[Senate Hearing 112-267]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 112-267
 
    VA MENTAL HEALTH CARE: ADDRESSING WAIT TIMES AND ACCESS TO CARE 

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 30, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director




























                            C O N T E N T S

                              ----------                              

                      Wednesday, November 30, 2011
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Akaka, Hon. Daniel K., U.S. Senator from Hawaii..................     5
Tester, Hon. Jon, U.S. Senator from Montana......................     5
Isakson, Hon. Johnny, U.S. Senator from Georgia..................    44
Boozman, Hon. John, U.S. Senator from Arkansas...................    48
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia...   101
    Prepared statement...........................................   104

                               WITNESSES

Washington, Michelle, Ph.D., Coordinator, PTSD Services and 
  Evidence-Based Psychotherapy, Wilmington, DE, VA Medical 
  Center, representing American Federation of Government 
  Employees, AFL-CIO, and the AFGE National VA Council...........     7
    Prepared statement...........................................     9
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    14
      Hon. Richard Burr..........................................    15
      Hon. John D. Rockefeller IV................................    15
      Hon. Bernard Sanders.......................................    16
Hoge, Charles W., M.D., Colonel, U.S. Army (Ret.)................    16
    Prepared statement...........................................    17
    Response to posthearing questions submitted by:
      Hon. Richard Burr..........................................    20
      Hon. John D. Rockefeller IV................................    21
      Hon. Bernard Sanders.......................................    22
Dahlen, Barbara Van, Ph.D., Founder and President, Give an 
  HourTM..............................................    22
    Prepared statement...........................................    24
    Response to posthearing questions submitted by:
      Hon. Richard Burr..........................................    28
      Hon. John D. Rockefeller IV................................    29
      Hon. Bernard Sanders.......................................    30
Roberts, John, Executive Vice President, Mental Health and 
  Warrior Engagement, Wounded Warrior Project....................    30
    Prepared statement...........................................    32
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    36
      Hon. Richard Burr..........................................    37
      Hon. John D. Rockefeller IV................................    38
      Hon. Bernard Sanders.......................................    39
Schohn, Mary, Ph.D., Director, Mental Health Operations, Veterans 
  Health Administration, U.S. Department of Veterans' Affairs, 
  accompanied by Antonette Zeiss, Ph.D., Chief Consultant, Office 
  of Mental Health Services; and Janet Kemp, R.N., Ph.D., 
  National Director, Suicide Prevention Program..................    50
    Prepared statement...........................................    52
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    55
      Hon. Richard Burr..........................................    73
      Hon. John D. Rockefeller IV................................    76
      Hon. Bernard Sanders.......................................    78
      Hon. Mark Begich...........................................    78
      Hon. Roger F. Wicker.......................................    81
      Hon. Scott P. Brown........................................    83
    Response to additional posthearing questions submitted by 
      Hon. Richard Burr..........................................    85
    Response to request arising during the hearing by Hon. 
      Richard Burr...............................................    98

                                APPENDIX

The American Psychiatric Association; prepared statement.........   109


    VA MENTAL HEALTH CARE: ADDRESSING WAIT TIMES AND ACCESS TO CARE

                              ----------                              


                      WEDNESDAY, NOVEMBER 30, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:57 a.m., in 
room 418, Russell Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Rockefeller, Akaka, Tester, Burr, 
Isakson, Wicker, Johanns, Brown of Massachusetts, and Boozman.

