan Woodson.

 STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY 
                 OF DEFENSE FOR HEALTH AFFAIRS

    Secretary Woodson. Thank you, Mr. Chairman.
    Mr. Chairman, Ranking Member Davis, distinguished members 
of the subcommittee, thank you for the opportunity to appear 
before you today to update you on the Department of Defense's 
ongoing efforts to prevent suicides in the Armed Forces.
    We all know the facts. The rate of suicide among members of 
the Armed Forces has steadily increased over the last 10 years. 
And after many years in which the rate of suicide among 
military members was below the rate of the civilian population, 
over the last 3 years we have seen suicide rates for service 
members approach the civilian-sector experience. In fact, when 
updates to the civilian population rates are made available, we 
may even see that they exceed the adjusted civilian rates.
    The Department has invested tremendous resources to better 
understand how to identify those at risk of suicide, treat the 
at-risk individuals, and prevent suicide. We continue to seek 
the best minds from both within our ranks, from academia, other 
Federal health partners, and the private sector to further our 
understanding of this complex set of issues.
    One example of our research agenda is the Army Study to 
Assess Risk and Resilience in Service members, or Army STARRS, 
program. This is the largest single epidemiologic research 
effort ever undertaken by the Army and is designed to examine 
mental health, psychological resilience, suicide risk, suicide-
related behaviors, and suicide deaths.
    Renowned experts from the Uniformed Services University of 
the Health Sciences, the University of California, the 
University of Michigan, Harvard, and the National Institute of 
Mental Health are conducting retrospective and prospective 
studies of approximately 90,000 Active Duty soldiers to 
evaluate the relationship between soldiers' characteristics and 
experiences to subsequent psychological health issues, suicidal 
behavior, and other relevant outcomes.
    We are working exceptionally closely with other colleagues 
across Federal Government. With the Department of Veterans 
Affairs, we are developing shared clinical practice guidelines 
for providers in both organizations that use evidence-based 
guidelines for assessment and prevention of suicidal behavior. 
We are working with the Substance Abuse and Mental Health 
Services Administration in HHS [Department of Health and Human 
Services] to increase access to critical services for members 
of our Reserve and Guard communities. We continue to benefit 
from the addition of over 200 mental health professionals from 
the Public Health Service who are providing critical resource 
support in our medical facilities. And we have taken steps 
through our TRICARE [health care program] network to also 
expand access to services in our civilian communities.
    Within the Department, we have amended medical doctrine and 
embedded our mental health professionals far forward in-theater 
to provide care in the theater of operation. We have modified 
our electronic health record, AHLTA [Armed Forces Health 
Longitudinal Technology Application], to securely share needed 
information on at-risk individuals so that the entire care team 
understands the diagnosis and treatment plan and can 
communicate more effectively. And we are standardizing the 
collection and analysis of suicide data to better inform our 
prevention strategies.
    As important as any step, we have also made great attempts 
to remove stigma from seeking mental health services--a stigma 
that is common throughout society and not just in the military. 
This is a long-term effort, but both senior officers and 
enlisted leaders are speaking out with a common message. We are 
encouraged by the increased willingness of service members to 
seek professional help when it is recommended, and we continue 
to emphasize this message through every communication vehicle 
at our disposal.
    Suicide prevention involves far more than medical 
intervention. The efforts I have discussed today represent the 
input and involvement of multidisciplinary organizations across 
the Department of Defense, led by the Deputy Assistant 
Secretary for Readiness.
    While we have made real progress, there is much to be done. 
We have identified risk factors for suicide and factors that 
appear to protect an individual from suicide. As you well 
understand, the interplay of these factors is very complex. Our 
efforts are focused on addressing solutions in a comprehensive 
and holistic manner.
    Mr. Chairman, members of the subcommittee, your interest in 
and support for our efforts has been invaluable. I thank you 
again for the opportunity to share with you the progress we 
have made in addressing this very difficult and heartbreaking 
matter, and I look forward to your questions.
    [The prepared statement of Secretary Woodson can be found 
in the Appendix on page 36.]
    Mr. Wilson. Thank you very much, Doctor.
    Next, we have General Thomas Bostick.

STATEMENT OF LTG THOMAS P. BOSTICK, USA, DEPUTY CHIEF OF STAFF, 
                         G-1, U.S. ARMY

    General Bostick. Chairman Wilson, Ranking Member Davis, 
distinguished members of the subcommittee, thank you for the 
opportunity to appear here today to provide the status of the 
United States Army's ongoing efforts to reduce the number of 
suicides across our force.
    On behalf of our Secretary, the Honorable John McHugh, and 
our chief of staff, General Ray Odierno, I would also like to 
take this opportunity to thank you for your continued strong 
support and demonstrated commitment to our soldiers, Army 
civilians, and their family members.
    Our Nation has been at war for nearly 10 years. That has 
undeniably put a strain on the men and women serving in the 
United States Army and their families. Many individuals have 
deployed multiple times, and many have suffered the visible and 
the less visible wounds of war. This conflict continues to put 
a significant strain on our force. The most tragic indicator of 
this stress is the historically high number of suicides that we 
have experienced in recent years.
    We achieved modest success in reducing the number of 
suicides of soldiers serving on Active Duty this past year. We 
attribute this modest decrease in Active Duty suicides to the 
programs and policy changes that have been implemented since 
the establishment of the Health Promotion/Risk Reduction Task 
Force and Council in March of 2009. Our research is showing we 
are influencing soldiers serving on Active Duty and helping to 
mitigate the stressors affecting them.
    Conversely, it is much more difficult to do this for the 
Reserve Component soldiers not serving on Active Duty because 
they are often geographically removed from the support network 
provided by military installations. The challenge is that, in 
many cases, these soldiers have limited or reduced access to 
care and services as well as the oversight of a full-time chain 
of command.
    Over the past year, our commitment to health promotion, 
risk reduction, and suicide prevention has changed Army policy, 
structure, and processes. We have implemented a 
multidisciplinary approach and a team effort by leaders and 
soldiers at all levels, together with the Department of 
Defense, Congress, civilian health-care providers, research 
institutes, and care facilities, all to ensure that we are 
providing our soldiers with the most effective programs, 
treatment, and support. We still have much work to do.
    I assure the members of this committee that there is no 
greater priority for me and the other senior leaders of our 
United States Army than the safety and well-being of our 
soldiers. The men and women who wear the uniform of our Nation 
are the best in the world, and we owe them and their families a 
tremendous debt of gratitude for their service and their many 
sacrifices.
    Thank you again for this opportunity to appear before you 
concerning this important topic, and I look forward to your 
questions.
    [The prepared statement of General Bostick can be found in 
the Appendix on page 41.]
    Mr. Wilson. Thank you very much, General.
    And, again, it is an honor for the first time to have 
Admiral Kurta.

  STATEMENT OF RADM ANTHONY M. KURTA, USN, DIRECTOR, MILITARY 
            PERSONNEL, PLANS, AND POLICY, U.S. NAVY

    Admiral Kurta. Chairman Wilson, Ranking Member Davis, 
distinguished members of the subcommittee, thank you for the 
opportunity to discuss the Navy's efforts to promote the 
psychological health of our sailors and their families. 
Prevention of self-harm and suicide remains a high priority in 
the Navy, and we are grateful for your continued support of 
this critical issue.
    The loss of a single sailor to suicide is a tragedy deeply 
felt by all those who are left behind. Suicide takes away a 
future, shatters a family, and affects our unit cohesion and 
morale.
    From 2009 to 2010, we observed a decrease in our suicide 
rate. Regrettably, in 2011 we are seeing an increase over our 
rate from last year. In the face of high operational demands, 
we remain committed to fostering an environment where dealing 
with stress can be free of stigma and whereby seeking help is a 
sign of strength.
    Strengthening the resilience of our sailors and their 
families remains the cornerstone of our suicide-prevention 
efforts. Our Operational Stress Control and our Reserve 
Psychological Health Outreach programs and an integrated 
structure of health promotion, family readiness, and prevention 
programs are critical elements of our approach. We continue to 
adapt these programs to meet the needs of our sailors and their 
families.
    Our suicide-prevention efforts go well beyond these 
programs. We view suicide prevention as an all-hands, all-of-
the-time effort. It involves sailors, family members, peers, 
and leadership.
    One example is the Navy's Coalition of Sailors Against 
Destructive Decisions, a peer-to-peer mentoring program that 
empowers our most junior sailors to make responsible decisions 
and to reach out to their shipmates in need. Initiated in 2008, 
this program continues to grow, with more than 200 chapters 
across the Navy.
    Another example to raise awareness about suicide risk and 
ensure all sailors and their families have access to the 
resources they need 24 hours a day, every Navy Web site now 
includes a link to the National Suicide Prevention Lifeline and 
the Veterans Crisis Line.
    As a navy, we ask an incredible amount of our sailors and 
their families. In return, we remain committed to providing 
them with the level of support and care commensurate with their 
sacrifices.
    On behalf of the men and women of the United States Navy 
and their families, I extend my sincere appreciation to the 
committee and the Congress for your commitment to this issue 
and of your continued support to our Navy families.
    Thank you, and I look forward to your questions.
    [The prepared statement of Admiral Kurta can be found in 
the Appendix on page 54.]
    Mr. Wilson. Thank you very much, Admiral.
    General Milstead.

  STATEMENT OF LT. GEN. ROBERT E. MILSTEAD, JR., USMC, DEPUTY 
 COMMANDANT FOR MANPOWER AND RESERVE AFFAIRS, U.S. MARINE CORPS

    General Milstead. Good morning. Chairman Wilson, Ranking 
Member Davis, and distinguished members of the subcommittee, it 
is my privilege to appear before you today to discuss this 
critical issue.
    In 2010, we had an almost 30 percent decrease in our Marine 
Corps suicides from 52 to 37, and so far this year we are 
tracking even lower than in 2010. We are hopeful that this 
decrease represents the beginning of a downward trend, but we 
are not satisfied and will continue to aggressively implement 
and improve our suicide-prevention programs.
    Our main focus is building a resilient force and 
encouraging our marines to seek help early. Leaders at all 
levels of the Marine Corps are personally involved in efforts 
to help address and prevent future tragedies. As marines, we 
pride ourselves in taking care of our own. A marine struggling 
emotionally is a wounded comrade, and we don't leave our 
wounded on the battlefield.
    Thank you.
    [The prepared statement of General Milstead can be found in 
the Appendix on page 65.]
    Mr. Wilson. Thank you very much, General.
    And we now will be concluding with General Jones.