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

    Chairman Murray. Good morning. We will begin this hearing 
today on examining barriers that our veterans are facing in 
seeking mental health care.
    We have a number of Senators who are going to be joining us 
today. I am getting started a minute or two early. My Ranking 
Member, Senator Burr, will be hear in just a few minutes, but 
we are going to have votes in an hour. We have two panels today 
and a lot going on. So, we are going to go ahead and getting 
started.
    Today's hearing builds upon our July hearing on the same 
subject. At that hearing, the Committee heard about two 
servicemembers who, even after attempting to take their own 
lives, had their appointments postponed and difficulties 
getting through red tape in order to access the care that they 
needed.
    I know that like me many on this Committee were angered and 
frustrated by their stories, and I am glad that today that we 
are going to have the opportunity to both get more information 
and answers on why these delays persist.
    Today, we are going to be hearing from providers about the 
challenges that they face getting patients into care, including 
from Dr. Michelle Washington, who has been brave enough to come 
forward to give us a true sense of the daily frontline barriers 
at our VA facilities.
    We will also hear about the critical importance of access 
to the right type of care delivered on time by qualified mental 
health professionals.
    At our hearing in July, I requested that the VA survey 
their frontline mental health professionals about whether they 
have sufficient resources to get veterans into treatment. The 
results that came back to me shortly after that were not good.
    Of the VA providers that were surveyed, nearly 40 percent 
said that they cannot schedule an appointment in their own 
clinic within the VA mandated 14-day window. Seventy percent 
said that they did not have adequate staff or space to meet the 
mental health care needs of the veterans that they served. And 
46 percent said the lack of off-hour appointments prevented 
veterans from accessing care.
    The survey not only showed that our veterans are being 
forced to wait for care, it also captured the tremendous 
frustration of those who are tasked with healing our veterans.
    That hearing also identified wide discrepancies between 
facilities in different parts of the country, including the 
difference between access in urban and rural areas, and it 
provided a glimpse at a VA system that 10 years into war is 
still not fully equipped for the influx of veterans that are 
seeking mental health care.
    VA can and must do much better, and I am pleased to say 
that since I asked for the survey, they had taken some steps in 
the right direction. They worked to hire additional mental 
health staff to fill vacancies. They have increased their 
staffing levels at the Veterans Crisis Line and Homeless Call 
Center, and they have made VISN directors accountable for more 
standards of access to care. These are positive steps, but 
there is much more to be done as we will undoubtedly see today.
    Just yesterday before this hearing, I looked through the 
most recent statistics on PTSD that VA had provided the 
Committee, and they really showed what all of us know: this 
problem is not going anywhere.
    As thousands of veterans today return from Iraq and 
Afghanistan, you can see the number of PTSD appointments 
steadily rise over time. With another announcement yesterday of 
33,000 troops coming home by the end of next year from 
Afghanistan, the demand for care will only swell.
    This should not come as a shock to the VA, and it should 
not cause the waiting lines for care to grow, especially at a 
time when we are seeing record suicides among our veterans.
    We need to meet the veterans' desire for care with the 
immediate assurance that it will be provided and provided 
quickly. We cannot afford to leave them discouraged because 
they cannot get an appointment. We cannot leave them 
frustrated. We cannot let them down. We need to fix this now.
    The VA has had a decade to prepare. Now is the time for 
action and for effective leadership.
    I look forward to hearing from all of our witnesses today, 
and I hope that this hearing is another step to increased 
accountability of our efforts to provide timely mental health 
care.
    I do want to mention that Loyd and Andrea Sawyer, who 
testified at our July hearing, are here today, and I want to 
thank them for all they have done to help us understand this 
challenge.
    Even after coming before this Committee, they are 
continuing to have trouble navigating the system. I understand 
that Dr. Schohn has been personally working to help them get 
past some of the barriers, and I want to thank you, Dr. Schohn, 
for your help in this.
    But I think that they continue to highlight for all of us 
the continuing issues with the VA mental health care and the 
challenge that this Committee is going to continue to pursue 
and to follow and make sure that we are taking care of the 
mental health needs of our soldiers who are returning home or 
who have been home for some time.
    We have two panels this morning. We are going to have a 
vote at 11 o'clock which will interrupt the Committee.
    So, I am going to turn it over to my Ranking Member as soon 
as he is ready with his opening statement. I would ask any 
other Committee Members to try and keep their statements short.