 STATEMENT OF LT. GEN. DARRELL D. JONES, USAF, DEPUTY CHIEF OF 
        STAFF FOR MANPOWER AND PERSONNEL, U.S. AIR FORCE

    General Jones. Chairman Wilson, Ranking Member Davis, and 
distinguished members of the subcommittee, thank you for the 
opportunity to appear before you today to represent the men and 
women, the officers, the enlisted, and the civilian airmen of 
the United States Air Force.
    Last year, 4,500 officers, 28,000 enlisted members, and 
18,000 civilians stepped forward to join the total force of 
more than 693,000 airmen. Each member plays a critical role in 
accomplishing the Air Force mission and supporting our national 
objectives. As we know, people are our most important asset, 
and we must do everything we can to take care of them so that 
they will take care of the mission.
    Despite our best efforts, regrettably, 56 total force 
airmen--officer, enlisted, and civilian combined--took their 
lives so far this year. Although that number of suicides is 
lower than the same period last year, it is still a major area 
of concern for our force as it sends ripples across the family, 
the unit, and the community.
    We have redoubled our efforts on post-suicide care at the 
unit level. In cooperation with our health-care professionals, 
we developed a comprehensive guide designed to assist leaders 
in their initial response. We are keenly aware that a proactive 
response by unit leadership plays a role in prevention of 
additional suicides and attempts.
    We are encouraged by over 370,000 documented mental health 
visits for Active Duty members in 2010. This number includes 
initial appointments as well as repeat visits. In addition to 
our comprehensive mental-health-care programs, we also offer 
care through chaplains, military family life consultants, and 
our Military OneSource.
    How we care for our airmen is continuing to evolve. 
Recently, the Air Force developed a resilience-based program 
called Comprehensive Airmen Fitness, focused on bolstering the 
strength of our airmen through physical, mental, spiritual, and 
social fitness. By doing this, we put our airmen in the best 
possible position to handle whatever life stressors they happen 
to face.
    We will continue to develop our programs and improve them. 
We know that as society changes so do our airmen, and it is 
important that our strategies for building resilient airmen 
continue to be as resilient and as flexible as our force.
    I assure you, the leadership of the United States Air Force 
is personally committed to addressing the tragedy of suicide. 
On behalf of the chief of staff of the United States Air Force, 
we appreciate your unfailing support in this area, and I look 
forward to taking your questions.
    [The prepared statement of General Jones can be found in 
the Appendix on page 74.]
    Mr. Wilson. Thank you very much, General.
    And we now will begin under the 5-minute rule of asking 
questions individually. A person above reproach, Jeanette 
James, will be keeping the time--and we know that she is 
accurate--beginning right now. And I am under the 5-minute 
rule.
    First of all, I would like to thank each of you. As you 
were presenting your situation, I could tell it was heartfelt; 
it is not just another duty as assigned. And it fulfills my 
view, having served 31 years in the military, of a military 
family. People really do care about each other. I see it as I 
get around the district. I run into people who truly are our 
lifelong friends.
    And then I was happy to point out to General Bostick that 
our fourth son, Hunter, was just commissioned Second 
Lieutenant, Combat Engineer. And so we have four sons serving 
in the military, and it is truly like a family. So I want to 
thank you for what you are doing.
    Particularly, General Milstead, I was impressed by the 
success of the Marine Corps. And beginning with you, which of 
your suicide-prevention programs do you think are having the 
biggest impact on preventing suicides by members of the 
military, family members, and civilians?
    And beginning with you, and then each can join in.
    General Milstead. Yes, sir. First of all, we are so 
hesitant to use the word ``successful.'' We don't know what we 
don't know. We are still trying to connect the dots. You know, 
after a disturbing increase in '08 and '09, as I mentioned, 
last year we did see a slight decrease. We remained, I would 
put it, cautiously optimistic.
    I would offer that it is really three things that jump 
right to mind. One is engaged leadership, especially at the NCO 
[noncommissioned officer] level. Our NCOs told us, give us this 
problem. And we are allowing them to deal with it, to a great 
degree. And I think that has borne some fruit.
    I would also say our efforts in unit cohesion, which is 
part of our resiliency effort, the sense of belonging. 
Especially, we started out with unit cohesion being trying to 
ensure that we had the adequate, you know, leaders-to-led ratio 
prior to a deployment. And we quickly discovered that it was on 
the backside of that deployment where it was even more 
important, as we have come to call the ``dark side,'' for at 
least 90 days when a young marine returns from a deployment and 
may have to dance with some dragons of things that he has seen.
    Our efforts in the resiliency, our four pillars of 
resiliency: the physical, you know, things like diet, life 
skills; the psychological; the social, back to unit cohesion, 
belonging, that sense of belonging, being with the unit; and 
then the ever-important, the spiritual. I mean, it is a 
holistic approach, how we look at this.
    And I would just sum it up, as many have mentioned, the 
word ``stigma,'' reducing stigma. Change the culture. It is 
okay--it is okay to hurt, it is okay to ask for help, it is 
okay to be less than 100 percent. And I would offer that that 
surmises where we are heading.
    Mr. Wilson. Thank you very much.
    Would anyone else like to respond to which program that you 
have seen progress?
    General Bostick. Mr. Chairman, I would say I agree with my 
brother Marine Corps brethren there, that talking about success 
with suicides, unless you have no suicides, is really not 
appropriate. This is a complex problem; it has no simple 
solutions.
    I think what our leadership has done, both at OSD [Office 
of the Secretary of Defense] and the Army, is to try to better 
understand the problem and then to get the leadership involved 
at every level in what we learn from those conversations, what 
we learn from our monthly reviews of these suicides.
    And our vice chief of staff, General Chiarelli, has led a 
15-month study to really understand this, and published a book. 
And one of the things it talked about was the lost art of 
leadership and the lack, due to our rotation, due to the 
OPTEMPO [operations tempo] of our force coming in and out of 
Iraq and Afghanistan and not having the frontline leader able 
to help manage and work and understand the challenges of the 
individual soldier.
    So our main point is to reduce the stressors on these 
individuals, these soldiers, by increasing their resiliency, by 
ensuring that, as we talked about, we reduced the stigma and 
that we reduce high-risk behavior. But it is a complex issue, 
and we are tackling it on all fronts.
    Mr. Wilson. Well, again, I appreciate all of your efforts, 
and you are making a difference.
    In accordance with the 5-minute rule, Congresswoman Susan 
Davis of San Diego.
    Mrs. Davis. Thank you, Mr. Chairman.
    I would like to go to you, Dr. Woodson, and ask, in further 
detail--I think you certainly referenced some of this, but the 
Military Suicide Research Consortium has a number of proposals, 
targeted priority research areas.
    What do you believe we could really achieve in some of 
these research areas, and what do you think that they should 
be? Do you think they should be--or anybody on the panel--
different from, perhaps, what you think they are looking at? 
Are we looking at the right things?
    Secretary Woodson. Well, thank you for that question.
    And I think the first point to put out is, there is much 
that we don't know about suicide, factors that put individuals 
at risk, and factors that are protective.
    You know, we commissioned a study by RAND to try and 
catalog, of course, all of the suicide-prevention programs that 
we have within the services and within the Department of 
Defense. And one of the things we realized is that we don't 
have enough metrics against these programs to properly evaluate 
them so that we know which ones work and which ones don't. And 
one of the things we have to really be careful of in a 
resource-constrained environment is that we don't fund programs 
that are not effective and we allow others that would be 
effective to wither on the vine. So one of the clear issues for 
our research is to put metrics against these programs and 
evaluate them over time.
    I think that the issue is that, if you look over the 
literature, there are some programs that seem to work better 
than others. The Air Force has a program, which has been 
evaluated, in which individuals which particularly have gotten 
into legal difficulty and taken into custody are at risk, and 
ensuring that they get properly evaluated for their suicide 
risk is very important.
    We know some information out of the New York City Police 
Department, for example, that peer-to-peer programs seem to 
work, so that when an individual can confidentially go to 
someone who has been trained to recognize when an individual is 
at risk for suicide, allow them to talk to a peer, and then 
also secure any means with which they might commit suicide, a 
weapon, that becomes very important in trying to prevent 
suicide.
    The other issue that we know about is that having access to 
mental health care, and, more importantly, high-quality mental 
health care, by mental health professionals who understand how 
to evaluate for suicide risk and treat that appropriately also 
seems to be very important.
    So, in summary, I think the issue is that we need to spend 
our research efforts intensively looking at the broad programs 
that are out there, making sure that they have metrics so that 
we can define what success looks like.
    Mrs. Davis. As you mentioned on the metrics--and perhaps 
others can weigh in on this--how do we really assess the 
climate for people seeking help within their environment? How 
do you do that? How do you go about--leadership has been 
mentioned, certainly. But I am just wondering what kind of 
metrics you use to do that.
    Because that really is a problem. And I continue to hear, 
no matter how much we talk about stigma, people fear for their 
careers and that that is one reason that they don't seek help.
    Secretary Woodson. That is an excellent question. And we 
have some indirect indicators that we are getting at that issue 
by the number of behavioral health referrals that have gone up, 
the numbers of individuals who have actually sought care, and 
we have seen a tremendous increase.
    Now, the good news is that, in some sense, we see the 
numbers plateauing, so that what we are thinking is that we 
have enough capacity. But we have seen a dramatic increase in 
the number of referrals of people seeking care. So if that is 
an indirect indicator that people are reaching out, that is 
appropriate.
    Mrs. Davis. Thank you. I think my time is almost up, but I 
appreciate that and hope that we will join in the rest of the 
discussion. Thank you.
    Mr. Wilson. Thank you, Ms. Davis.
    We now proceed to Mr. Jones of North Carolina.
    Mr. Jones of North Carolina. Mr. Chairman, thank you very 
much.
    And I thank the panel for being here today.
    And, as many know, I have the privilege to represent the 
3rd District of North Carolina, the home of Camp Lejeune Marine 
Base, Cherry Point Marine Air Station, Seymour Johnson Air 
Force Base. We have done a tremendous amount--I want to give 
credit to a young man on my staff who served in the Marine 
Corps, Jason Lowry. The number of calls that we get from family 
members, from primarily Camp Lejeune--and, General, I want to 
commend the Marine Corps for seeing a reduction in the number 
of suicides at this point--sometimes is overwhelming for Jason.
    One area that through the years I have noted that he has 
brought to my attention--and, Dr. Woodson, this is for you, 
sir--is the medical board process. It seems that, too many 
times, that those--and I am sure it is probably true in the 
Army, as well--who come back with PTSD [post-traumatic stress 
disorder] or TBI [traumatic brain injury], and they do 
acknowledge--the command acknowledges that you have a problem, 
and many of these want to go ahead and move through the medical 
board process, and the complaint that we have been hearing, 
that maybe--maybe--leads to some suicides--I can't say it does, 
and I am not sure anyone on the panel can say it does. But the 
process itself, when it lingers, then that creates more of an 
environment for that individual to think about his or her 
problems and maybe sees that there is no help for them and they 
decide to take their life.
    Dr. Woodson, how do you feel with the medical review 
process across the board? Are you satisfied with the length of 
time that it takes for the board to come to a resolution on an 
individual, or do you see a problem there? Do you think it 
could be improved?
    That will be my first question. I have two.
    Secretary Woodson. Thank you very much for the question. 
And let me just say up front, there is definite room for 
improvement in the process.
    Let me just create, if you will, a context about the 
disability evaluation system and the medical evaluation board 
system. Historically, it was never designed as a system. It was 
a set of administrative processes and medical evaluations that 
were disconnected in two bureaucratic agencies, meaning 
Department of Defense and the Veterans Administration.
    With, of course, our recent experiences and with 10 years 
of war, it has become very clear that, in fact, it needs to be 
designed into a system so that you have a series of actions 
that feed into each other in an efficient way to produce the 
most rapid outcomes with the clearest decisions in support of 
our service members.
    What we have found is that there is room for improvement in 
the efficiency of the medical evaluations and in the 
administrative process. And we have made significant strides to 
coordinate the Department of Defense evaluation and 
adjudication with the Veterans Administration process to 
shorten the entire process. But there is more work to be done.
    I just want to address for a second the first part of your 
question, which has to do with the impact of mental health 
issues in this population. Many service members come into the 
medical evaluation process obviously for physical injury, but a 
substantial number of them have a co-morbid issue that relates 
to behavioral health, mental health, PTSD. And, in fact, we do 
bring substantial resources into this MEB [medical evaluation 
board] process to make sure that the mental health issues are 
evaluated. One of the things we have done is to bring more 
psychologists and psychiatrists into the process to complete 
the forensic evaluations, the forensic psychological 
evaluations, which has been shown to slow the process down.
    So we are working diligently on this, but much more work 
needs to be done. Thank you for that question.
    Mr. Jones of North Carolina. Mr. Secretary, thank you for 
your answer.
    And, if you would, just touch--I have about 19 seconds. You 
mentioned mental health professionals. Are the numbers, status 
current? Are they going up? Are more and more professionals 
coming into the military?
    Secretary Woodson. Again, thanks for that question because 
it allows me to highlight two points.
    One, we have done, I think, a very good job of bringing 
more behavioral health and mental health specialists. And we 
are really tracking in the high 90s to almost 100 percent when 
you look at the global numbers. And we can provide for the 
record, if you wish, the breakdown of these individuals.
    Mr. Jones of North Carolina. Please.
    [The information referred to can be found in the Appendix 
on page 89.]
    Secretary Woodson. But the important issue for committee 
members to recognize is that not every behavioral health 
specialist is the same, that we have different levels of 
competencies, from psychiatrists, psychologists, social work, 
mental health nurses, nurse practitioners. And, really, the job 
for us, the challenge for us, is using all of those 
professionals appropriately.
    And so the strategy that is being unrolled is to bring in 
to primary-care practices individuals who can appropriately 
screen individuals, embed mental health specialists in units 
where they can appropriately screen, and then save, if you 
will, our high-end specialists to treat the more complex 
problems. So it is not only a question of numbers, it is a 
question of the right distribution of specialists to make sure 
that we get the job done.
    Mr. Jones of North Carolina. Thank you, Chairman.
    Mr. Wilson. Thank you, Mr. Jones.
    We now proceed to Mr. Loebsack of Iowa.
    Mr. Loebsack. Thank you, Mr. Chair.
    Thanks to all of you for being here today, for your 
service, and for what you are trying to do to clearly deal with 
a significant problem within our military. And I think we can 
all agree that, as was mentioned, that even one suicide is too 
many. And I appreciate your take on what progress means, what 
success means, and going forward.
    As was mentioned, I think everybody here is all too aware 
that it is not just the Active Duty folks that we have to be 
concerned about, but it is the Reserve Components as well. And 
that was acknowledged, and I very much appreciate that, 
especially at a time when, I think it was mentioned too, we 
have a lot of economic problems--unemployment, what have you. A 
lot of these Reserve folks, these National Guard folks come 
home, they can't even find a job. Maybe their spouse has been 
put out of work. They have a lot of family issues.
    And what is interesting too, last year, half of the Army 
National Guard soldiers who committed suicide had never been 
deployed. So it is not just a deployment issue, although it is 
that too. In the case of the Iowa National Guard, we just had 
about 2,800 or so National Guard return from Afghanistan this 
summer. Many of them had been deployed multiple occasions. But, 
again, it is not just a deployment issue. I think that is 
something that we all need to acknowledge.
    We also know, as you mentioned, that it is particularly 
hard to get the Guard and Reserve folks because they don't have 
a base where they are located, where they would perhaps have 
access on a regular basis to mental health professionals.
    So it is a particular problem when it comes to the Reserve 
Component, so that is why I introduced my Embedded Mental 
Health Providers for Reserves Act. And thanks to the chairman 
and ranking member, we did get that incorporated into the 
National Defense Authorization Act. And that is designed, of 
course, to increase access on the part of our Reserve 
Components to behavioral professionals, whereas they wouldn't 
have that normally when they don't have a regular base that 
they are attached to.
    But if you would, Dr. Woodson, what is the military doing 
at the moment to try to reach those Reserve Components, in 
particular? And are we being successful with that? Is that 
access available? And are folks, in fact, taking advantage of 
whatever services there may be?
    Secretary Woodson. Thank you for the question. It is an 
extraordinarily important one. Our Reserve Component service 
members contribute so much to the defense of this Nation, and, 
clearly, they need not be forgotten in terms of all of their 
needs.
    My answer is along several lines. First of all, we do 
appropriate post-deployment screening to identify individuals 
at risk, and referrals are made. So, on the immediate front 
end, we do everything possible to identify individuals who 
might need care.
    But we know issues like PTSD and other mental health issues 
don't show up immediately. And, of course, we have transitional 
assistance medical care. They do get TRICARE benefits for 180 
days, and in cases where it is identified as service-connected, 
it can be extended.
    But, more importantly, we partnered with the Department of 
Veterans Affairs to really open up all of their assets and 
services, in terms of mental health services, to Reserve 
Component service members.
    Also established within the 54 States and territories are 
State behavioral health counselors, whose sole job it is to 
coordinate care for our Reserve Component service members and 
allow them to get access to care and to be, if you will, staff 
counselors to commanders to ensure that they have the 
appropriate programs and access to care.
    And then, finally, let me just say we have partnered with 
the Department of Veterans Affairs to address the issue of 
Reserve Component service members in rural areas by really 
enhancing the whole concept of tele-behavioral health. And this 
is a very interesting concept which will allow via Internet 
connection for someone who might be in crisis or have a problem 
to talk directly with a behavioral health specialist and get 
care. And preliminary results suggest that it is a very 
acceptable means to provide care.
    So, along a number of different lines we are trying to 
address this very important question.
    Mr. Loebsack. I appreciate that. I think it really 
important, too, that CBOCs [community-based outpatient clinic], 
you know, especially in rural areas like Iowa and other places, 
those CBOCs provide mental health care, as well. I think that 
is really critical.
    But, again, I want to stress that half of those suicides 
that happened were for folks who had not been deployed yet. You 
mentioned post-deployment. I think we have to think about pre-
deployment, too. And that is why I think it is important that 
we do embed mental health professionals or at least make sure 
that people are aware of the situation prior to deployment when 
they meet on the weekends when they get together, and their 
families as well.
    Thanks to all of you. I appreciate it.
    And thank you, Mr. Chair.
    Mr. Wilson. Thank you, Mr. Loebsack. As a former National 
Guard member, I appreciate your questions.
    We now proceed to Dr. Heck of Nevada.
    Dr. Heck. Thank you, Mr. Chair, for holding this hearing, 
and to Mrs. Davis for her continued interest and support on 
this important issue, and to the panel members for everything 
you are doing.
    This is, especially right now, a bit of a personal issue 
for me. I just had a soldier recently under my command commit 
suicide. And this happened--he was actually seen 2 hours 
earlier by another member of his unit. And both had been 
through the Army Reserve suicide-prevention training program. 
And his colleague did not recognize anything that was out of 
ordinary, and 2 hours later this other soldier took his own 
life.
    General Woodson--sorry, still calling you ``General.'' As 
people may remember, Secretary Woodson used to be my rater when 
he was General Woodson.
    I have copies, as I have seen, you know, the PDHA [Post-
Deployment Health Assessment] and the PDHRA [Post-Deployment 
Health Reassessment], which we use for post-deployment 
assessments and reassessments. And I guess it goes back to the 
issue of the stigma. And this is self-report. That is how we 
are doing it, is by self-reporting. And there are a lot of 
issues with self-reporting, one, because of the stigma, but, 
two, because a lot of folks know that if they check a box that 
is what is going to stand between them and getting home or 
getting back to their unit or getting their leave.
    So how are we looking at changing how we actually do these 
post-deployment assessments so that it is not so reliant on 
self-reporting when we know there is a lot of barriers to folks 
being forthcoming on self-reporting?
    Secretary Woodson. Thank you very much, Dr. Heck, for that 
question.
    You know, this is part of the difficulty and challenge of 
this problem. You can do periodic assessments, but what happens 
in between those assessments? So one issue is, we need to do 
them regularly to see if we can pick up individuals who have 
risk factors and then address them.
    But I really think the answer to the question is a very 
diligent, more robust, concerted, constant effort at educating 
the broader public, families who come in contact with 
individuals who might be at risk. Let me give you an example of 
what I am talking about.
    A couple of months ago, I was in my office, and we received 
a call. And one of my office staff took the call, and it was 
from a veteran who, on the surface, was inquiring about his 
pharmacy benefit, but, luckily, the staff member picked up on 
something that was not quite right and gave me the phone. And I 
engaged this veteran, who was very agitated and had, sort of, 
erratic thought.
    To make a long story short, this veteran was in another 
State, in Texas. And I was very concerned about the individual. 
And we held, collectively, the staff, this individual on the 
phone until we could get the emergency medical services to this 
individual. The individual was eventually hospitalized and 
taken care of.
    What am I really saying here? Is that all of us, no matter 
who we are, need to understand who is at risk, because it is 
going to be that personal encounter that you are going to pick 
up on something that will allow you to ask the question, care 
for the individual, and then escort the individual to 
treatment. I can't impress upon that enough, because any 
periodic assessment is going to create gaps.
    So I think that what the services have done in terms of 
raising the awareness, training leadership, training the 
enlisted officers and leadership, and training peers is so 
important in trying to address this issue.
    Dr. Heck. Thank you.
    General Milstead, in your written testimony, you briefly 
mentioned the pilot program, DSTRESS [Marine Corps 24/7 
counselor hotline]. And you mentioned that you are looking at 
perhaps rolling it out Corps-wide, which would make me think 
that there have been some indicators of success. Could you 
briefly talk a little bit about that program that you have done 
in conjunction with TriWest [Healthcare Alliance]?
    General Milstead. Yes, sir. And it kind of goes back to 
your question about the Reserves. You know, the further you get 
away from the flagpole, the little more challenging it becomes.
    The DSTRESS program was begun with TRICARE West as a pilot 
program. To date, they say maybe eight saves. But people will 
call, and it is a by-marine, for-marine. If you do Military 
OneSource, you are going to have to give your Social Security 
number. Marines, when we call the number, if we get a social 
worker or someone, they are going to know it is not a marine. 
But when there is a marine there or someone that talks marine, 
then they will open up. It goes back to that social pillar of 
resiliency.
    And we have been able to work on it, and we are indeed 
looking at expanding that. But we have not yet done that. But 
we are very, very happy with what we are seeing from that 
DSTRESS.
    Now, what is important to add is that DSTRESS, although it 
is TRICARE West, they will take a phone call from anybody. If a 
marine from Camp Lejeune gives them a call, or that area, they 
are going to talk to him and they are going to deal with him 
and take care of him.
    So, thanks for asking about that because that is going to 
be a challenge to continue that program fiscally and to expand 
it. But we are not about to lose the momentum that we have seen 
in it.
    Dr. Heck. Well, thank you. And I believe that that 
reinforces what Secretary Woodson talked about with the one-on-
one connection as opposed to just looking at a computerized, 
generated form. So thank you very much.
    Thank you, Mr. Chairman. I yield back.
    Mr. Wilson. Thank you, Dr. Heck.
    We now proceed, Ms. Tsongas of Massachusetts.
    Ms. Tsongas. Thank you, Chairman Wilson.
    And thank you all for being here and the extraordinary work 
you are doing to address this issue. We all know how very 
challenging it is.
    And we have been hearing some of the conversations about 
how to minimize the stigma associated with the seeking out 
help. And this summer, as we were back in our districts, I had 
the opportunity to meet with a young man who had just returned 
from Afghanistan. He was an extraordinary young man. I was so 
impressed by him. And his task had been to be the driver in the 
lead of the convoy whose job it was to go out and find IEDs 
[improvised explosive devices]. And so, as he had come back, he 
recognized he needed to get some help, that he was suffering 
from post-traumatic stress disorder. And he alluded to it, he 
said, you know, I know there is sort of still a stigma 
associated with it, but he recognized that he really did need 
to get some help.
    And just a quick story he told me was that because in that 
role he played his task was to drive very, very slowly, and as 
he was back in the civilian world out driving his family's car, 
he was stopped by a police officer, not because he was driving 
too fast, but because he was driving too slow.
    So it does take time for our young troops to come back and 
reintegrate and, sort of, absorb the fact that they are now in 
a very different environment. And I appreciate all of the work 
that you are doing to help them in that transition and to 
hopefully transition to a very safe place for them and for 
their families.
    But I wanted to ask a slightly different question. 
Secretary Woodson, in your written testimony, you have spoken 
about the importance of data collection through the Department 
of Defense Suicide Event Report system and how that data 
collection system helps the DOD [Department of Defense] target 
prevention strategies. And we have heard questions around just 
how important it is that we have real facts to sort of assess 
the work that you all are doing.
    But is the DOD currently collecting data on suicides among 
female service members? If it is, what are the findings? And is 
the DOD currently looking at a causal relationship between 
military sexual trauma and suicide? Because we do know--and it 
is another issue that this committee has had to deal with--the 
extraordinary prevalence of military sexual trauma.
    A study conducted by a researcher at Portland State 
University that was published in December 2010 found that 
female veterans, age 18 to 34, are 3 times as likely as their 
civilian peers to die by suicide. And we have anecdotal 
evidence of a number of suicide attempts that are related to 
military sexual trauma. As we are too painfully aware and as we 
often discuss here, as many as one in three women leaving 
military service report that they have experienced some form of 
military sexual trauma. In the civilian world, victims of 
sexual assault are four times as likely to contemplate suicide 
than people who have not experienced this kind of trauma.
    So, again, my question, in the context of data collection, 
are you looking at the prevalence of suicide among female 
veterans for service members and any causal relationship 
between being a survivor of military sexual trauma and suicide?
    Secretary Woodson. Thank you for that important question. 
And the answer is ``yes.'' We would hope, as the database 
matures, that we will be able to dissect out a number of 
different demographics and subgroups.
    As you know, there is a separate effort to look at the 
whole strategy about sexual assaults in the military. We do 
know that mental health problems arise at a much higher 
frequency in individuals who have experienced sexual abuse or 
sexual assault. And so we have redoubled our effort to make 
available to these individuals mental health counselors so that 
they can get the type of care that they need and assessed for 
their risk of suicide.
    To date--and I will take for the record--I have not heard 
of any directly related death by suicide as a result of sexual 
assault. But, as I said, I will take for the record to ensure 
that I am speaking true facts. But let me just say that we 
consider this a very important set of issues and will be 
examining this problem, as well.
    [The information referred to can be found in the Appendix 
on page 89.]
    Ms. Tsongas. But by gender you are not collecting data 
separately to, sort of, track the prevalence of--you know, the 
numbers, the men who are committing suicide versus the numbers 