    But before I turn it over to the Ranking Member, I 
understand it is his birthday today. [Laughter.]
    So, welcome. I am glad that you are spending it with all of 
us. I am sure you have other ideas, but we are glad that you 
are here with us today.
    So, Senator Burr, if you want to go into your opening 
statement.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Chairman Murray. It is good to 
have you back. I wish the outcome of the Super Committee had 
been different, but I know that on both sides Members committed 
a lot of hours to try to complete that process and it shows how 
daunting the task is.
    And I thank you for the kind birthday remarks, but I have 
now reached the point where I enjoy this versus the alternative 
but I just as soon not count the numbers as they add up.
    I want to thank you for holding this important hearing 
today to examine the barriers that veterans face in receiving 
the mental health services from the VA.
    I welcome all of our witnesses. It is insights from people 
like you that help this Committee truly do our oversight 
duties.
    As you know, this hearing is a follow-up to the July 14 
mental health hearing where serious issues were raised by two 
of our witnesses, Andrea Sawyer and Daniel Williams, about 
problems assessing appropriate mental health care.
    VA told Daniel and Andrea's husband Loyd that they would 
have to wait months to see a provider. Then, when Loyd was 
finally able to get treatment from the VA, we were told there 
was no coordination of care among his providers.
    Unfortunately, their stories are not unique. I continue to 
hear from veterans about the problems they run into trying to 
get mental health care.
    As the Chairman mentioned after the last mental health care 
hearing, she requested that the VA conduct a survey of the 
mental health care providers to try to get to the root of the 
problem.
    The results of the survey confirmed what we already knew, 
that some veterans have a very difficult time in getting an 
appointment scheduled. This is simply unacceptable. The men and 
women of the Armed Forces suffering from the invisible wounds 
of war deserve better.
    So, today we will again look at what is causing these 
problems, why they have not been fixed, and more importantly, 
when veterans will be able to get the appropriate and timely 
care that they need and deserve.
    At a hearing in May, Dr. Zeiss indicated that the VA does 
have the resources it needs to meet the mental health care 
needs of our veterans. In fact, in fiscal year 2011, Congress 
appropriated $5.7 billion for mental health care services, a 25 
percent increase over the previous year's budget and a 136 
percent increase since 2006.
    What has VA been doing with the resources Congress has 
provided over the years?
    Also, as the VA's testimony points out, there has been a 
47.8 percent increase in mental health staffing since 2006. 
Yet, in a VA Inspector General's report published earlier this 
year, the IG reported that only 16 percent of the sites they 
visited met their staffing requirements for mental health care.
    Why have not the staffing increases been affected?
    To top it all, the VA's response to the survey was to put 
together an action plan to develop a plan to address the issues 
raised by VA clinicians.
    What is the plan of action the VA outlines? Focus groups, 
audits and publishing yet more policy guidelines. The question 
is how does this help our veterans in need of mental health 
care services today? How does this action plan help veterans 
waiting to get follow-up treatment?
    As Dr. Hoge will testify today, 70 to 80 percent of the 
patients diagnosed with PTSD can get better. We stress that. 
Seventy to 80 percent can get better if the patients are able 
to get the care and continue with the treatment over the long 
term.
    At VA, however, veterans may get their initial visit but 
many are not able to get the ongoing treatments that they need.
    What is really troubling is the problems we will hear about 
today are not different from what we have discussed at the 
July 14 hearing.
    I had expected that four and a half months would have been 
enough time for the VA to come up with solutions but it appears 
that that is not the case.
    As we will hear today, aggressive steps must be taken, and 
they must be taken now. If VA is not able to provide the 
appropriate care to veterans in a timely fashion, VA should 
consider sending veterans to someone who can help them 
promptly, using their fee-based authority.
    Madam Chairman, I am confident today that this is not 
something we are going to let get away from us; and if VA 
believes that this is going to be a once-a-year topic of a 
hearing, let me assure you: it is not going to be.
    The fact that we are four and half months down the road, 
and the response is to do focus groups and to put out new 
guidelines to me is unconscionable, given the fact that every 
medical professional that has come before us says that the most 
important thing is to get these servicemembers into treatment, 
keep them in treatment for as long as it takes, to take that 
disability and to drive it as close to zero as we can possibly 
get it.
    My hope is that the Committee will recognize the fact that 
we have funded and now it is a process of execution that we 
have got to seriously look at, and I pledge to the Chairman to 
work side-by-side with her on this.
    I thank the Chair.
    Chairman Murray. Thank you very much. I appreciate it.
    Senator Akaka.