of women?
    Secretary Woodson. Oh, yes.
    Ms. Tsongas. You are?
    Secretary Woodson. Yes.
    Ms. Tsongas. You are. So you are segregating the 
information by gender.
    Secretary Woodson. Yes.
    Ms. Tsongas. I would be interested to get a report on how 
that breaks down.
    Secretary Woodson. Sure.
    Ms. Tsongas. Thank you.
    Secretary Woodson. Absolutely.
    [The information referred to can be found in the Appendix 
on page 89.]
    Mr. Wilson. Thank you, Ms. Tsongas.
    We now proceed to Colonel West of Florida.
    Mr. West. Thank you, Mr. Chairman, and also, Ranking 
Member.
    And thanks to the panel for being here today.
    And I will kind of dovetail off of what my colleague Ms. 
Tsongas was talking about. I would like to look at, you know, 
some trend analysis here. Because as we sit down and look at 
some of these years, it seems that 2009, 2010, we definitely 
saw a little bit of a spike.
    So my first question would be, did we go back and maybe 
look at those years and maybe do an overlay with some previous 
combat operations, be it World War II, Korea, Vietnam, to look 
and see if there is some type of trend, some type of cultural, 
generational things that we could learn lessons learned from 
there?
    And then the second part of the question I would like to 
ask is, are we seeing a correlation between the length of 
combat tours and also the repetitiveness of combat tours? As 
well, do we see any trends with any certain MOSs [military 
occupational specialty] or certain units so that--I think it is 
so important, when we talk about these programs, maybe if we 
can identify certain types of trends, we can focus our 
resources to where we see a prevalence of these type of things 
occurring so that--you know, it is the difference between 
precision-guided munitions and carpet bombing. I guess that is 
what I am trying to get at.
    So those are my two questions, looking at trend analysis 
across our services as they deal with this problem.
    General Jones. Since you used an Air Force analogy, sir, I 
will jump in with that one.
    Sir, we have looked at our career fields to see which ones 
are more susceptible. And, obviously, we have discovered that 
our security forces, our aircraft maintenance, and our 
intelligence career fields have a higher incidence of suicide.
    To counter that, we have done specific supervisor training 
in those career fields. Because as we have all said, it is the 
person who is looking them in the eye. This is a leadership 
issue, not a medical issue, not a personnel issue, and the 
person who sees them every day at the officer level, at the NCO 
level, that has to look for what RAND describes is that trigger 
event. We all know the things that contribute to suicide--the 
legal problems, mental problems, alcohol abuse, things like 
that--but there is usually a trigger event that is overlooked 
when we go back to do an analysis of a suicide event.
    In the Air Force--I know it differs by service--it is not 
related to deployment, ironically. In fact, 68 percent of 
everyone in the Air Force who has committed suicide has never 
deployed. And of those who actually--of the small number who 
actually do commit suicide, only 10 percent of that small 
number were deployed in the last 6 months. And so, really, we 
can't find the direct causal relationship there.
    But we continue to look. The data has to be analyzed and 
read over and pored over, over, and over again. But we are 
trying to focus, in our service, on those career fields that 
tend to have a higher incidence. And I can tell you, 
specifically in security forces, they are paying great 
attention to this on the individual basis.
    General Milstead. We, too, sir, have taken a look at this 
and gone back through a forensic psychological autopsy, if you 
would, to look back. And to kind of dovetail on what my brother 
said, it is interesting: Only 3 of the past 100 suicides have 
any issue--hint of an issue with PTS. And in '08 and '09, which 
were our peak years for our suicides, less than 20 percent of 
those had ever seen combat.
    So it is almost counterintuitive here. Again, it goes back 
to, as we were talking about, we don't know what we don't know. 
And there are still these dots out there that we are trying to 
connect, and we are working pretty hard.
    General Bostick. The Army has also done a lot of deep 
analysis on the trends. And as we have talked about before, 
this is very complex. There is not one solution; there is not 
one type of person that you can say is going to commit suicide. 
Ninety-seven percent are males that commit suicide. Most of 
them are Caucasian. Most of them are in the range of 17 to 25.
    In previous years, we thought that, up until this year, 
that if you had one deployment--no deployments or one 
deployment, you were highly at risk. For example, in 2009, 
about 76 percent of those that committed suicide had one 
deployment. That is starting to change. This year, we are 
seeing those with multiple deployments starting to--that 
number, for the first time, is starting to increase. It is 
early. We don't know why that is happening, but we are looking 
at it very closely.
    But for us, it is the stressors: the work-related, 
financial and legal, and failed relationships. Those are the 
primary areas where much of the stress on individuals is 
focused and where we place a lot of our attention.
    Admiral Kurta. And, Congressman, I would just add, much 
like the Air Force, we do not see a causal relationship between 
the deployments and our suicide rate.
    I will say, though, that we have had seen a general 
correlation that after periods of great drawdown in the force, 
particularly in the Navy, the next year we often see a spike in 
our suicide rate. So we have seen that three times over the 
past 20 years. So it makes us remain ever-vigilant as we go 
into a period now here of potential end-strength reductions. 
But that is one of the factors that we have identified.
    Secretary Woodson. Just one quick comment on the first part 
of your question, about the historical comparisons. It is hard 
to do, simply because our thinking about mental health issues 
in the Second World War and Vietnam were so dramatically 
different. Remember, PTSD was defined really after Vietnam and 
given--and codified. And the criteria for making that diagnosis 
really came after that conflict.
    So, to be able to compare--and, culturally, we were in a 
different place in even recognizing and giving credence to this 
very important problem. So I don't know that we can make 
accurate historical comparisons that will help us in this 
effort.
    Mr. West. Thank you very much, panel.
    And thank you, Mr. Chairman. I yield back.
    Mr. Wilson. Thank you very much, Colonel.
    And we now proceed to Ms. Pingree of Maine.
    Ms. Pingree. Thank you very much, Mr. Chair.
    Thank you to the entire panel. We, I think, all appreciate 
your sensitivity and hard work on what is an excruciatingly sad 
issue. I think sometimes it is hard to picture that we are here 
talking about military suicide, those very people who served 
the country feeling so desperate about their own lives. And I 
appreciate, on the other hand, that we are here to talk about 
it and the work that you have done, as you say, to reduce the 
stigma, bring it out in the open, and try a whole variety of 
programs to make it work better. And I am impressed with both 
my colleagues' questions but also all the things that you have 
brought forward today.
    One thing I wanted to ask a little bit about--we are often 
talking about the individual, themselves, who chooses or 
considers committing suicide, but I am interested in the 
families and the spouses. I know that many times it is the 
spouse who sees the red flags who wants to reach out for help. 
And I am interested--I know there are probably a lot of privacy 
concerns, but what is the protocol when a spouse contacts a 
service member's chain of command with those kinds of warnings? 
And how are you dealing with that side of it?
    To anyone; I am interested in anyone.
    General Bostick. One of the things we have really learned 
over the last 10 years of war is that we are successful because 
of our families. We have always known that, but the strength of 
the Army is our soldier, the strength of our soldiers is their 
families. So we have wrapped our arms around our families 
during Family Readiness Groups and throughout their 
deployments.
    And there is not a chain of command in the Family Readiness 
Group, but there is a partnership and the sharing of 
information and a knowledge that you can go to your leaders 
either within that Family Readiness Group or you can seek out 
help through the chain of command, and the chain of command 
would be more than happy and more than willing to assist.
    We have also asked through a buddy system that our young 
soldiers, who really know their friends the best, that when 
they see something, that they ask about the challenges that may 
be there and that they care for them, they escort them to where 
they need help. So there are multiple venues where spouses have 
the opportunity to engage.
    The last thing I would say is, as I talked about before, 
one of the high stressors is failed relationships. And the 
program that we have with Strong Bonds, led by our chaplains, 
and bringing in--in a retreat-type format--bringing in those 
families that wish to talk about things that are ongoing, that 
is another venue where they can go and feel no obligation, no 
concern about risk to their spouse's career and talk openly 
about what is happening.
    General Milstead. We, too, are concerned about the 
families. There is a dual-edged piece to this. You know, we are 
a Corps of 202,000, but we have about 207,000, 208,000 
dependants, we have 90,000 spouses. So what do we do for the 
spouses? I mean, it is more than just, how does the spouse 
recognize something with her husband or his wife and report it 
to the chain of command? But what about that spouse that is 
bearing some of that burden of multiple deployments?
    So we, too, are looking at this. We are expanding programs. 
And the family readiness is the centerpiece of our efforts at 
this time.
    Secretary Woodson. I appreciate your question, and I am 
going to take a little bit of a different spin because my 
colleagues have so directly addressed the issue of the spouse 
recognizing symptoms in the service member. But, as was just 
said, there is an important issue in terms of the stress of the 
family, and we understand that there is increased stress in the 
spouses and children.
    What I would like to say is that we have recognized this 
and that we have enhanced the ability for spouses to get mental 
health care and counseling, as well as children to get mental 
health care and counseling.
    Now, one of the challenges in society is, in particular, 
finding enough pediatric mental health counselors, but we have 
expended every effort to ensure that the network has those 
available for children, as well.
    Ms. Pingree. Well, thank you for your answers. I do think--
I appreciate that you are looking at it from this side. We 
certainly hear about that, that spouses and families are an 
important place for early warning. And also reducing the stigma 
with families, which I think you are talking about, making it 
possible for them to talk about it, is also critically 
important.
    I have run out of time, so I will end. But thank you, Mr. 
Chair, and thank you, to the panel.
    Mr. Wilson. Thank you, Ms. Pingree.
    We now proceed to Mr. Coffman of Colorado.
    Mr. Coffman. Thank you, Mr. Chairman.
    Let me go over a number of points, and if somebody could 
address them when I raise a question.
    First of all, I think that suicide in the military is a 
failure of small unit leaders really at the noncommissioned 
officer level. And so I think that everything has to be done to 
make sure that the NCOs at the fireteam level, at the squad-
leader level, or whatever the equivalent in the respective 
branch of service is for that position, feels responsible for 
those under their leadership.
    Secondly, I think it is important that we preserve 
deployments as units and never revert back to individuals being 
deployed, as was done in Vietnam, where I don't think you 
develop that unit cohesion. And I think unit cohesion is 
essential to reducing suicides.
    I think that what the military has done in terms of 
decompression from members who have been deployed before they 
return home to their families or before they revert to a 
Reserve status, again united with their families, I think is 
very important. And I think we have gone a long ways in doing 
that. I want to encourage that.
    I was in Marine Corps Light Armored Reconnaissance in the 
first gulf war. A lot of stress in the buildup to the ground 
war in anticipating casualties at a level that did not occur, 
fortunately. But strong, interdependent bonds are built, 
certainly in ground combat units and I suspect in other 
components, as well. And then, all of a sudden, I was released 
back as a civilian. And so it took 72 hours, literally, to 
process us out. Once I hit the ground in North Carolina to 
being home in Colorado was about 72 hours. That is way too--you 
know, that is way too fast. And I think that we know better, in 
terms of doing that, now.
    I understand that the United States Army has gone forward 
with some innovative programs in terms of having collateral 
assignments, I think even down to the small unit level, of 
folks that are trained in terms of stress management, if I 
understand that correctly. And I would like to know if the 
Marine Corps, in terms of its ground combat units, has done the 
same. If you could comment on that.
    Post-traumatic stress disorder, we have to elevate it to 
the status of a wound. And we don't. In any other wound, we 
require treatment and we do everything we can to mitigate that 
wound before we release that individual. And we need to--and we 
don't do that in post-traumatic stress disorder, it is my 
understanding. We need to do that. And I would love to have 
somebody comment on that.
    I think that, having also served in Iraq with the United 
States Marine Corps in 2005-2006, when I look back between the 
first gulf war and the Iraq war, I think a big difference is, 
in the Iraq war, you could go out on patrol in the day, come 
back to whether it is a forward operating base or a major base 
camp and have access to electronic communications in realtime 
with your family. And I think in the first Gulf war, we just 
checked out. I think people that went to Vietnam checked out. 
They didn't have that access. And so, they departed the 
pattern, went off to war, only communicated by snail mail.
    But I think the notion of communications in realtime is a 
stressor, in and of itself. I mean, obviously, we want that to 
occur, but now they are dealing with problems at home and they 
are dealing with the problems of being in a combat environment. 
And I think the confluence of those things is tough on people.
    And so I have raised some issues and some questions, and 
take it away.
    General Milstead. Well, I will answer the first one, 
Congressman.
    We do have an embedded program. We are very proud of it. It 
is called OSCAR. And this is our Operational Stress Control and 
Readiness program. And we have three tiers to this OSCAR. The 
first are the providers. These are the mental-health-care 
specialists. And we have them at the division and down at the 
regimental level. Then our next one is we have what we call the 
extenders. And these are Corpsmen and other professional health 
care, as well as our chaplains. And they receive some training. 
And then we have what we call the mentors. And we have 
approximately 75 mentors per unit.
    And this is battalion level, battalion/squadron level, but 
right now it is focused on the battalions. And so we have 
embedded this in these forward units that are forward deployed 
so that they can ask for help and so that they can receive that 
quick referral while they are forward deployed and still 
dancing with the dragon, if you will.
    Your other point about NCO leadership, I think you are 
spot-on. And that is why we did our Never Leave a Marine Behind 
program. We began our peer-to-peer suicide prevention bystander 
intervention-type training with the NCO program, focused on the 
NCO.
    I think it was in 2009, on our peak of our suicides, that 
we were having an Executive Force Preservation Board, and the 
NCOs that were represented there said, ``Give us this problem. 
Let us take this on.'' And we gave it to them, as I mentioned 
in my statement, and we have seen some benefits.
    So I hope that answers your two questions. We are embedded, 
and we are embedded forward, and we have seen some fruit.
    General Bostick. The only thing I would add is that our 
noncommissioned officer corps is the backbone of our Army. I 
mean, they carry the heavy load in our Army each and every day. 
And when there is a suicide, it is all of us--officers, the 
noncommissioned officers, the civilians, the families--we all 
hurt and we all feel terrible about it.
    But to your point, we understand the importance of 
leadership and frontline leadership. Some of the second- and 
third-order effects that we are feeling from our own rotation 
process, the strength of rotating units is very sound. And then 
when you bring those units back and you have to break them 
apart to get the next units ready, that lack of leadership and 
knowledge and transition of that individual soldier that was on 
a hilltop in Afghanistan under all types of stress and not 
having the same noncommissioned officer there in the next year 
when he moves to his next unit or when he goes to a school, 
sometimes there is a breakdown there.
    And that is what we are trying to get after. How do we 
identify, within the HIPAA [Health Insurance and Portability 
and Accountability Act] laws and all the requirements, to 
manage that individual's personal well-being but also let 
leaders and behavioral health specialists where he is going 
know the challenges and stresses that he is under?
    Mr. Wilson. Thank you, Mr. Coffman.
    We now proceed to Ms. Hartzler of Missouri.
    Mrs. Hartzler. Thank you, Mr. Chairman.
    Thank you, each of you, for being here today and all that 
you are doing on this very, very important topic.
    It is just tragic to look at your testimony and to see the 
numbers that you are, you know, sharing. In 2010, 37 marines 
died. In 2010, 39, Navy; 56, Air Force; 300, Army. Those are, 
you know, soldiers, those are fathers, those are husbands, 
those are sons, those are husbands, those are wives, and it 
just is tragic. And so we want to do everything we can in 
Congress to support you and to help you in these efforts.
    And I know that you have a lot of prevention efforts that 
you are trying to do. And I wondered, what processes are in 
place to evaluate the success of the prevention programs that 
you have tried to implement? And have you done away with some 
that you have found are not successful? Are you moving forward 
with some others that are more successful? What is working and 
what isn't? And what evaluation processes are in place with the 
programs that you are attempting to do?
    General Bostick. Let me take on a couple of those.
    First, the answer to your question, it is very, very 
difficult to assess the effectiveness of the programs. I think 
some are very early; some we are still in the progress of 
piloting. And because it is not one-solution-fits-all, we 
really need to come at this at multiple levels from multiple 
directions. It is very, very complex.
    Let me take an area, alcohol and substance abuse, which 
sometimes is involved in some of the suicides. And what we have 
done there is to make sure that we have a solid alcohol/
substance abuse program, that we also have a confidential 
alcohol treatment education program. What we found is, if you 
have an alcohol problem, you probably don't want to run to your 
squad leader and tell him about it. So we have tried in three 
locations, and now we have piloted in six locations, where you 
can come in and confidentially say, ``I have an issue with 
alcohol, and I would like some help,'' and we work with those 
individuals.
    We believe that we have to continue to work these programs 
and, over time, decide which ones are working and which ones 
are not. We are finding some great success in the virtual world 
with tele-behavioral health, as Dr. Woodson said, and virtual 
behavioral health, where we are able to allow the individual to 
talk virtually to some of these behavioral health specialists 
and have the privacy but get the care that they need.
    But the bottom line is, these are complex problems. There 
is no simple solution. And we need to move on a broad front to 
try to tackle these.
    Mrs. Hartzler. Uh-huh.
    Go ahead.
    General Milstead. I would echo that. We have integrated our 
behavioral health efforts. We have put our Combat Operational 
Stress--to go back to your question, ma'am, our Sexual Assault 
Prevention and Response is now a part of that. We have wrapped 
in the substance abuse. Many times, we see that there are 
multiple of these involved in this complex issue, and so we 
have wrapped them and put them under an umbrella of our 
integrated behavioral health.
    Again, it is an extremely complex issue, and we have to 
continue to kick over rocks and look at successes and where we 
have done better and where we haven't done better and continue 
to morph this program. And even when you do get to zero, zero, 
zero attempts and zero suicides, there are still--you got to 
keep going, because now you are into the maintaining.
    Mrs. Hartzler. Right.
    Just very quickly, I was wondering, with the families and 
the stresses that they are undergoing, are there any statistics 
on suicides within the military family community?
    Secretary Woodson. So, we have very little data on that. 
And part of the issue is that the family members are not 
subject to the same scrutiny that the service members are. And 
we are looking for ways to sensitively, in a sensitive way, get 
at that so that we can provide assistance. But it is different; 
they have other rights and protections that we need to be aware 
of.
    Mrs. Hartzler. Thank you for all your efforts.
    Thank you, Mr. Chairman.
    Mr. Wilson. Thank you, Ms. Hartzler.
    And at this time I am going to be turning the gavel over to 
Mr. Coffman. As I leave, I want to thank the panel, I want to 
thank the subcommittee members. They have all been so dedicated 
on this issue, particularly Ms. Davis.
    And I know that we have also been very appreciative of DOD 
and VA [Department of Veterans Affairs] personnel for what they 
have done. A volunteer organization in my home community is 
Hidden Wounds, established by Anna Bigham in memory of her 
brother, Lance Corporal Mills Bigham, who passed away. So we 
have seen what can be done.
    I am departing to go to the funeral at Arlington of Colonel 
Charles P. Murray, Jr., a recipient of the Medal of Honor, a 
great American hero of World War II, Korea, Vietnam.
    We now proceed to Mr. Coffman, who will recognize Mr. 
Scott.
    Mr. Coffman. [Presiding.] Mr. Scott of Georgia, 5 minutes.
    Mr. Scott. Thank you, Mr. Chairman.
    Gentlemen, most of my questions have been answered. I again 
want to thank you for the work you have done here.
    General Bostick, you gave a lot of the statistics about who 
it is where we have the highest rates. And my question would 
then focus on statistics of when. Is there a month that stands 
out where we have the most suicides where maybe we should turn 
up the prevention? Is it the first of the month, the middle of 
the month, the last of the month where we see that? Do we have 
the statistics on when it is happening, and are we working to 
turn up the prevention based on those statistics?
    General Bostick. Yes, Congressman, we have taken a very 
close look at that, as well.
    And the other thing we find is transitions--anywhere in 
life and in the Army, transitions can be a very difficult time. 
And, up until last year, those soldiers that were one-time 
deployers and coming back to a unit, so they enlisted in the 
Army, went to their first unit, deployed, came back to their 
unit, that that period when that unit was breaking apart after 
going through a deployment together, that was a high-risk 
period for us.
    We know months where it is traditionally high.
    We also know that another period that we have to watch is 
when a unit deploys and a new soldier is assigned to that unit 
but has not yet deployed, that soldier is now--the welcome and 
the entrance into the traditions of the Army and all of the 
chain of command that he is going to have when he deploys may 
not be as strong as when the unit is there. So we are making 
sure that how we welcome soldiers into units that have already 
deployed, that that is sound.
    But it is any time that we are transitioning. Those periods 
of transition are very important for us to focus on.
    As I said in my opening comments, we are now seeing a 
higher number of the multiple deployers. And this is very 
recent, in 2011, where those that have been on two, three, and 
four deployments, the numbers of suicides, which had been low 
in the past, have more than doubled this year.
    Mr. Scott. Thank you.
    Mr. Coffman. Ms. Chu of California for 5 minutes.
    Ms. Chu. Thank you.
    I want to tell you about something that happened in April 
of this year. Lance Corporal Harry Lew was moved to a unit in 
his first tour in Afghanistan and sent to Helmand province. 
Eleven days after transfer, he was found asleep on watch. It 
had happened before in those 11 days. And his fellow marines 
believed he let them down, and they let him know it.
    At 11:30 p.m., the sergeant called for peers to correct 
peers. At 12:01 a.m., Lance Corporal Lew was beaten, berated, 
and forced to perform rigorous exercise. He was forced to do 
pushups and leg lifts wearing full-body armor, and sand was 
poured in his mouth. He was forced to dig a hole for hours. He 
was kicked, punched, and stomped on. And it did not stop until 
3:20 a.m.
    At 3:43 a.m., Lance Corporal Lew climbed into the foxhole 
that he had just dug and shot himself and committed suicide.
    Lance Corporal Lew was my nephew. He was 21 years old. And 
he was looking forward to returning home after 3 months. He was 
a very popular and outgoing young man known for joking and 
smiling and breakdancing.
    But he wasn't the only soldier that this happened to. And, 
in fact, in June, Stars and Stripes shared the story of Army 
Specialist Brushaun Anderson, who was severely hazed and 
mistreated by his superior officers on a remote base in Iraq. 
They said that he was dirty, that he performed poorly, and they 
made him wear a plastic trash bag and made him perform physical 
exercise in his body armor over and over again and made him 
build a sandbag wall that served no military purpose.
    In 2009, Army soldier Keiffer Wilhelm shot himself in a 
portable toilet after being accused of being overweight and 
forced to perform excessive physical exercise while his 
superiors showered him with verbal abuse.
    Your data shows that 40 percent of the individuals who 
committed suicide last year were involved in a legal or 
disciplinary problem in the year before they died.
    I would like to know, for each service, is hazing expressly 
prohibited under your regulations? How are you actually 
preventing suicide from hazing? And in each of these cases, 
superior officers were involved. What are you doing to actually 
enforce the regulations pertaining to hazing with superior 
officers?
    General Milstead. Yes, ma'am. This is unfortunate. Hazing, 
to use the term that you have used, is inconsistent with the 
Marine Corps core values. It is expressly prohibited, and by 
regulation. And when found, it is investigated. And where 
substantiated, it will be dealt with appropriately. We don't 
condone hazing in the United States Marine Corps.
    Ms. Chu. Dr. Woodson, what is actually being done about 
the--well, first of all, I would like to know whether, for each 
service, whether you know hazing is expressly prohibited and 
what is actually being done about it.
    General Bostick. I can say, for the Army, hazing is 
specifically prohibited. It is written clearly in our 
regulations that it is prohibited. And if it occurs, then we 
take the appropriate actions based on investigations that we 
hold commanders accountable for executing.
    But we expect soldiers to treat each other with dignity and 
respect and adhere to the Army values, and that is the bottom 
line. And if they don't, then we will investigate and take 
appropriate actions.
    Admiral Kurta. And, Congresswoman, for the Navy, as with 
the other services, hazing is not consistent with our core 
values and is definitely expressly prohibited. And, again, like 
the other services, when actions of hazing come to light, we 
take very strong and proactive action to bring all of those 
involved to justice.
    General Jones. Congresswoman, first off, we are very sorry 
for your loss. And I promise you that, from the Air Force 
standpoint, that we do not condone hazing. We have regulations 
against it.
    And having been a commander five different times, including 
command of the Air Force's Lackland Air Force Base's 37th 
Training Wing, where we do all basic training for the Air 
Force, we watch for things like that. Whenever we have someone 
who is in subordinate position and, obviously, superiors, like 
military training instructors, instructors of tech training, we 
watch for that very carefully. And when someone does get out of 
line, we take swift action. It is inconsistent with our core 
values, and we do not tolerate it.
    Secretary Woodson. I, too, want to express great sorrow for 
your loss and state affirmatively that hazing is inconsistent 
with Department of Defense policy.
    It is also clear that the uniformed services, each of the 
services, have the UCMJ [Uniform Code of Military Justice] 
responsibilities. And so we want to assure that we enforce the 
policies of carrying out the appropriate investigations, but it 
is each of the service's responsibilities to conduct those 
investigations and apply UCMJ as appropriate.
    Mr. Coffman. Ms. Davis of California.
    Mrs. Davis. Mr. Chairman, thank you. I know that the votes 
are going, and so I know that we need to stop.
    I think the concern that we would all have, of course, is 
that the reports that are done on all the suicides that occur 
within the services are done in a comprehensive manner so that 
we have a good understanding and the ability to go back and 
really understand what is going on when those times of 
transition occur and how that impacts those; what role, if any, 
the military plays obviously in the tragic story that my 
colleague has shared, and that we are certain that everything 
is done as properly and the investigations go forward.
    So I think that this is certainly a difficult topic, as we 
all talked about. I had a few more questions, but I know that 
we will be back again.
    And I just want to thank you all, as I know my colleagues 
have all done, because as we began over the last number of 
years in first Iraq and Afghanistan, we know that this issue 
has escalated and is difficult. It involves families, great 
sacrifices on the part of those families. And we want to be 
certain that we are doing all within our power, I think, to 
understand it as best we can and make certain, as has been 
stated, that we are down to zero. That would be certainly 
something that we would hope we could look forward to in the 
future.
    So thank you very much. I appreciate it.
    Mr. Coffman. Secretary Woodson, I am wondering if there is 
one question you could get back to me on the record with on a 
related behavioral health issue, and that is on post-traumatic 
stress disorder.
    And it is my understanding that when someone self-reports 
post-traumatic stress disorder and they are placed in a Warrior 
Transition Unit for potential out-processing that there is no 
mandatory requirement for treatment. And I am wondering if you 
could confirm that back to the committee in writing.
    Again, I believe we ought to elevate post-traumatic stress 
disorder up to a wound and that we ought to make every effort 
to treat folks before they are released from Active Duty.
    Secretary Woodson. Yes, sir.
    [The information referred to can be found in the Appendix 
on page 89.]
    Mr. Coffman. Thank you.
    And the committee is adjourned.
    [Whereupon, at 10:35 a.m., the subcommittee was adjourned.]


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




                            A P P E N D I X

                           September 9, 2011

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


              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                           September 9, 2011

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

      
                      Statement of Hon. Joe Wilson

           Chairman, House Subcommittee on Military Personnel

                               Hearing on

           The Current Status of Suicide Prevention Programs

                            in the Military

                           September 9, 2011

    Today the Subcommittee meets to hear testimony on the 
efforts by the Department of Defense and the military services 
to prevent suicide by service members, family members and 
civilian employees.
    I want to preface my statement by recognizing the 
tremendous work the Department of Defense and the service 
leadership has done to respond to the disturbing trend of 
suicide in our Armed Forces. I understand this has not been an 
easy task and I thank you for your hard work. I particularly 
see military service as an opportunity to be all you can be and 
I want service members to know they are talented people who are 
important and appreciated by the American people. They can 
overcome challenges.
    I am also grateful for Ranking Member Susan Davis's work 
she did as Chairman of the Military Personnel Subcommittee to 
bring attention to psychological stress in the Military and the 
behavioral health needs of service members.
    With that said, clearly there is more work to be done.
    Suicide is a difficult topic to discuss. Every suicide is a 
tragedy but suicide by members of our military is even more 
difficult because they have given so much to this Nation. 
Ultimately, it is an individual decision to take one's own 
life. But we must make sure every opportunity to redirect or 
change that decision is available before it's too late.
    Suicide is a multifaceted phenomenon that is not unique to 
the military. Unfortunately, in addition to the unique 
hardships of military service, our service members are subject 
to the same pressures that plague the rest of society today. 
They are exposed to the same stressors, such as the current 
unemployment and economic situation that may lead to suicide by 
their civilian counterparts. I am very concerned these 
stressors will only get worse in the coming months as debate 
regarding cuts to the Defense Department budget intensifies.
    Each of the military services and the Department of Defense 
has adopted strategies to reduce suicide by our troops. I would 
like to hear from our witnesses whether those strategies are 
working. What are your benchmarks for success? How do you 
determine whether your programs incorporate the latest research 
and information on suicide prevention? I am also interested to 
know how Congress can further help and support your efforts.

                    Statement of Hon. Susan A. Davis

        Ranking Member, House Subcommittee on Military Personnel

                               Hearing on

           The Current Status of Suicide Prevention Programs

                            in the Military

                           September 9, 2011

    I am pleased that the subcommittee is maintaining its 
attention on suicides in the military. Over the past several 
years, as we have seen the number of suicides by service 
members grow, the subcommittee has been forward-leaning in 
attempting to support the Services and the Department of 
Defense in their efforts to develop a strategy to reduce and 
prevent suicides in the force.
    Suicide in the military has been a focal point for the 
subcommittee, but we are not the only ones focused on this 
issue. In 2007, suicide was the third leading cause of death 
for young people ages 15 to 24, while our forces shares this 
demographic, it is important that we share what we learn and 
what is learned by others if our country is to be successful in 
addressing this societal issue.
    The subcommittee's efforts have included the establishment 
of the Department of Defense Task Force on the Prevention of 
Suicide by Members of the Armed Forces in the Duncan Hunter 
National Defense Authorization Act of Fiscal Year 2009. The 
task force, comprised of fourteen individuals--civilians and 
military--with expertise in national suicide prevention policy, 
military personnel policy, research in the field of suicide 
prevention, clinical care in mental health and other similar 
backgrounds, submitted their final report in August 2010. There 
were 76 recommendations made by the task force, the majority of 
which were directed at the Department of Defense and the 
Services. I am interested in learning from the Department and 
the Services on where they are in implementing many of these 
recommendations.
    Let me welcome our witnesses. I look forward to hearing 
from them on where we are in our efforts.




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


                   DOCUMENTS SUBMITTED FOR THE RECORD

                           September 9, 2011

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

      


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


              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                           September 9, 2011

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

      
              RESPONSE TO QUESTION SUBMITTED BY MR. JONES

    Secretary Woodson. As indicated in the table below, the numbers of 
mental health professionals (psychologists, psychiatrists, social 
workers, and psychiatric nurses) have increased in all occupations over 
the period covered. These figures include military, contractor, and 
civilian employees. The number of psychiatric nurses includes nurse 
practitioners working in the field. [See page 12.]


------------------------------------------------------------------------
        Occupation               2009            2010       3 Qtr. 2011
------------------------------------------------------------------------
                            Total           Total          Total
------------------------------------------------------------------------
Psychologist                1,520           1,815          1,917
------------------------------------------------------------------------
Psychiatrist                652             758            774
------------------------------------------------------------------------
Social Worker               1,789           2,082          2,189
------------------------------------------------------------------------
Nursing (including NP)      570             580            637
------------------------------------------------------------------------
GRAND TOTAL                 4,531           5,235          5,517
------------------------------------------------------------------------

                                 ______
                                 
             RESPONSE TO QUESTION SUBMITTED BY MR. COFFMAN
    Secretary Woodson. This is true. There is no requirement that the 
Warrior Transition Unit (WTU) mandate a Service member's participation 
in behavioral health treatment. When any Service member self-reports to 
any behavioral health clinic for the treatment of post-traumatic stress 
disorder (PTSD) (or any mental health disorder), their behavioral 
health care provider has the due diligence to conduct a comprehensive 
mental health evaluation, but cannot mandate treatment unless the 
Service member is imminently dangerous to themselves or others. There 
are several guiding policies and standard operating procedures which 
require both behavioral health providers and their respective units to 
do everything possible to provide the appropriate level of care for all 
Service members. In addition, these regulations address the ethical and 
legal responsibilities of the providers, while ensuring that all 
possible efforts are made to offer high quality care while preserving 
the rights of Service members during their time in the military, and 
prior to any separation from the service. [See page 28.]
                                 ______
                                 
            RESPONSES TO QUESTIONS SUBMITTED BY MS. TSONGAS
    Secretary Woodson. Suicide is a multi-faceted issue and many 
factors play a role in whether or not a person decides to take their 
own life. The 2010 DOD Suicide Event Report is a compilation of over 
250 data elements collected on every Active Duty suicide that occurred 
in Calendar Year 2010. This report indicates that 2.85% of the suicides 
(a total of eight) had a known history of sexual abuse, which may refer 
to either a childhood history or an assault as an adult. However, it is 
not known with any degree of certainty that a specific instance of 
sexual assault directly contributed to the Service member's decision to 
end his or her life by suicide. The Department takes the issue of 
sexual assault very seriously and is committed to establishing a 
culture free of sexual assault. [See page 17.]
    Secretary Woodson. Through the Department of Defense (DOD) Suicide 
Event Report program, the Department tracks suicides by gender, as well 
as many other factors, including age, rank, marital status, location, 
setting, etc. In Calendar Year (CY) 2010, the last year for which we 
have complete data, there were 14 female Active Duty Service members 
who died by suicide. This comprises 4.75% of the total number of 
suicides in 2010. Looking back through the last decade, the total 
number of female Service members who have died by suicide has been very 
small, especially when compared to the percentage of the force 
comprised of women, which ranges from approximately 20% in the Air 
Force, 15% in the Army and Navy, to 6.5% in the Marine Corps. However, 
women, as a whole, are much more likely to attempt suicide that 
actually complete suicide. For CY 2010, the Department recorded 863 
attempts, 75.67% male and 24.33% female. [See page 18.]

----------------------------------------------------------------------------------------------------------------
   Gender      2001    2002    2003    2004    2005    2006    2007    2008    2009    2010    2011      Total
----------------------------------------------------------------------------------------------------------------

Females------4--------8-------11------9-------9-------13------11------13------9-------14------11------112-------
----------------------------------------------------------------------------------------------------------------
Males        156      163     179     186     180     200     212     254     300     281     199     2,310
----------------------------------------------------------------------------------------------------------------
%            2.50     4.68    5.79    4.62    4.76    6.10    4.93    4.87    2.91    4.75    5.24    4.6
 Females
----------------------------------------------------------------------------------------------------------------
Total        160      171     190     195     189     213     223     267     309     295     210     2,422
----------------------------------------------------------------------------------------------------------------

    Source: DOD Mortality Registry, Mortality Surveillance Division, 
Armed Forces Medical Examiner
?

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


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                           September 9, 2011

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

      
                   QUESTIONS SUBMITTED BY MRS. DAVIS

    Mrs. Davis. Historically, we've heard about the difficulty in 
hiring behavioral health and related providers within the Services. 
What are the recruiting and hiring challenges? Are there significant 
shortfalls within the Services? What are the Services doing to address 
those shortfalls?
    Secretary Woodson. The recruiting and hiring challenges for DOD 
mirror the challenges in the private sector. There is a nationwide 
shortage of behavioral health providers, which means that the 
Department of Defense (DOD) must compete with the civilian sector for 
the best qualified professionals. However, the Department has succeeded 
in significantly increasing the number of behavioral health providers 
over the past several years. We have increased Uniformed Services, 
Government Civilian, and contract providers to address the Department's 
behavioral health concerns. The DOD and the Services have worked 
closely to develop a yearly consensus on appropriate adjustments to 
military accession, bonus, and incentive pays. The Department has also 
recently started implementing the Physician and Dentists Pay Plan, 
which helps to ensure our ability to provide competitive compensation 
for Government Service medical professionals.
    We defer to the Services for responses regarding Service-specific 
problems as they implement and fund the program.
    Mrs. Davis. What are some challenges senior leadership faces 
regarding efforts to reduce suicide and suicide attempts?
    Secretary Woodson. The Department recognizes that preventing 
suicide is not simply a problem for the behavioral health care provider 
or Chaplain; it is a leadership responsibility. One of the biggest 
challenges senior leaders face is gaining a full understanding of the 
problem. Two comprehensive reports, the Department of Defense (DOD) 
Suicide Prevention Task Force Report and RAND Suicide Prevention 
Report, identify leadership as key in the prevention of suicide. Since 
suicide is a multi-faceted issue, efforts to prevent it touch virtually 
every aspect of a Service member's life.
    The Department is moving aggressively to enhance protective factors 
through the various Service resilience programs such as Army's 
Comprehensive Soldier Fitness and the Marine's Combat Operation Stress 
Control Program. With this effort comes the challenge of changing the 
mindset of a force that has been solely focused only on physical 
fitness to one that embraces psychological fitness as being of equal 
importance. The Department is making progress enhancing our 
surveillance methods as well as the fidelity of our data, but there is 
much work still to do.
    Suicide prevention is part of a larger effort dealing with health 
promotion and risk reduction, a strategy that examines policy, 
structure, processes and programs to reduce suicides, risk-related 
deaths, and other negative outcomes of high risk behavior. DOD 
leadership remains committed to conveying the message to all that 
seeking help for behavioral health issues is not a symptom of weakness, 
but a sign of strength. While overcoming the stigma and myths 
associated with behavioral health care has been a challenge, the 
Department is making progress on multiple fronts.
    Mrs. Davis. The DOD Task Force for Prevention of Suicide Among 
Members of the Armed Forces conducted a systematic review of prevention 
efforts and provided 76 recommendations. Where is the Services and the 
Department in implementing any of those recommendations?
    Secretary Woodson. The Department has reviewed and assessed the 
Final Report of the Department of Defense Task Force on the Prevention 
of Suicide by Members of the Armed Forces. The Department sent an 
initial response to the congressional defense committees in March, 2011 
and recently sent a final response on September 21, 2011 in accordance 
with section 733 of the Duncan Hunter National Defense Authorization 
Act for Fiscal Year 2009. This final response contains a synopsis of 
the Department's implementation plan addressing each of the 76 
recommendations contained in the report. After a complete and thorough 
review, the Department determined that 36 recommendations require new 
actions to be taken, 34 recommendations have actions planned, underway, 
or completed, and 6 recommendations do not merit any action. For 
recommendations requiring action, when the way ahead is clear and 
straightforward, those actions will be initiated immediately. In cases 
where additional clarification or more data are needed, the Department 
will devote the required time and resources to clarify or assess the 
extent of the problem so that the Task Force's objective can be 
properly evaluated and an enduring outcome achieved. The Department 
will continue to review, implement, and revise its plan to ensure the 
best possible solutions are identified and implemented promptly.

    Mrs. Davis. Why did the July 2011 Army numbers spike to an all time 
high? What is being done to mitigate the spike in July from occurring 
again?
    General Bostick. This was a very unexpected and unfortunate outcome 
for July. After unusually high months in April and May, the Army's Vice 
Chief of Staff sent an email to every battalion and brigade commander 
in the Army asking them to ``remain vigilant of emerging high-risk and 
self-harming behavior.'' Suicide is a very complex issue that is 
without question the most severe and tragic outcome of a very difficult 
situation. There are a number of factors that contribute to the 
decision to commit suicide, and the Army leadership continues to focus 
highest priority efforts to better understand the causes of Soldier 
suicides. We are currently reviewing each of these individual cases and 
looking to identify factors that could explain this unexpected spike.
    In an effort to learn as much as possible from every suicide, in 
March 2009 the VCSA established the monthly VCSA Suicide Senior Review 
Group (SSRG). The SSRG involves senior commanders from affected 
commands across the Army who meet and review approximately 15 to 20 
suicide cases each month. The cases are discussed to glean lessons 
learned and identify trends and themes in an effort to help prevent 
future suicides.
    Additionally, since 2009, the Army has had a Health Promotion and 
Risk Reduction, Task Force to dedicate focused energies and resources 
to address all aspects of suicide. This Task Force continues to examine 
the complexity of suicide, taking into account national suicide trends, 
individual Soldier risk factors and the Army's institutional approach 
to suicide prevention. The task force has taken a holistic approach to 
the identification and mitigation of identified risk factors. The focus 
continues to be on promoting Soldier wellness (physical, mental and 
spiritual health). This includes investigating ways to promote 
resiliency, reduce stressors, improve the ability and willingness to 
identify when someone needs help, and institutionalize and normalize 
help-seeking behaviors.
    Mrs. Davis. Historically, we've heard about the difficulty in 
hiring behavioral health and related providers within the Services. 
What are the recruiting and hiring challenges? Are there significant 
shortfalls within the Army? What is the Army doing to address those 
shortfalls?
    General Bostick. As of September 2011, the Army has 5,912 
Behavioral Health (BH) providers. The current estimated active 
component Army BH requirement is 6,107 providers, including 
professional providers and BH technicians, which represents an unmet 
requirement of 195 supporting the Active Component. Since 2007, the 
Army has added 2,613 civilian, military and contract BH providers 
supporting the Active Component. This represents a 92% increase in 
credentialed BH providers.
    BH recruiting and hiring challenges are not due to lack of funding. 
Recruiting and hiring challenges continue to stem from a national 
shortage of qualified providers, especially in remote locations, and 
compensation limitations inherent to government employment.
    Given the significant national shortages of qualified providers, 
the Army has implemented several initiatives to resolve its shortfalls 
including bonuses, scholarships, and an expansion in training programs. 
In partnership with Fayetteville State University, the US Army Medical 
Command (MEDCOM) developed a Masters of Social Work program which 
graduated 19 in the first class in 2009. The program has a current 
capacity of 30 candidates. MEDCOM increased the number of Health 
Professions Scholarship Allocations dedicated to Clinical Psychology 
and the number of seats available in the Clinical Psychology Internship 
Program. To enhance recruitment of potential candidates and retention 
of staff, MEDCOM provided centrally funded reimbursement of recruiting, 
relocation, and retention bonuses for civilian BH providers.
    Mrs. Davis. What are some challenges senior leadership faces 
regarding efforts to reduce suicide and suicide attempts?
    General Bostick. Senior Army leadership recognizes that the effort 
to reduce suicide and suicide attempts goes beyond suicide prevention. 
Suicide prevention is part of a larger effort dealing with health 
promotion and risk reduction and is nested within a ``meta health 
promotion and risk reduction portfolio management'' strategy that 
examines policy, structure, processes and programs to reduce suicides, 
risk-related deaths, and other negative outcomes of high risk behavior.
    Army leadership understands that a decade of war has 
unintentionally limited garrison leadership and management requirements 
by emphasizing combat, technical and tactical training that is focused 
on reset, readiness cycles, and pre-deployment preparation while in 
garrison. These activities have tipped the balance from institutional 
readiness, measured by Soldier/Family wellbeing and good order and 
discipline in garrison, to combat readiness, as measured by Army force 
generation of units and tactical skills in theater.
    To counter the effects of a decade of war, the Army is 
institutionalizing Professional Military Education training programs to 
``re-green'' leaders in the lost art of garrison leadership (the art of 
commanding units, running daily operations, and taking care of Soldiers 
and Families in peacetime), the importance of enforcing policies and 
procedures that instill good order and discipline in units, recognizing 
high risk behavior related to suicide and accidental death, reducing 
stigma associated with behavioral health and treatment, and increasing 
resiliency in our Soldiers, DA civilians and Families.
    Mrs. Davis. What are the Services doing to reduce the stigma in 
seeking help for mental health issues, especially suicide? Are there 
confidential reporting mechanisms, and if so, are how do the Services 
assess their effectiveness?
    General Bostick. Army leaders have developed and implemented 
numerous initiatives to address the issue of ``stigma'' as it relates 
to seeking mental health services. Policy revisions have been 
promulgated to discontinue use of the term ``mental'' when referring to 
mental health services and replaced it with ``behavioral.'' 
Additionally, policy guidance has been implemented for leaders and 
Soldiers regarding stigma, its impact, and their responsibilities. 
Initiatives were also taken to ensure that the most recent Suicide 
Prevention and Awareness training videos contain scenarios that model 
supportive leader behavior and address leader responsibilities relative 
to promoting health-seeking behavior and the available resources and 
applicable policies. Strategic communications initiatives have been 
launched by the Office of the Chief of Public Affairs in conjunction 
with members of the Army Staff, to utilize various media to promote 
help-seeking behavior for Soldiers and their Families. These efforts 
include the use of public service announcements using celebrities as 
well as Army leaders to include the Army Chief and Vice Chief of Staff 
and Sergeant Major of the Army. One of the most successful 
interventions taken by the Army to alleviate stigma is the co-locating 
of behavioral health and primary healthcare providers (Respect-Mil and 
Medical Home Model) within medical service facilities. This initiative 
decreases the differentiation between behavioral health and primary 
care services and addresses concerns regarding Soldiers being seen by 
peers as they enter behavioral health treatment facilities. 
Additionally, this initiative encourages informal communication between 
the services and improves patient ``hand-off'' from medical service to 
behavioral health services. The Army continues to explore opportunities 
to employ confidential behavioral health and related services. A 
promising program is the Confidential Alcohol Treatment Pilot program. 
This program is being piloted at six installations and provides 
eligible Soldiers the opportunity to self-refer to the Army Substance 
Abuse Program and receive confidential treatment for alcohol abuse 
issues. Additional support is provided via improved access to 
behavioral health services through the advent of the TRICARE Assistance 
Program (TRIAP) and the Tele-Behavioral Healthcare service. These 
services facilitate private interactions between members and licensed 
counselors. Eligible beneficiaries can access TRIAP an unlimited number 
of times, and services are confidential and non-reportable. 
Confidential services are also offered through the utilization of the 
Veterans Crisis Line and Military One Source. Both resources, as well 
as similar services, are heavily promoted through various 
communications platforms, to include the Army, G-1, Suicide Prevention 
website. Stigma is measured during several surveys and assessments. The 
Army has standardized stigma related questions in the Mental Health 
Assessment Team Survey (administered in theater), Sample Survey 
Military Personnel (administered at installations), and Periodic Health 
Assessment Surveys (for not on active duty Reserve Component personnel) 
to gauge perceptions on the impact of stigma relative to seeking 
behavioral health assistance, career impact, leadership support and 
loss of confidence by peers and leaders. The results of these surveys 
are used to target opportunities to launch additional education and 
awareness initiatives. The Army is committed to the goal of cultivating 
a climate in which its members will actively engage in help-seeking 
behaviors when faced with behavioral health issues and other concerns. 
A comprehensive Stigma Reduction Campaign Plan is being developed to 
aggressively address the issue, both institutionally and culturally.
    Army has focused efforts to combat stigma:

          Raise awareness and promote self-care by focusing on 
        skill building to reduce known risk factors such as substance 
        abuse and mental health problems. Skill building emphasizes 
        help-seeking behaviors such as teaching service members to 
        refer themselves to behavioral health professionals or 
        chaplains.

          Facilitate access to high-quality care by detecting 
        and reducing barriers such as stigma, educating service members 
        on the benefits of accessing behavioral health care, and 
        ensuring that a sufficient supply of behavioral health care 
        professionals and chaplains is available.

          Provide high-quality care by training providers on 
        state-of-the-art practices for behavioral health and 
        implementing specific interventions focused on suicide.

          Respond appropriately by focusing on how details of 
        the suicide are communicated in the media as well as the 
        dissemination of information to acquaintances of the suicide 
        victim. Commanders should be provided with formal guidance on 
        how to respond to suicides and suicide attempts.
    Mrs. Davis. Have the Services noticed any differences between 
Active Duty and Reserve Component suicides? What suicide prevention 
programs exist in each Service that geographically dispersed members of 
the Reserves can take advantage of?
    General Bostick. Several suicide prevention programs provide 
support to geographically-dispersed Soldiers and Family members to 
include Army Community Services (ACS) Geographically Dispersed 
Outreach. This program supplements ACS-centric programs with outreach 
to Soldiers and Families who are geographically or socially isolated. 
The ACS programs are delivered either through distance methods or 
through partnerships with local community-based programs.
    Geographically-dispersed members can also take suicide prevention 
training conducted at the nearest reserve component unit. Some of those 
programs are Applied Suicide Intervention Skills Training (ASIST), Ask, 
Care, Escort Suicide Intervention (ACE-SI) Yellow Ribbon Reintegration 
Program, Strong Bonds, Army Strong Community Centers, the Army Reserve 
Fort Family hotline, Army Family Team Building training, virtual and 
real-world Family Readiness Groups, and Army Reserve Child and Youth 
Services.
    Mrs. Davis. The DOD Task Force for Prevention of Suicide Among 
Members of the Armed Forces conducted a systematic review of prevention 
efforts and provided 76 recommendations. Where is the Services and the 
Department in implementing any of those recommendations?
    General Bostick. The Department of Defense has reviewed and 
assessed the Final Report of the Department of Defense Task Force on 
the Prevention of Suicide by Members of the Armed Forces. The 
Department sent an initial response to the Congressional defense 
committees in March 2011 and recently sent a final response on 
September 21, 2011. This final response contains a synopsis of the 
Department's implementation plan addressing each of the 76 
recommendations contained in the report. After a complete and thorough 
review, the Department determined that 36 recommendations require new 
actions to be taken, 34 recommendations have actions planned, underway, 
or completed, and 6 recommendations do not merit any action.
    The Army has implemented 11 of the 36 recommendations that DOD has 
accepted for action. Eight of the 36 do not require any Army action. 
The Army is working with DOD to address the remaining 17 
recommendations.

    Mrs. Davis. Historically, we've heard about the difficulty in 
hiring behavioral health and related providers within the Services. 
What are the recruiting and hiring challenges? Are there significant 
shortfalls within the Navy? What is the Navy doing to address those 
shortfalls?
    Admiral Kurta. Navy Medicine has increased the size of the mental 
health workforce to support the readiness and health needs of Sailors 
and their families throughout the deployment cycle, including at 
medical treatment facilities, as well as within our Fleet and deployed 
units by providing embedded mental health support. The Navy is 
committed to improving the psychological health, resiliency and well-
being of our Sailors and their family members and ensuring they have 
access to the programs and services they need. The military is not 
immune to the nation-wide shortage of qualified mental health 
professionals. Throughout the country, the demand for behavioral health 
services remains significant and continues to grow. Within the Navy, 
mental health professional recruiting and retention remains a top 
priority for active and reserve component personnel, contractors and 
civilians, particularly for psychiatrists, clinical psychologists, 
social workers and mental health nurse practitioners. The Navy is 
actively using numerous accession and retention bonuses (including 
educational incentives and special and incentive pays) to attract and 
retain uniformed mental health professionals. While not yet fully 
staffed, the success of these incentive programs is greatly improving 
our active duty mental health provider staffing.
    We have also made progress with our civilian mental health 
workforce. The use of direct hire authority, pay flexibilities, and 
centralized recruiting has enabled us to locate and attract the talent 
that we need. Continued success will depend on the ability of the 
Federal personnel system to adjust and respond to the associated 
challenges presented by changes in market conditions. We will continue 
to carefully assess our efforts to ensure we employ the appropriate 
tools to recruit and retain our civilian mental health professionals.
    Mrs. Davis. What are some challenges senior leadership faces 
regarding efforts to reduce suicide and suicide attempts?
    Admiral Kurta. The primary leadership challenge is to foster a 
climate where Sailors can openly acknowledge when they are under 
increased personal stress and ask for and receive help when they need 
it.
    Ensuring the perception that seeking help will affect a Sailor's 
career, lead to the loss of their security clearance, or result in a 
loss of trust or different treatment from their leaders and peers is 
removed from the Sailor's decision process in seeking support.
    Ensuring logistical barriers to accessing early support resources 
are fully removed. The Navy continues to embed mental health providers 
on carriers and within other operational units so early assistance is 
more readily accessible. Flexible support resources such as Military 
Onesource, Chaplains, and Fleet and Family Support Centers help expand 
early access.
    Raising the level of understanding of Navy Operational Stress 
Control among all Sailors in order to mitigate stress effects and 
encourage taking early actions for themselves or others.
    Mrs. Davis. What are the Services doing to reduce the stigma in 
seeking help for mental health issues, especially suicide? Are there 
confidential reporting mechanisms, and if so, are how do the Services 
assess their effectiveness?
    Admiral Kurta. Navy's suicide prevention strategic communications 
and program outreach efforts focus on removing barriers to Sailors 
seeking assistance. These efforts include the dispelling of inaccurate 
myths, such as a security clearance is not likely to be removed for 
seeking help, which in turn facilitate stigma reduction.
    The Navy continues to embed mental health providers on carriers and 
within other operational units so early assistance is more readily 
accessible. Flexible support resources such as Military OneSource, 
Chaplains, and Fleet and Family Support Centers help expand early 
access.
    The Navy Operational Stress Control program raises the level of 
understanding among all Sailors regarding stress effects and how to 
take early actions for oneself or others to avoid or mitigate stress 
effects.
    Despite the above efforts many Sailors continue to believe that 
seeking help will affect their careers, lead to loss of clearance, or 
result in the loss of trust or different treatment from their leaders 
and peers.
    A level of confidentiality is available within all care services 
including Military Medicine, Fleet and Family Services, and Tricare 
Network care. Sailors can also seek confidential assistance from 
Military OneSource, Chaplains, and the National Lifeline and Veteran's 
Crisis Chat Line. Most of these resources have legal limits to 
confidentiality and each of them will take immediate life saving 
actions in emergency situations regardless of confidentiality.
    It is difficult to evaluate the effectiveness of confidential 
assistance. However, quarterly medical care utilization surveillance 
data from the Navy and Marine Corps Public Health Center shows a marked 
increase in both in-house and Tricare network purchased mental health 
care utilization by active duty Sailors. These data suggest that an 
increasing number of people are finding the courage and capacity to 
seek mental health care.
    Mrs. Davis. Have the Services noticed any differences between 
active duty and reserve component suicides? What suicide prevention 
programs exist in each Service that geographically dispersed members of 
the reserves can take advantage of?
    Admiral Kurta. The relatively small size of the Reserve Component 
and correspondingly low number of Reserve Sailors lost to Suicide while 
on Active Duty limits comparability between Active Duty and Reserve 
Component suicides. However, information suggests that stressors 
related to economic and job difficulties are more prevalent among the 
Reserve Component Sailors who have died by suicide.
    Geographically dispersed Sailors are accessed through the Reserve 
Psychological Health Outreach Program, included in their unit suicide 
prevention program activities, and have access to a variety of 
resources including the National Lifeline and Veteran's Chat Line and 
Military Onesource for immediate counseling or crisis response.

      Navy Reserve units are fully included in Navy suicide 
prevention program activities including training, surveillance and 
analysis, and outreach.

      Scenario-based Navy Suicide Prevention Peer to Peer 
training is conducted throughout the Navy Reserve. Each unit has an 
assigned Suicide Prevention Coordinator (SPC) who works with the 
command leadership team to ensure execution of a robust prevention 
program that engages peers in risk identification and response. Navy 
includes Operational Stress Control principles in all programs. 
Bystander intervention curriculum trains peers in identifying risks and 
effective intervention techniques. Many Navy Reserve units have 
chapters of the grass roots Coalition of Sailors Against Destructive 
Decisions (CSADD) program that includes peer to peer support to Navy 
Reserve Sailors.

      The Navy Reserve Psychological Health Outreach Program 
provides enhanced training, consultation, and local community outreach 
for Reserve Component service members. The Navy Psychological Health 
Outreach Program teams help find, refer to, and follow-up with 
appropriate military, VA and local community support services for 
Reservists.

      The Yellow Ribbon initiatives, including the Returning 
Warrior Workshops, and other pre- and post deployment activities have 
improved awareness of and access to local community support services.

      Other evidence-based counseling programs are available 
for those reservists living near military bases, such as Families Over 
Coming Under Stress (FOCUS).
    Mrs. Davis. The DOD Task Force for Prevention of Suicide Among 
Members of the Armed Forces conducted a systematic review of prevention 
efforts and provided 76 recommendations. Where is the Services and the 
Department in implementing any of those recommendations?
    Admiral Kurta. The Navy has thoroughly reviewed and provided input 
to Department of Defense on each of the 76 Task Force Recommendations. 
35 recommendations require further action and are in work in 
coordination with USD(P&R), 35 are completed and require no further 
action and 6 required no action.
    We have implemented many of the recommendations including 
resilience building, building program evaluation into all new suicide 
prevention initiatives, and resourcing our headquarters level staff. 
The Navy will work with DOD in continuing to implement other 
recommendations such as better standardizing the DOD Suicide Event 
Report (DODSER) process.
    Navy will also continue to monitor those initiatives that address 
the 35 recommendations that were assessed as completed and those areas 
addressed in the 6 recommendations where no action was directed.

    Mrs. Davis. In 2009, the Marine Corps documented 172 suicide 
attempts, that is nearly double the 82 attempts that was documented in 
2002. Given the steady increase over the past three years, what efforts 
has the Marine Corps taken to review the data and determine what 
efforts should be undertaken to address the increase in attempted 
suicides? What, if any, lessons can be taken from the fact that as the 
number of support programs seem to be increasing, attempts at suicide 
have also increased?
    General Milstead. Marine Corps carefully reviews suicide attempt 
data and continually updates programs and policies in an effort to 
foster resilience and encourage Marines to engage helping services 
early, before problems worsen to the point of crisis. There does not 
appear to be a relationship between the increasing number of support 
programs and the increasing number of suicide attempts. Increased 
attempts are due in part to steady improvement over the past few years 
in suicide attempt surveillance. In addition, improved Marine suicide 
prevention skill is leading to more suicide attempts being discovered 
and stopped before completion.
    In cooperation with OSD Telehealth and Technology, we analyze 
quarterly and annually aggregate suicide data, studying close to 100 
variables associated with suicide in an effort to identify groups that 
may be at higher risk. Thus far, no group of Marines appears to be at 
greater risk than another. The variables most associated with suicide 
are so common in the general population, that there is little to act 
upon. In other words, we have not yet figured out how to predict ahead 
of time WHO will attempt suicide. We are, however, learning more about 
WHEN a Marine might attempt suicide. We recognize the warning signs of 
imminent risk that sometimes follow onset of extreme life stressors.
    As a result, we use a community approach to suicide prevention, 
arming ALL Marines with the knowledge to recognize warning signs of 
suicide, and charging each with the duty to act upon recognizing those 
signs and to ask the difficult question, ``Are you thinking about 
killing yourself?'' In addition, we continue to study risk and 
protective factors associated with suicide, through various research 
projects including the Marine Resiliency Study, the Psychological 
Autopsy study underway with the American Association of Suicidology, 
the Penn State study of the effect of suicide on Family Members, and a 
Blue Ribbon Panel with suicidologists to explore better screening for 
suicide risk.
    Mrs. Davis. Historically, we've heard about the difficulty in 
hiring behavioral health and related providers within the Services. 
What are the recruiting and hiring challenges? Are there significant 
shortfalls within the Marine Corps? What is the Marine Corps doing to 
address those shortfalls?
    General Milstead. The military is not immune to the nation-wide 
shortage of qualified mental health professionals. Throughout the 
country, the demand for behavioral health services remains significant 
and continues to grow. Within Navy Medicine, mental health professional 
recruiting and retention remains a top priority for active and reserve 
component personnel, contractors and civilians, particularly for 
psychiatrists, clinical psychologists, social workers, and mental 
health nurse practitioners. The Navy is actively using numerous 
accession and retention bonuses (including special and incentive pays) 
to attract and retain uniformed mental health professionals.
    Navy Medicine has increased the size of the mental health work 
force to support the readiness and health needs of Marines and their 
families throughout the deployment cycle, including at medical 
treatment facilities, as well as within our deployed units by providing 
embedded mental health support. The Marine Corps is committed to 
improving the psychological health, resiliency, and well-being of our 
Marines and their family members and ensuring they have access to the 
programs and services they need.
    Mrs. Davis. What are some challenges senior leadership faces 
regarding efforts to reduce suicide and suicide attempts?
    General Milstead. Preventing Marine suicide hinges on our leaders' 
ability to build a resilient Force and encourage Marines to overcome 
stigma and engage helping services early, before problems worsen to the 
point of suicide.
    The Marine Corps has recently adopted a resiliency model that 
identifies the interconnectedness between four spheres of resilience 
(social, physical, psychological, and spiritual) and the key agencies 
and support programs that deliver services to Marines and families. The 
end product will result in a resilience approach that draws on 
strengths of existing programs to infuse resilience content throughout 
training and programming capabilities. This approach focuses on Marine 
total `fitness' as a model that includes not only physical, but also 
psychological, spiritual and social fitness. Efforts are well underway 
to inventory current capabilities, assess effectiveness and future 
operations utility, and identify gaps and redundancies. Identified 
agencies are collaborating to develop a series of resilience-based 
training courses that will be offered throughout the course of a 
Marine's career.
    Marines have been ingrained with the ethos that whether in battle 
or at home, we `never leave a Marine behind.' By making the language 
and process of help-seeking consistent with the ethos, Marine Corps 
leadership is leveraging the culture of the Corps to overcome the 
stigma against help seeking. According to the Joint Mental Health 
Assessment Team--7th edition, the Marine Corps has seen a small 
reduction in the stigma surrounding behavioral health problems and 
healthcare, but reducing stigma still remains a challenge. Senior 
leadership messages underscore that seeking help for distress is a duty 
not an option, and is consistent with Marine Corps culture, ethos, and 
values.
    Mrs. Davis. What are the Services doing to reduce the stigma in 
seeking help for mental health issues, especially suicide? Are there 
confidential reporting mechanisms, and if so, are how do the Services 
assess their effectiveness?
    General Milstead. Our leaders emphasize to all Marines that 
psychological and physical fitness are equally important to mission 
readiness, and that asking for help is a sign of strength. All Marines 
receive annual suicide prevention education that includes testimonials 
by Marines who have sought help for stress problems, benefitted from 
treatment, and continued on to achieve career milestones. Suicide 
prevention peer trainers discuss their own struggles with stress and 
their successful use of helping services. Operational Stress Control 
and Readiness training teaches Marines how to listen to one another and 
offer trusted referral for more serious issues. Senior leaders are 
trained to manage command climate in a way that reduces stigma and 
encourages Marines to engage helping services early, before problems 
worsen to the point of crisis. Training for senior leaders emphasizes 
the importance of trust between Marines and their leaders. Training is 
being modified to include education about behavioral health symptoms, 
treatment, and treatment effectiveness, a recommended practice for 
reducing stigma. Due to their nature, anonymous and confidential 
services are challenging to evaluate for effectiveness. Current 
assessment includes utilization rates and numbers of suicides possibly 
averted due to emergency response coordinated by the service. Anonymous 
and confidential services available to Marines include DSTRESS Line 
counseling service (currently a pilot program in the Western US, 
scheduled to expand Corps-wide in 2012); Military Family Life 
Consultants; Military One Source; Veterans Crisis Line; Defense Centers 
of Excellence for Psychological Health and Traumatic Brain Injury 
Outreach Line; Psychological Health Outreach Program (reserves); Yellow 
Ribbon Reintegration Events (reserves); and Families Overcoming Under 
Stress.
    Mrs. Davis. Have the Services noticed any differences between 
Active Duty and Reserve Component suicides? What suicide prevention 
programs exist in each Service that geographically dispersed members of 
the reserves can take advantage of?
    General Milstead. Active duty and selected reserve not on active 
duty suicides share similar stressors--relationship problems, financial 
problems, behavioral health diagnosis, legal and occupational problems, 
and substance abuse.
    Marine leaders mitigate the effect of geographic dispersion on 
selected reserve suicide prevention efforts by reaching out to Marines 
in non-duty status and encouraging strong relationships between Marines 
both on and off duty. Currently, the Marine Corps offers several 
programs to support geographically dispersed Marines. The DSTRESS Line 
is an anonymous, by-Marine-for-Marine counseling service, currently 
piloted in the Western US and scheduled to expand Corps-wide in 2012; 
it is available to all Marines and their loved ones. The Psychological 
Health Outreach Program assists Marine reservists with screening for 
behavioral health issues, referring them for appropriate treatment, and 
assisting with follow up to ensure they are receiving the appropriate 
behavioral health services. Additionally, our Yellow Ribbon 
Reintegration Events/Returning Warrior Workshops address suicide 
prevention and promote resilience in Marine reservists and their 
families.
    External programs available to Marine reservists in non-duty status 
include Military One Source, Veterans Crisis Line, TRICARE transitional 
assistance, Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury Outreach Center, and Department of Veterans 
Affairs OIF/OEF care management teams.
    Mrs. Davis. The DOD Task Force for Prevention of Suicide Among 
Members of the Armed Forces conducted a systematic review of prevention 
efforts and provided 76 recommendations. Where is the Services and the 
Department in implementing any of those recommendations?
    General Milstead. Marine Corps has implemented half of the 76 
targeted recommendations. Our goal is to implement over the next two 
years the remaining recommendations that have been accepted by the 
Secretary of Defense.

    Mrs. Davis. Historically, we've heard about the difficulty in 
hiring behavioral health and related providers within the Services. 
What are the recruiting and hiring challenges? Are there significant 
shortfalls within the Air Force? What is the Air Force doing to address 
those shortfalls?
    General Jones. We have four top challenges for recruiting and 
retaining all health professions, including those in the behavioral 
health specialties:

        1.   Recruiting fully qualified ``ready to practice'' medical 
        professionals is extremely difficult; available incentives 
        cannot match private sector compensation. Additionally, 
        accession bonuses are not viewed as such since they are offered 
        in lieu of specialty pay.

        2.   Retention in general is a problem, forcing increased 
        pressure on accessions. Medical professions are extremely 
        lucrative in the private sector and it is difficult to retain 
        people beyond their first commitment even in a sluggish 
        economy.

        3.   Securing funds and ensuring synchronization of funds for 
        the two portions of the Health Professions Scholarship Program 
        (HPSP) is problematic. Defense Health Program (DHP) and Reserve 
        Personnel Appropriation (RPA) dollars must BOTH be available to 
        start a student in the program.

        4.   Recruitment of civil service healthcare professionals is 
        challenging due to the lengthy hiring process. Maximizing 
        utilization of available Federal Employee Pay and Compensation 
        Act (FEPCA) incentives is a must to compete with private sector 
        hiring.

    We cannot speak for the Army, but shortfalls continue for the Air 
Force with active duty Licensed Clinical Psychologists. Even with 
accession and retention bonuses, scholarship and education loan 
repayment programs, we remain at 85% of our authorized/funded manning 
(218/257) based on the latest mental health provider data presented to 
the Wounded Ill and Injured (WII) Senior Oversight Committee (SOC) for 
third quarter FY11.
    The AFMS uses a three-prong approach to recruiting and retention by 
promoting education opportunities, enhancing direct compensation 
packages, and improving quality of life programs. Success with this 
approach is indicated by improvements to average career length over the 
last 5 years for each of the Corps. To compensate for shortfalls in 
specific specialties, the Air Force must continue to rely on 
contractors and private sector care through the Tricare network.
    Due to the critical need for civilian Defense Health Program (DHP) 
funded behavioral health providers, the Air Force has exempted these 
positions from the current hiring freeze. The non-DHP Family Advocacy 
behavioral health providers are also being considered for exclusion 
from the hiring freeze.
    Mrs. Davis. What are some challenges senior leadership faces 
regarding efforts to reduce suicide and suicide attempts?
    General Jones. Suicide is one of the most challenging issues senior 
leaders face. We always want our Airmen to ask for and receive the help 
they need. Unfortunately, the 2011 Air Force Community Assessment 
Survey of over 64,000 Airmen suggests interpersonal and individual 
stigmas continue to represent significant barriers to help-seeking. The 
Air Force has initiated a number of programs and policies to address 
the issue of stigma. For example, we recently developed a strategic 
communication plan to promote help-seeking and dispel myths about the 
potential career impact from seeking mental health care. Additionally, 
the Chief of Staff of the Air Force and Chief Master Sergeant of the 
Air Force released public service announcements encouraging Airmen to 
ask for help when they need it.
    One challenge is to identify Airmen who may have a higher risk 
factor. The Air Force has a focused curriculum to target suicide 
prevention training toward high risk career fields such as Security 
Forces and Aircraft Maintenance. Supervisors in higher-risk career 
fields also complete the intensive Frontline Supervisors Training, 
which teaches more advanced peer-to-peer intervention techniques. 
Perhaps the greatest challenge leaders face is dealing with a suicide 
that occurs in their unit. Until recently, there was very little 
information to guide leaders through the process of healing their unit. 
We know that the time immediately following a suicide is a period of 
increased risk for friends, family, and co-workers of the deceased. To 
fill this knowledge gap, the Air Force issued comprehensive post-
suicide guidance for leaders. We are hopeful this guidance will help 
the bereaved in the difficult time following a suicide.
    Suicide is a very complex human behavior. Typically, there are a 
number of factors that contribute to suicidal events. We are working 
hard to objectively study suicidal behaviors in the Air Force so we can 
educate senior leadership on the most accurate warning signs and risk 
factors. To this end, the Air Force is working in concert with the 
Defense Centers of Excellence Telehealth and Technology to mature and 
expand the DOD Suicide Event Report (DoDSER). We hope that systematic 
surveillance and study of Air Force suicides will increase our 
understanding of how to better prevent suicides in the future.
    Mrs. Davis. What are the Services doing to reduce the stigma in 
seeking help for mental health issues, especially suicide? Are there 
confidential reporting mechanisms, and if so, are how do the Services 
assess their effectiveness?
    General Jones. The Air Force has been working continuously to 
enhance access to psychological health care and reduce the stigma 
associated with seeking such care. One of the areas that has seen 
considerable attention is our Suicide Prevention Program, and the 
following are some features and improvements. Initial and annual 
suicide prevention training, Frontline Supervisor Training, and Wingman 
Day training all now include stigma-reduction messages. The recently 
published Strategic Communication Plan includes public service 
announcements, media reporting guidelines, leadership talking points, 
and post-suicide guidance for commanders. The Air Force's Limited 
Privilege Suicide Prevention program affords increased confidentiality 
for Airmen under investigation that are suicidal and seeking mental 
health care.
    There is little objective data which indicates the level of mental 
health stigma in the Air Force. However, mental health clinic visits 
have been increasing steadily year by year, suggesting more Airmen are 
overcoming concerns about stigma. To gain additional objective data, 
the 2011 Community Assessment Survey contained several questions 
specifically targeted to mental health stigma. This survey of over 
64,000 Airmen began January 2011. Results suggest that interpersonal 
and individual stigma is more of a barrier to help-seeking than 
institutional stigma. Another Air Force initiative that targets stigma 
reduction is Comprehensive Airman Fitness (CAF) that emphasizes a 
strength-based approach to help withstand stressful life demands. This 
Air Force-wide initiative includes the widespread implementation of the 
Leadership Pathways model that provides incentives to Airmen and family 
members to take existing psychoeducational classes offered by base 
helping agencies. The CAF initiative also makes Airmen aware of helping 
resources and encourages good Wingmanship and responsible help-seeking 
through semi-annual Wingman Days.
    The Behavioral Health Optimization Program (BHOP) is another Air 
Force effort to enhance access to psychological health care and reduce 
stigma associated with seeking such care. BHOP places mental health 
providers in primary care clinics to consult with primary care 
providers and provide brief psychological interventions to all 
beneficiaries in a primary care setting. This not only provides mental 
health services earlier in the treatment process, it facilitates 
referrals to specialty mental health care for those who need that level 
of service. NDAA 2010 Section 714's requirement to increase active duty 
mental health staff by 25 percent will allow a fulltime BHOP at each 
military treatment facility by Fiscal Year 2016. Non-medical 
counseling, such as Military OneSource, Military Family Life 
Consultants, and chaplains, allows Airmen and their families to obtain 
confidential preventative counseling services before problems rise to a 
clinical level. Similarly, Mental Health Resiliency Elements at each 
installation collaborate with key community leaders and helping 
agencies to provide services that enhance the resilience of Air Force 
communities and reduce the incidence of unhealthy behaviors. This 
includes personal visits to base units for outreach and prevention 
activities.
    The Air Force's deployment screening process affords another 
opportunity for Airmen to access mental health services in a more 
routine fashion. Airmen now receive a person-to-person assessment with 
a healthcare provider at four time points: once prior to deployment and 
three times after a deployment.
    Finally, the Air Force Guard and Reserve employ regional, and in 
many cases installation, psychological health assets to assist Air 
Reserve Component members and their families to prevent and manage 
psychological health issues.
    Mrs. Davis. Have the Services noticed any differences between 
Active Duty and Reserve Component suicides? What suicide prevention 
programs exist in each Service that geographically dispersed members of 
the Reserves can take advantage of?
    General Jones. Suicides rates in the Active Duty (AD) Air Force and 
the Air Reserve Component (ARC) historically are similar from year to 
year; however, the Total Force (Active Duty, Guard and Reserve) suicide 
rate this year is slightly lower than the rate for the same period last 
year. Air Force leadership believes in using a tiered-training approach 
model that will help all Airmen from both the active duty and reserve 
components withstand the pressures of military demands. Air Force 
regulations specifically direct unit commanders and first sergeants to 
take an outreach approach and proactively contact and provide support 
for family members of deploying ARC members. The ARC provides education 
and resources for families on deployment-related conditions through 
unit leadership. The unit commander also tasks various support 
agencies, including Airman and Family Readiness, to ensure that 
families are contacted and their needs are met. The Yellow Ribbon 
Program offers resources on Post Traumatic Stress Disorder (PTSD) and 
suicide mitigation and is offered to ARC members and their families 
pre-deployment, during deployment, and 30 and 60 days post deployment.
    The Air National Guard (ANG) assigns an individual to all its wings 
to provide education on PTSD and suicide prevention through Yellow 
Ribbon events. This individual is available to answer any questions the 
ANG member or family member may have related to PTSD, suicide 
mitigation, or other psychological health-related questions or resource 
availability. Family Program Managers also work with ANG family members 
during a spouse's deployment, providing access to information on PTSD 
and suicide awareness.
    The Air Force Reserve Command (AFRC) employs three regional teams 
to locate resources and provide case facilitation for AFRC members and 
their families for psychological health issues, including PTSD and 
suicide. AFRC also has the Wingman Project 
(www.AFRC.WingmanToolkit.org) that provides education about suicide 
prevention. The Wingman Toolkit has been targeted and distributed to 
Air Force Reserve members.
    Finally, Military OneSource and the Military Family Life Consultant 
Program are both available to family members and can provide 
information and guidance on PTSD and suicide. The unit commander is 
responsible for educating families about these services.
    Mrs. Davis. The DOD Task Force for Prevention of Suicide Among 
Members of the Armed Forces conducted a systematic review of prevention 
efforts and provided 76 recommendations. Where is the Services and the 
Department in implementing any of those recommendations?
    General Jones. The Air Force (AF) fully believes a multi-faceted 
strategy designed to reduce risk and increase protective factors will 
provide a framework to reduce the trend of increasing suicide rates in 
the military and save lives. The AF helped develop Task Force 
recommendations that provide a structure to enhance wellness, promote 
total fitness, and sustain a military force fit in mind, body and 
spirit while providing the support mechanisms necessary to meet the 
demands of the high operations tempo required of individuals serving in 
today's military.
    The AF has worked aggressively with the DOD Task Force Response 
Working Group to analyze the 76 targeted recommendations made in the 
Task Force report and to address any potential organizational obstacles 
to implementing the solutions as quickly as possible. In a report to 
Congress, the AF helped identify 36 recommendations that require new 
DOD actions to be taken, 34 recommendations that have action planned, 
underway, or completed and 6 are pending further discussion. For 
recommendations requiring DOD and Military Service action when the way 
ahead is clear and straightforward, those actions will be initiated 
immediately. In cases where additional clarification or more data are 
needed, the AF will devote the required time and resources to clarify 
or assess the extent of the problem so the Task Force's objective can 
be properly evaluated and an enduring outcome achieved. The AF will 
continue to work closely with the Defense Suicide Prevention Oversight 
Council to review, implement, and revise its plan to ensure the best 
possible solutions are identified and implemented within 24 months.
                                 ______
                                 
                    QUESTIONS SUBMITTED BY MR. JONES
    Mr. Jones. Here is a clip from the Watertown Daily Times of Sept. 
8:
    ``A decade ago, Fort Drum had 15 providers and now it has 50, 
according to Dr. Todd L. Benham, the post's behavioral health chief. 
But current wait times are about a month, he said, as visits to 
behavioral health specialists grew from 14,000 in 2001 to 75,000 in 
2010. The numbers increased not only from PTSD visits, but from more 
outreach and an addition of a clinic for traumatic brain injuries, 
which have grown because of IED attacks.
    ``Off-post providers have a three- to four-month waiting list, 
Jefferson County Community Services Director Roger J. Ambrose said. A 
maximum of four to six weeks to see a practitioner would be a good 
start for him, but the number of specialists still must grow.'' [See 
page 83 for full article.]
    a) How can we begin to address the PTSD issue when service members 
are waiting weeks, months for appointments?
    b) This leads to another question: Are we overmedicating our 
service members because of the shortage of mental health professionals? 
I've received many complaints from service members about being 
overmedicated.
    c) I would also be interested to know the correlation between the 
medications being prescribed and suicide, as I think that perhaps our 
service members may be overmedicated.
    Secretary Woodson. a) How can we begin to address the PTSD issue 
when Service members are waiting weeks, months for appointments? In 
CONUS, military treatment facility (MTF) clinics endeavor to have 
Active Duty Service members (ADSMs) seen on-post, and within the 7-day 
intake standard for routine visits. All mental health clinics have 
triage capabilities that allow acute cases to be seen within a 24-hour 
standard, and cases that might warrant psychiatric admission or 
immediate medical intervention are seen emergently, either in the 
clinic or another medically appropriate venue (for example, when 
patients with delirium, intoxication, or substance withdrawal present 
to a mental health clinic, they are often brought to the Emergency 
Department for stabilization and a safer assessment). In less common 
cases where ADSMs require subspecialty mental health care, this is 
provided within a 28-day standard. In these cases, the primary mental 
health provider is responsible for ongoing management and acute 
disposition, if necessary. Clinic managers make consultation resources 
available to generalist practitioners, and the option to defer a 
patient's treatment to a higher level of care (e.g. a partial 
hospitalization program or an inpatient facility) is always available.
    b) Are we overmedicating our Service members because of the 
shortage of mental health professionals? The DOD supports the use of 
psychopharmacological treatments as an important component of mental 
health care. Scientific evidence over the past several decades shows 
that appropriately selected and timed medications can limit the 
severity and duration of mental illness. Medication management is one 
of several strategies pursued to prevent mental health problems in our 
troops. Prescribing safeguards include guidelines in clinics that limit 
the number of pills dispensed to potentially high-risk patients, 
warning flags that appear in electronic drug dispensing menus which 
require physician attention, the MTF prescription restriction program, 
and real-time monitoring and reconciliation of prescriptions dispensed 
through MTFs, mail-order, and network pharmacies. We have also 
increased our reviews of the circumstances of manual overrides of 
system warning flags by physicians.
    c) Is there a correlation between medications being subscribed and 
suicide? In 2004, the Food and Drug Administration (FDA) issued a black 
box warning for antidepressants, the most serious type of warning in 
prescription drug labeling, to inform health care professionals about 
the increased risk of suicide associated with antidepressant use. The 
FDA's black box warning states that antidepressants increased the risk 
of suicidal thinking and behavior in children, adolescents, and young 
adults (ages 18 to 24), and is most likely to occur early in the course 
of treatment. The subsequent decrease in antidepressant prescriptions, 
specifically Selective Serotonin Reuptake Inhibitors in the United 
States corresponded with the largest year-to-year increase in 
adolescent suicides 2003 and 2004 (18%). In fact, evidence supports the 
possibility that antidepressant treatment protects against suicide, by 
treating one of the causal mental health conditions, depression. A 
study in 226,866 veterans indeed confirmed that the rates of suicide 
attempts in patients treated with an antidepressant were roughly one-
third of those observed for patients who were not treated with an 
antidepressant. Therefore, the risk of suicide must be balanced against 
the benefits of antidepressant treatment, including a reduction in 
depressive symptoms and improvement in overall functioning.
    Mr. Jones. Has there been any analysis of family members of service 
personnel committing suicide? What support mechanisms to include 
counseling and therapy have been implemented by DOD to address stress 
on family members of deployed service personnel?
    Secretary Woodson. There are limits on investigative jurisdiction 
regarding deaths that do not occur on military installations and many 
other factors restrict the Department's ability to have a comprehensive 
picture of family member suicides. The Services have limited authority 
and ability to investigate family deaths, mandate training, and monitor 
the stressors faced by family members. Therefore, there is currently no 
consistent and systematic process to track suicides by family members, 
despite the Department of Defense (DOD) being highly concerned.
    However, despite these limitations, the DOD and the Services 
provide a comprehensive range of support mechanisms and preventative 
resources for families, coupled with ongoing assessment of existing 
efforts:

          The Suicide Prevention and Risk Reduction Committee 
        (SPARRC)--Family Subcommittee focuses on current prevention 
        programs and best practices and supports the development of 
        resources like the ACE (Ask, Care, Escort) card for families.

          There are 104 suicide prevention resources available 
        to Service members and their families across all Services, DOD, 
        Department of Veterans, and several non-profit organizations. 
        There are also many avenues for accessing suicide prevention 
        information, including 23 e-mail addresses, 14 phone numbers, 
        52 websites, and 44 hand-outs.

          The Defense Centers of Excellence for Psychological 
        Health and Traumatic Brain Injury (DCoE) coordinates suicide 
        prevention issues with the National Suicide Prevention 
        Lifeline, Military OneSource, the National Resource Directory, 
        and Service hotlines.

          DCoE has also established an Outreach Center that is 
        open 24-hours per day, seven days per week to provide 
        information and resources regarding psychological health to 
        Service members, veterans, and their family members. It may be 
        accessed via telephone, email or online chat and provides the 
        caller with a live chat feature.

          The DOD has also expanded its efforts to address the 
        needs of the Reserve Components and National Guard. For 
        example, the Navy Reserve Psychological Health Outreach Program 
        was established in 2008 to help affected Reserve family and 
        unit members. In addition, the DOD Yellow Ribbon Program Office 
        is expanding services to include suicide prevention, 
        intervention, and postvention for National Guard, Reserve 
        Components, Service members and their families, and 
        communities.

          The Department is currently working with the Services 
        to establish guidelines for postvention and provide guidance on 
        Service postvention programs, a need that was identified by the 
        DOD Suicide Prevention Task Force.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MS. TSONGAS
    Ms. Tsongas. Over August I had the opportunity to meet with a group 
in Massachusetts that was composed of the veterans, counselors, the 
Massachusetts Department of Veterans Services, and the Department of 
Public Health that has come together to meet the needs of Massachusetts 
veterans who have experienced Military Sexual Trauma and post traumatic 
stress. And one thing that kept coming up over and over were examples 
of service members who began experiencing mental health problems and 
were suffering punitive consequences as a result. As all the witnesses 
mentioned in their testimony, there is still stigma associated with 
asking for behavioral health treatment.
    At this meeting, Colman Nee, the Secretary of Veteran Services for 
Massachusetts, told the story of an Active Duty service member who, due 
to a post traumatic stress related issue, hadn't showed up for duty for 
two days. He was actively afraid he was going to be discharged. 
Regarding this issue, I have to ask how do we (a) reach these service 
members for behavioral health treatment before they do something 
drastic and (b) how do we change military rules so that people who 
break rules because of their trauma related issues aren't instantly 
penalized?
    Secretary Woodson. In order to reach these Service members for 
treatment before their situation escalates, the DOD is currently 
engaged in a number of stigma reducing efforts with the end state 
occurring when Service members seeking needed help is considered a sign 
of strength, and not a weakness. These efforts apply to all behavioral 
health needs regardless of the root cause of the problem or trauma. Our 
data show that we are making slow, but steady progress in this area. 
The Services continue to be engaged in reviewing and evaluating polices 
that improve access to care and decrease stigma.
    In addition to working to show that seeking help is not a weakness 
and working to reduce the stigma of asking for help, the DOD has 
collaborated with Service leadership to impress to all Service members 
the various options for help. Especially how it is possible to seek 
help and not get in trouble with your chain of command. While working 
to keep an open door for Service members it is essential for Service 
members to stay accountable with behavioral standards and proactively 
address any barriers, regardless of their medical condition, as long as 
help is available.
    Commanders are duty bound to ensure the safety, welfare, and 
accountability of all of their Soldiers, Sailors, Marines and Airmen. 
Our Commanders are well-versed about the problems of post-traumatic 
stress and other related mental health problems and are already taking 
into consideration their Service members' needs as it relates to these 
problems.

    Ms. Tsongas. Given that PTSD has a significant effect on families, 
and that marital and relationship distress, divorce and social support 
difficulties are key risk factors for suicidal behavior, how are 
Service Members' families and support networks being engaged in suicide 
prevention strategies and services (e.g. couples interventions, family 
support, psycho education of parents and spouses etc)?
    General Bostick. Our focus is on sustaining healthy relationships. 
Accordingly, Commanders continue to encourage the Army's Strong Bonds 
Relationship events to provide skills training and resiliency to 
Soldiers and specialized events to support Family situations 
(predeployment, while deployed and post-deployment modules). A Strong 
Bonds website is available to provide resources and provide a link to 
available training events. Although the Strong Bonds program is not 
primarily a suicide program it does contribute significantly to the 
reduction of distress that can lead to thoughts of suicide, domestic 
violence and other unhealthy behaviors.
    Army Community Services provides voluntary suicide prevention 
training to Family members. Support networks for Family members, whose 
Soldier contemplates/attempts/commits suicide include Behavioral 
Health, Chaplains, TRICARE, Command, Military OneSource, Military 
Family Life Consultants, Army OneSource, Army Community Service and 
civilian community resources. Families may also contact the National 
Suicide Prevention Lifeline at 1-800-273-TALK(8255).
    Additionally, the Chaplains Unit Ministry Teams provide a quick 
pastoral response to crises, conduct programs to help build unit and 
family cohesion and facilitate opportunities to help Soldiers connect 
with faith communities.
    Ms. Tsongas. If the family member or dependants are worried that 
their Service Member is suicidal, what is the process they would take 
to get help (whether the dependant is co-located with them on base, or 
a family member from the Service Members home of record)?
    General Bostick. The first step for a family member is to talk with 
their Soldier about the family member's concerns. There are several 
confidential counseling programs that are available at no cost to the 
Soldier or family member. These programs include Military One Source, 
Military Family Life Consultants, and the TRICARE Assistance Program. 
If the Soldier does not respond to the family members' concerns, the 
family member may notify the unit chain of command or a chaplain.
    Chaplains and Chaplain Assistants form the Unit Ministry Team (UMT) 
in almost every battalion-sized unit in the Army. They provide a quick 
pastoral response to crises, conduct programs to help build unit and 
family cohesion and facilitate opportunities to help Soldiers connect 
with faith communities. Due to the confidentiality policy, chaplains 
provide countless interventions to prevent self-destructive behavior.
    Ms. Tsongas. What efforts are being made to educate and engage the 
civilian community in preventing suicide among returning service 
members and veterans?
    General Bostick. The Army uses various venues to inform Family 
members of suicide prevention material, services, and efforts to 
promote the psychological health of Soldiers and themselves. A plethora 
of information is disseminated through websites such as ArmyOnesource 
and MilitaryOneSource, and through Family Readiness Groups, word of 
mouth, social networking, installation marquee signage, installation 
news papers, bulletins, pamphlets, Suicide Prevention Awareness 
Campaigns, and inserted in Family Program's training curricula, such as 
Family Advocacy, Army Family Team Building, Mobilization and 
Deployment, and Financial Readiness. In addition, the National helpline 
number: 1-800-273-TALK(8255) is included in training material and 
pamphlets. Finally, the Army has played an integral part in working 
with the Suicide Prevention and Risk Reduction Committee (SPARRC), 
Family Sub Working Group (Joint Services) to identify the multiple 
programs and services available to Family Members to promote 
psychological health, and to develop a plan for disseminating this 
information to Family members and other target groups.
    Ms. Tsongas. In Massachusetts, the Massachusetts Department of 
Veterans Services has found that peer to peer work is key to suicide 
prevention. What is your branch of the Service doing to further promote 
peer to peer intervention?
    General Bostick. Peer-to-peer intervention is promoted through 
Applied Suicide Intervention Skills Training (ASIST) workshops and Ask, 
Care, Escort Suicide Intervention (ACE-SI) training. The Army Reserve 
hosted five LivingWorks ASIST train-the-trainer workshops, certifying 
over 124 AR personnel as ASIST instructors. Instructors are charged to 
train first-line leaders as gatekeepers at company size units. Army 
Reserve has trained 1,800 first-line leaders.
    Every Soldier must complete ACE-SI training. ACE-SI is designed to 
help Soldiers become aware of steps they can take to prevent suicides 
and encourages Soldiers to ask a fellow Soldier whether he or she is 
suicidal, care for that Soldier, and escort him/her to the source of 
professional help.
    The Army National Guard (ARNG) considers Peer to Peer (P2P) 
programs to be a foundational best practice for its Risk Reduction, 
Resilience and Suicide Prevention Programs. In early 2011 the ARNG 
reviewed the existing state programs and developed a model P2P program 
for implementation in all the states. Many states have adopted programs 
based on this model. States like California, Nebraska, New Hampshire 
and Illinois have developed unique P2P programs in which they provide 
extensive training to Soldiers in awareness and response to Soldiers in 
crisis. Both Oregon (Oregon Partnership) and New Jersey (Vet to Vet) 
have developed peer based call in centers that have proven to be highly 
effective. New Jersey's program has gone so far as to train veterans to 
provide peer support and then pairing them up with Soldiers prior to 
deployment. Michigan developed a program called Buddy to Buddy in which 
they train Soldiers and then pay them to call other Soldiers post 
deployment to check on them and provide peer support and referral. An 
initiative is being implemented this fall to make the New Jersey Vet to 
Vet program a national peer based program called Vet to Warrior which 
will be modeled after the work they have done in New Jersey and at Fort 
Hood, TX.

    Ms. Tsongas. Given that PTSD has a significant effect on families, 
and that marital and relationship distress, divorce and social support 
difficulties are key risk factors for suicidal behavior, how are 
Service Members' families and support networks being engaged in suicide 
prevention strategies and services (e.g. couples interventions, family 
support, psycho education of parents and spouses etc)?
    Admiral Kurta. Navy unit level (Command) programs are the primary 
method of support, outreach and communication with the families of 
Sailors. They include:

          Command Family Readiness Program. A family readiness program 
        is established at every Navy command to integrate family 
        readiness tools, resources, processes, and procedures into the 
        command's standard operating procedures and culture. Commanders 
        ensure an appropriate, proactive, and accessible family 
        readiness program is maintained and reinforced. This policy 
        prescribes the base-line level of support that will be provided 
        to Sailors and their families; however, senior leaders, 
        commanders, and commanding officers (COs) may go beyond this 
        guidance to ensure a timely and vital continuum of care and 
        support is provided.

          Command Ombudsman. The Ombudsman is a volunteer, appointed by 
        the commanding officer, to serve as an information link between 
        command leadership and Navy families. Ombudsmen are 
        instrumental in providing information and resources to resolve 
        family issues before the issues require extensive command 
        attention. The Command Ombudsman Program is shaped largely by 
        the commanding officer's perceived needs of his/her command. 
        The command ombudsman is appointed by, and works under the 
        guidance of, the commanding officer who determines the 
        priorities of the program, the roles and relationships of those 
        involved, and the type and level of support it will receive. 
        Ombudsmen are trained to disseminate information both up and 
        down the chain of command, including official Department of the 
        Navy and command information, command climate issues, and local 
        quality of life (QOL) improvement opportunities. They also 
        provide resource referrals when needed. Fleet and Family 
        Support Centers provide standardized Ombudsman Basic Training 
        (OBT), which is required for all Command Ombudsmen. During the 
        training module on Crisis Calls and Disasters, suicide 
        prevention training is conducted and includes the actions to 
        take when confronted with suicide behaviors.

          Command Family Readiness Group (FRG). An FRG is a private 
        organization, closely-affiliated with the command, comprised of 
        family members, Sailors, and civilians associated with the 
        command and its personnel, who support the flow of information, 
        provide practical tools for adjusting to Navy deployments and 
        separations, and serve as a link between the command and 
        Sailors' families. FRGs help plan, coordinate and conduct 
        informational, care-taking, morale-building and social 
        activities to enhance preparedness, command mission readiness, 
        and increase the resiliency and well-being of Sailors and their 
        families. FRGs are an integral part of a support service 
        network that includes ombudsmen, fleet and family support 
        centers (FFSCs), chaplains, school liaison officers, and child 
        development centers at the command-level, to provide services 
        in support of service members and their families.

          Commander Navy Installations Command (CNIC) Deployment 
        Readiness Program supports Navy unit level family support and 
        deployment readiness programs with a wide variety of 
        complementary training and support activities including unit 
        level deployment cycle training, online information and 
        individualized one-on-one counseling. Topics include how to 
        identify possible symptoms of depression, anxiety, and other 
        psychological health issues. These topics are covered through 
        Life Skills education workshops such as Stress Management, 
        Conflict Management, Communication Skills, Anger Management and 
        Parenting. This information is provided on demand and as part 
        of the pre-deployment, during deployment, post-deployment, 
        return, reunion, and reintegration training cycle. Operational 
        Stress Control awareness is incorporated into all deployment 
        support programs and briefings to assist with problem 
        identification, support, and early intervention. Additionally, 
        installation Fleet and Family Support Centers have information 
        available, including brochures and public service-type 
        announcements, on how to identify symptoms of depression, 
        anxiety, and other psychological health issues and where to go 
        to get help. Navy also addresses these issues on our 
        Operational Stress Control blog.

          Project FOCUS (Families Overcoming Under Stress), initiated 
        by the Navy Bureau of Medicine and Surgery (BUMED) in 2008, 
        provides state-of-the-art family resiliency services to 
        military children and families at over 20 Navy and Marine Corps 
        sites and online for those in remote locations. FOCUS promotes 
        a culture of prevention and the reduction of stigma through a 
        family-centered array of programs, to include community 
        briefings, educations workshops, individual and family 
        consultations, and resiliency training. This approach teaches 
        military members and their families to understand their 
        emotional reactions, communicate more clearly, solve problems 
        more effectively, and set and achieve their goals throughout 
        the deployment cycle. Feedback on the program has been very 
        positive. Participants report high levels of satisfaction with 
        the services provided, reduced psychological distress, and 
        improved individual and family functioning.

    Additionally, as of June 1, 2011, every Navy web site, including 
those providing information on family support programs, was required to 
include the message ``Life is Worth Living'' and a link to the National 
Suicide Prevention Lifeline and Veterans Crisis Line and Stress Control 
training, materials, and counseling are available for Sailors and their 
families at Fleet and Family Support Centers.
    Ms. Tsongas. If the family member or dependants are worried that 
their Service Member is suicidal, what is the process they would take 
to get help (whether the dependant is co-located with them on base, or 
a family member from the Service Members home of record)?
    Admiral Kurta. Concerned family members can contact the service 
member's command. Every Navy command is required to maintain a crisis 
response plan to ensure command members understand how to quickly and 
effectively get help to someone in distress or keep someone who is at 
acute risk safe until they can receive professional care.
    Although most Navy commands have a duty office or duty officer 
available 24/7, some family members may be unsure of how to contact the 
service member's command. This is why Navy also works closely with the 
VA to coordinate information and resources with the National Suicide 
Prevention Lifeline (1-800-273-TALK). This partnership facilitated a 
modification to the introductory message on the Lifeline, by pressing 
the number 1, that enables veterans, service members, or callers 
concerned about a veteran or service member to access a crisis 
counselor who is knowledgeable about the military and has access to 
resources designed specifically for this community. Additionally, as of 
1 June 2011, every Navy web site was required to include the message 
``Life is Worth Living'' and a link to the National Suicide Prevention 
Lifeline and Veterans Crisis Line.
    Ms. Tsongas. What efforts are being made to educate and engage the 
civilian community in preventing suicide among returning service 
members and veterans?
    Admiral Kurta. The Real Warriors Campaign is an initiative launched 
by the Defense Centers of Excellence (DCoE) for Psychological Health 
and Traumatic Brain Injury to promote the processes of building 
resilience, facilitating recovery and supporting reintegration of 
returning service members, veterans and their families. The Real 
Warriors Campaign presents real world examples of successful use of 
services to overcome personal crises and psychological health problems. 
This campaign is progressing steadily.
    OSD has representatives working with the Action Alliance Task Force 
to help develop a Suicide Prevention National Strategic Plan and with 
the Substance Abuse and Mental Health Administration (SAMHSA) on the 
Partners in Care pilot projects throughout the country. The Suicide 
Prevention & Resiliency Resource Inventory (SPRRI) Project is planning 
a Community Organization Response Effort (CORE) Roundtable with 
civilian agency representatives and consultants from across the United 
States to review their experience working with the National Guard and 
Reserves around suicide prevention in their communities.
    Because Navy installation-based Fleet and Family Support Centers 
provide information and referral services to Service members and their 
families, they also make contact with appropriate resources in their 
communities that can provide support. For Reserve personnel, Navy and 
Marine Forces Reserve Psychological Health Outreach Program (PHOP) 
teams, located at regionally central Reserve Commands throughout the 
country, connect and work with local community agencies where 
Reservists live. Team members educate and engage these community 
resources concerning the psychological health needs of Reservists and 
their families.
    Project FOCUS (Families Overcoming Under Stress), initiated by the 
Navy Bureau of Medicine and Surgery (BUMED) in 2008, provides state-of-
the-art family resiliency services to military children and families at 
over 20 Navy and Marine Corps sites, and online for those in remote 
locations. FOCUS promotes a culture of prevention and the reduction of 
stigma through a family-centered array of programs, to include 
community briefings, educations workshops, individual and family 
consultations, and resiliency training. This approach teaches military 
members and their families to understand their emotional reactions, 
communicate more clearly, solve problems more effectively, and set and 
achieve goals throughout the deployment cycle. Feedback on the program 
has been very positive. Participants report high levels of satisfaction 
with the services provided, reduced psychological distress, and 
improved individual and family functioning. Part of the FOCUS 
repertoire to is to educate the community in which Service members and 
their families live on psychological health and increasing resiliency--
as part of that education and awareness, suicide prevention and stress 
detection is included.
    Navy fully endorses coordinating communications efforts using 
science of health communication to engage the civilian community in 
preventing suicide among returning Service members and veterans, 
encouraging them choosing to live life fully and use every available 
resource to be the best professional service members (and family) 
possible. However, recent experience and research indicates such 
communications must be carefully crafted to avoid unintentionally re-
enforcing negative stereotypes some civilians may hold about ``mentally 
unbalanced'' veterans. Additional research to understand 
repercussions--the real positive or negative effects of support service 
utilization--is essential to address barriers and publish myth-busting 
facts.
    DCoE (and the Services) also work closely with the VA to coordinate 
information and resources with the National Suicide Prevention Lifeline 
(1-800-273-TALK). This partnership facilitated a modification to the 
introductory message on the Lifeline, that enables veterans, service 
members, or callers concerned about a veteran or service member, to 
access a crisis counselor knowledgeable about the military and who has 
access to resources designed specifically for this community. 
Additionally, as of June 1, 2011, every Navy web site was required to 
include the message ``Life is Worth Living'' and a link to the National 
Suicide Prevention Lifeline and Veterans Crisis Line.
    Ms. Tsongas. In Massachusetts, the Massachusetts Department of 
Veterans Services has found that peer to peer work is key to suicide 
prevention. What is your branch of the Service doing to further promote 
peer to peer intervention?
    Admiral Kurta. Navy has several training initiatives that promote 
peer-to-peer, as well as front line supervisor, intervention:

          Peer to Peer Suicide Awareness and Prevention 
        Training--a 60 minute training aimed at junior Sailors that 
        applies information about risk and protective factors, warning 
        signs, and ACT (Ask, Care, Treat) to a scenario and includes 
        video clips, discussion and role play exercises and a music 
        video.

          Video: ``Suicide Prevention: A Message from 
        Survivors'' augments facilitated training with powerful 
        accounts from Sailors and family members who were impacted by a 
        suicide loss or helped overcome a suicide crisis.

          Front Line Supervisor Training--a 3 to 4 hour 
        facilitator-led interactive training that leads deck plate 
        supervisors that uses role play, case examples, and discussion 
        to learn how to prepare an environment to recognize and engage 
        a member in distress and refer them to appropriate support when 
        needed.

    Additionally, the Coalition of Sailors Against Destructive 
Decisions (CSADD), a grassroots peer mentoring program led by and for 
young Sailors, continues to grow with over 200 chapters across the 
Navy. CSADD focuses on empowering our most junior Sailors with the 
tools and resources to promote good decision-making processes and 
leadership development while reinforcing a culture of shipmates helping 
shipmates. CSADD members promote awareness and discussion among their 
peers across a range of areas, to include suicide prevention, financial 
management, responsible use of alcohol, personal safety, and domestic 
violence. Examples of CSADD initiatives include the ``Stop and Think 
Campaign,'' which highlights the potential consequences of poor 
decisions, an active Facebook page where Sailors can ask questions, 
access information and training materials, and share lessons learned, 
and a semi-annual newsletter to highlight best practices across the 
Navy.

    Ms. Tsongas. Given that PTSD has a significant effect on families, 
and that marital and relationship distress, divorce and social support 
difficulties are key risk factors for suicidal behavior, how are 
Service Members' families and support networks being engaged in suicide 
prevention strategies and services (e.g. couples interventions, family 
support, psycho education of parents and spouses etc)?
    General Milstead. An important component of the Marine Corps' 
suicide prevention strategy involves behavioral health education for 
parents, spouses, and peers. We offer a wide variety of training 
programs and classes that build stronger support networks and families, 
and help them to identify and intervene in those problems that if left 
unnoticed could develop into a suicide crisis. ``LifeSkills'' Education 
and Training Workshops teach communication skills, relationship skills, 
and conflict resolution for spouses, parents, and children. Family 
Readiness Officers at the unit level offer deployment cycle training to 
all Marines and families. This training includes ``Marine Operational 
Stress Training'' (MOST) with an emphasis on recognizing both stressors 
as well as reactions to stress. A new, two-hour training package 
designed to teach families about combat operational stress control 
fundamentals and enhanced communication skills is in the final stages 
of development.
    Our Family Readiness Officers routinely provide families with 
suicide prevention resource information to include the National Suicide 
Prevention Lifeline and Military One Source. Additionally, we have 
recently completed the evaluation of our pilot program in the western 
U.S., ``DSTRESS Line''. The DSTRESS Line is a 24/7, anonymous, peer-to-
peer counseling service following a `By Marine/For Marine' concept, 
where veteran Marines, corpsmen, and Marine Corps spouses will answer 
calls and online chats from our Marines, attached Sailors, and 
families. For complex issues or crisis calls such as a suicide event 
that are out of the scope of a peer responder, onsite licensed clinical 
counselors take over to provide more in-depth assistance. The pilot 
program proved a success, and the DSTRESS Line will open Corps-wide 
during early 2012.
    Ms. Tsongas. If the family member or dependants are worried that 
their Service Member is suicidal, what is the process they would take 
to get help (whether the dependant is co-located with them on base, or 
a family member from the Service Members home of record)?
    General Milstead. When concerned for the safety of their Service 
member, family members and dependents should call 911 to engage 
emergency response services. Alternately, they may contact anyone in 
the member's chain of command, who will then ensure the Service member 
is safe and immediately referred to care. Other resources available to 
family members and dependants are the Defense Center of Excellence 
Outreach Call Center, the Veteran's Crisis Line, and Marine Corps 
Community Services counseling centers.
    Additionally, we have recently completed the evaluation of our 
pilot program in the western U.S., ``DSTRESS Line''. The DSTRESS Line 
is a 24/7, anonymous, peer-to-peer counseling service following a `By 
Marine/For Marine' concept, where veteran Marines, corpsmen, and Marine 
Corps spouses will answer calls and online chats from our Marines, 
attached Sailors, and families. For complex issues or crisis calls such 
as a suicide event that are out of the scope of a peer responder, 
onsite licensed clinical counselors take over to provide more in-depth 
assistance. The pilot program proved a success, and the DSTRESS Line 
will open Corps-wide during early 2012.
    Ms. Tsongas. What efforts are being made to educate and engage the 
civilian community in preventing suicide among returning service 
members and veterans?
    General Milstead. The Marine Corps trains its retail and 
recreational services employees to recognize signs of distress in 
Marines, engage with Marines, and help Marines in distress find helping 
services. The Marine Corps is studying the feasibility of creating 
suicide-specific prevention training for all civilian employees.
    Community involvement is equally important to suicide prevention. 
The Yellow Ribbon Reintegration Program (YRRP), which is a DOD-wide 
effort mandated in Public Law 110-181, Section 582, calls for 
informational events and activities for National Guard and Reserve 
Service members and their families, to facilitate access to services 
supporting their health and well-being throughout the deployment cycle. 
Yellow Ribbon Events provide interactive and informative seminars on: 
communication, stress management, post-military career opportunities, 
money management, health education, parental skills, suicide 
prevention, resilience training, and other life-skills training. In 
addition to these seminars, YRRP provides access or referrals, through 
our relationships with other Federal and non-federal entities, to 
support services for issues concerning: mental health and substance 
abuse disorder; traumatic brain injury; housing stabilization; and 
family support. YRRP also offers access to employment resources and 
career counseling to support those Service members facing unemployment/
underemployment or who have career concerns after being demobilized/
redeployed.
    In addition, we recognize that individuals who feel ``connected'' 
to one another are more engaged at work and home and, therefore, tend 
to be more resilient. Over the course of the next year, we will be 
working to develop and implement a plan that utilizes a more community-
based approach to taking care of our Marines and their families. 
Connecting our Marines, their units, and their families to the programs 
and services in the Marine Corps, as well as those in their 
communities, will encourage them to become more involved and active in 
their communities, and ultimately build and maintain their overall 
resiliency.
    Ms. Tsongas. In Massachusetts, the Massachusetts Department of 
Veterans Services has found that peer to peer work is key to suicide 
prevention. What is your branch of the Service doing to further promote 
peer to peer intervention?
    General Milstead. In 2009, the Marine Corps redesigned its suicide 
prevention and awareness training with the evocative, award-winning 
peer-led training--``Never Leave A Marine Behind'' for Non-Commissioned 
Officers. Last year, we released courses for Junior Marines, officers, 
and staff noncommissioned officers. Marines from the operating forces 
were included in all stages of course development. The courses contain 
various degrees of training in personal resilience, peer-to-peer and 
frontline supervisor intervention, and managing command climate to 
build resilience and encourage Marines to engage helping services 
early, before problems escalate to suicide.
    In addition, our Combat and Operational Stress Control (COSC) 
Program provides Operational Stress Control and Readiness (OSCAR) Team 
Training. OSCAR training creates teams of leaders, Marines, medical and 
religious ministry personnel within each battalion-sized operational 
unit with the skills and knowledge to help the commander in the 
prevention of stress injuries, and early identification of Marines 
impacted by stress. By changing social norms and common beliefs, OSCAR 
Team Members reduce stigma associated with behavioral health treatment, 
which improves referral, rapid case identification and treatment, and 
contributes to our Marines' overall well-being.
    Lastly, the DSTRESS Line, our pilot program in the western U.S., is 
based on peer to peer counseling for our Marines, attached Sailors, and 
families. Callers speak or chat anonymously with `one of their own'--a 
veteran Marine, corpsman, or Marine family member who shares our common 
culture and ethos.

    Ms. Tsongas. Given that PTSD has a significant effect on families, 
and that marital and relationship distress, divorce and social support 
difficulties are key risk factors for suicidal behavior, how are 
Service Members' families and support networks being engaged in suicide 
prevention strategies and services (e.g. couples interventions, family 
support, psycho education of parents and spouses etc)?
    General Jones. In 2009 the Air Force acknowledged the need for a 
more robust set of strategies to assist our Air Force Community (Active 
Duty, Reserve, National Guard, Civilians and families) in coping with 
the challenges of military lifestyles and stood up the Air Force 
Resilience office. The mission of the office is to ``build and sustain 
a thriving and resilient Air Force Community that fosters mental, 
physical, social and spiritual fitness.'' This is accomplished through 
a multi-faceted approach which incorporates assessments, education and 
training programs and support services all under the umbrella of the 
Comprehensive Airman Fitness (CAF) initiative.
    Education and training programs include martial, family and 
parenting workshops. Additional resources are available to help address 
PTSD such as Airman and Family Readiness Centers, Chaplains, Mental 
Health facilities, Military Family Life Consultants and Health and 
Wellness Centers are available to all members of our AF Community. The 
Yellow Ribbon Program also offers resources on Post Traumatic Stress 
Disorder (PTSD) and suicide mitigation and is offered to ARC members 
and their families pre-deployment, during deployment, and 30 and 60 
days post deployment.
    Finally, we are developing larger initiatives to promote personal 
growth. Leadership Pathways is a new initiative which incentivizes 
participation in resilience building events, activities and classes. 
There is also a plan to employ Master Resilience Trainers (MRTs) at 
each Air Force base to conduct needs assessments, perform program 
evaluation and design custom-tailored, resilience-based training.
    In sum, CAF is designed to promote a resilient AF community by 
employing a number of education and training programs and support 
services. The end goal is to equip the Air Force community with the 
tools they need to manage the rigors of military life.
    Ms. Tsongas. If the family member or dependants are worried that 
their Service Member is suicidal, what is the process they would take 
to get help (whether the dependant is co-located with them on base, or 
a family member from the Service Members home of record)?
    General Jones. The Air Force has a number of services in place to 
support family members. The frontline of support for families is always 
the unit leadership. If a family member is concerned about the 
wellbeing of an Airman they should immediately reach out to the 
Squadron Commander, First Sergeant or supervisor. Additionally, 
chaplains, mental health providers and primary care physicians are 
standing ready to assist family members who are concerned that their 
service member is suicidal. If a family member believes that the 
service member poses an imminent risk to themselves or others they 
should call 911 or local law enforcement, who can engage emergency 
services right away.
    Outside of the military a number of more confidential resources 
exist to support family members. The Department of Veterans Affairs 
offers both a 24-hour suicide prevention crisis line and online chat. 
Military OneSource also offers confidential counseling and referral 
options to military dependents.
    Ms. Tsongas. What efforts are being made to educate and engage the 
civilian community in preventing suicide among returning service 
members and veterans?
    General Jones. The primary forum for suicide prevention 
collaboration and community engagement at the Department of Defense 
level is the Suicide Prevention and Risk Reduction Committee (SPARRC). 
The SPARRC provides a forum for the Department of Defense and the 
Department of Veterans Affairs (VA) to partner and coordinate suicide 
prevention and risk reduction efforts with civilian organizations like 
Substance Abuse and Mental Health Services Administration (SAMSHA) and 
Tragedy Assistance Program for Survivors (TAPS). This committee is 
chaired by the Defense Centers of Excellence for Psychological Health 
and Traumatic Brain Injury (DCoE). Members include suicide prevention 
program managers from each of the services and representatives from the 
National Guard Bureau, Office of the Assistant Secretary of Defense 
Reserve Affairs, VA, Office of Armed Forces Medical Examiner, National 
Center for Telehealth and Technology, SAMSAH and others. Information is 
disseminated by committee members to their respective stakeholders, 
including service members, families, health care providers and the 
field of psychological health research.
    At the local level, the Air Force uses the Community Action and 
Information Board (CAIB) to integrate installation and community 
helping resources. The Air Force Reserve Component installations employ 
Directors of Psychological Health and Psychological Health Advocacy 
Program managers to collaborate with local resources to support service 
members and prevent suicide.
    Ms. Tsongas. In Massachusetts, the Massachusetts Department of 
Veterans Services has found that peer to peer work is key to suicide 
prevention. What is your branch of the Service doing to further promote 
peer to peer intervention?
    General Jones. Peer-to-peer intervention is a center piece of the 
Air Force Suicide Prevention Program. All Airmen receive annual suicide 
prevention training based on the Ask, Care, Escort (ACE) peer-to-peer 
model of suicide prevention. The peer-to-peer concept is also 
reinforced at semi-annual Wingman Days, which emphasize responsible 
help-seeking and unit cohesion. Supervisors in higher-risk career 
fields also complete the intensive Frontline Supervisors Training, 
which teaches more advanced peer-to-peer intervention techniques.
    The Air Force is also working on training and placing four Master 
Resiliency Trainers (MRT) at each installation. These MRTs will 
function as peer mentors to Airmen and advise on ways to manage stress 
and improve coping so Airmen are able to deal with adversity and avoid 
crises. Finally, Applied Suicide Intervention Skills Training (ASIST) 
and Safe Talk are chaplain-sponsored programs for teaching skills to 
uncover thoughts of suicide and bring a person with thoughts of suicide 
to a more experienced caregiver.
                                 ______
                                 
                  QUESTIONS SUBMITTED BY MS. BORDALLO
    Ms. Bordallo. DOD noted in its response to Congress that it agreed 
that there was a need for an OSD suicide prevention office, when can 
Congress expect to see that office stood up? Can OSD share a copy of an 
implementation plan? Who will be the Executive Director of the office? 
Will this office be adequately staffed to address suicide issues for 
the Services' Total Workforce (AC, RC, Civilians and their family 
members)?
    Secretary Woodson. While the effort to meet the full intent of the 
Task Force's recommendation to establish an office has been challenging 
in this fiscal environment, the USD P&R has given direction and 
provided initial funding to establish the baseline manning for a 
suicide prevention team. This team will conduct day-to-day activities 
and provide direct support to the Defense Suicide Prevention Oversight 
Council (DSPOC) which will continue to be the primary entity to provide 
strategic direction, oversight, and policy standardization of DOD 
suicide prevention efforts and programs.
    This team will be supported by five government subject matter 
experts, to include a clinical psychologist. Additional contract 
support will be added to provide specific expertise and support as 
required. Resources are also being budgeted in FY13 and beyond to 
further support this effort without duplicating programs being executed 
at the Service level. As this is a lengthy process, the exact manpower 
requirements and specific personnel to fill the billets are still being 
determined.
    It is the intent of the USD P&R that this effort will be focused on 
addressing suicide prevention issues not just for the active duty 
force, but for the Reserve Component as well.
    Ms. Bordallo. How will DOD improve its tracking and data on 
suicides among members of the Armed Forces? How will it go about 
tracking suicides among family members?
    Secretary Woodson. The Department currently has an excellent 
surveillance process to collect data on fatal and non-fatal suicide 
events for active duty service members. The Department is working to 
further refine these procedures based on the recommendations of the 
Final Report of the Department of Defense Task Force on the Prevention 
of Suicide by Members of the Armed Forces. For example, the Department 
is working more closely with the Department of Veterans Affairs, the 
National Center for Telehealth and Technology, and the Office of the 
Armed Forces Medical Examiner to coordinate and develop a joint 
database to gather and report suicide prevention surveillance data, 
analyze data, and help translate findings into policy updates and 
program strategy in a dynamic manner. Also, the Principal Deputy Under 
Secretary of Defense for Personnel and Readiness signed a memorandum 
directing the Department to adopt a standardized system of nomenclature 
for clinical events related to suicide. This will allow the Department 
to more accurately classify these events and bring the Department into 
alignment with the Centers for Disease Control and Prevention and the 
Department of Veterans Affairs. Furthermore, the Department is 
currently working to issue a DOD instruction to codify the process for 
publishing and using the DOD Suicide Event Report. This will enhance 
the fidelity and accuracy of suicide event data and improve the process 
of dissemination.
    The Department is concerned about any suicide that occurs in the 
military community, to include suicides among family members, and is 
committed to meeting the needs of the survivors and providing the 
necessary support. While we have reliable methods of collecting data on 
suicides for service members, we have no such method for family 
members, as the Department is sensitive to their federally protected 
rights to privacy.
    Ms. Bordallo. How will DOD go about identifying key areas for 
additional research into suicide? How will research be translated into 
best practices at the clinical level and among line commanders?
    Secretary Woodson. The Department has already identified key areas 
for additional research. For example, the Department has awarded a $17 
million federal grant to Florida State University and the Denver 
Veterans' Affairs Medical Center to establish the Department of Defense 
(DOD) Military Suicide Research Consortium (MSRC). The consortium is 
the first of its kind to integrate DOD and civilian efforts in 
implementing a multidisciplinary research approach to suicide 
prevention.
    In addition and in response to the Final Report of the Department 
of Defense Task Force on the Prevention of Suicide by Members of the 
Armed Forces, the Department will review and evaluate all organizations 
within the Department (and those organizations outside of the 
Department that receive funds from DOD) that are involved in suicide 
prevention research. This review is for the purposes of identifying 
overlap, duplication of effort, and identifying gaps; make 
recommendations to create a unified, strategic, and comprehensive plan 
for research in military suicide prevention. After review, the report 
the findings will be submitted to the Defense Suicide Prevention 
Oversight Council for further action.
    In order to promote the translation of mental health related 
research into action, the VA/DOD Integrated Mental Health Strategy, 
Translation of Mental Health Research Work Group, will promote 
innovative action, programs, and policies for service members. 
Specifically, this Work Group is tasked to facilitate the rapid 
translation of research findings into innovations in mental health 
care. They are monitoring on-going research, making recommendations for 
adoption of models and practices to promote translation, and creating 
standardized operating procedures to ensure collaboration and 
communication between the Department of Defense and the Department of 
Veterans Affairs and throughout their respective Departments.
    Ms. Bordallo. What will DOD do to improve support and services to 
survivors of suicide (for the Total Force) among unit members and next 
of kin?
    Secretary Woodson. The Department has taken several actions to 
support unit members and family members in the aftermath of a suicide. 
Each Service has traumatic response teams and mental health providers 
available to meet the emotional needs of unit and family members. Each 
Service has disseminated guidance for commanders and first sergeants to 
assist in their response to suicides and non-fatal suicide attempts. 
Normally, the unit commander will conduct an installation or unit 
memorial service following the death of a Service member, to include a 
death by suicide. For eligible relatives, it is Department policy to 
provide funds for authorized travel and transportation expenses for one 
round-trip to the installation or unit memorial service. In addition, 
each Service has an officer or senior non-commissioned officer who has 
been trained and assigned to support the family in the event of a 
Service member's death.

                                  
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