              STATEMENT OF HON. DANIEL K. AKAKA, 
                    U.S. SENATOR FROM HAWAII

    Senator Akaka. Thank you very much, Madam Chairman. I 
appreciate you and Senator Burr holding this very important 
hearing. I want to add my welcome to the witnesses and thank 
you for all you have been doing for our veterans.
    Through the efforts of the VA and its many stakeholders, 
our country is doing a better job for caring for veterans. 
While we continue to improve educational benefits such as the 
G.I. Bill, job training, and other opportunities through 
legislation spearheaded by the Chairman, we must keep working 
to improve the mental health provided to our veterans.
    Over the last decade, the men and women of our Armed Forces 
have bravely served in two wars. Now, it is our turn to look 
after them and to get them access to the care they need.
    Many of our men and women currently in uniform will be 
returning to the civilian world and seeking VA services in the 
coming years. Hopefully, the stigma which once discouraged some 
veterans in need from seeking mental health treatment will 
continue to decrease and there will be a welcome increase in 
demand for these services.
    I know that Secretary Shinseki and his team have made 
strides and will continue to do so, but I have concerns as we 
all do. And as we look to the future and consider the capacity 
and projected requirements for mental health care, I think that 
this hearing is another vital step as we work to improve the 
services our veterans have earned and deserve.
    So, I look forward to hearing our witnesses' testimony and 
how we are doing and how we might improve in meeting the needs 
of veterans and their families and we will continue to look 
forward to working with the Chairman and the Committee on this.
    Thank you very much, Madam Chairman.
    Chairman Murray. Thank you very much.
    Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Sen Tester. Thank you, Madam Chairman, and I want to thank 
you and Senator Burr for convening this hearing today. I want 
to thank the witnesses in this panel and the next panel that is 
going to be up.
    You know, the work that we did before the Thanksgiving 
break was employment opportunities for veterans. I know the 
Chairman is very proud of and I am very proud of, and this 
Committee should be very proud of that work. Working together 
to get that done was important.
    This is another one of those issues that is going to 
require a bipartisan effort to move forward because we have got 
a steady flow of returning veterans to this country.
    The signature injury from those folks from Iraq and 
Afghanistan is one that deals with mental health. They need 
care. There are no ifs, ands, or buts about it. I can tell you 
that that care can only happen if we work together: Democrats, 
Republicans, and policymakers with the VA.
    I think the VA has made some strides but not enough. They 
have hired a lot of folks in the mental health arena, but 
because of the number of folks we have got coming back, because 
of the stigma I believe that is attached to issues that revolve 
around mental health, it is critically important that we work 
together.
    If Senator Burr is correct, if the response to the folks 
that come back with unseen injuries is to develop focus groups 
and guidelines, that ain't good enough.
    But if the response is to get more mental health 
professionals in the field, if the response is looking to the 
private sector when necessary to be able to contract out some 
of these services, if the response is to make sure that we have 
the VA facilities available to those veterans, if the response 
is making sure that we have Vet Centers around this country 
where vets can talk to vets, then we are moving in the right 
direction.
    We have done a lot of good work on this issue as a 
Committee. It continues to be a huge issue. It continues to be 
a big concern because I think--we have three docs up here and a 
civilian. I can tell you that from my perspective if we can get 
treatment earlier, we can help save a ton of money and improve 
quality-of-life for a ton of folks that deserve every benefit 
that we can give them because they put their lives on hold and 
their lives on the line for this country.
    So, with that, I look forward to this hearing. I look 
forward to further hearings after this. Ultimately, in the end, 
I think that if we work together with the VA and amongst 
ourselves we can do a lot of good work and satisfy some of the 
needs that are out there.
    Thank you, Madam Chairman.
    Chairman Murray. Thank you very much.
    With that, we would like to welcome our first panel. Thank 
all of you for being here and for your testimony. We are going 
to start with Dr. Michelle Washington, who is representing the 
American Federation of Government Employees.
    Then, we will hear from retired U.S. Army Colonel, Dr. 
Charles Hoge. Next, we will hear from Dr. Barbara Van Dahlen, 
founder and president of Give an Hour.
    And finally, we will hear from Mr. John Roberts, who is the 
Executive Vice President of Mental Health and Warrior 
Engagement, with the Wounded Warrior Project.
    So, we will start with Dr. Michelle Washington.
    Just before she proceeds to her testimony, I do want to say 
how important it is for us on this Committee to hear from 
providers who are dealing with this issue firsthand.
    If we cannot hear their accounts, none of us is going to 
learn what we need to do to improve help for our veterans, and 
I expect that as always our witnesses will be treated 
appropriately. No witness who comes before this Committee or 
one of our hearings should be treated unfairly just because 
they did the right thing in bringing us the issues and 
responding to this Committee and telling us the truth so that 
we can make sound policy decisions.
    So, Dr. Washington, we will begin with you.

  STATEMENT OF MICHELLE WASHINGTON, PH.D., COORDINATOR, PTSD 
    SERVICES AND EVIDENCE-BASED PSYCHOTHERAPY, WILMINGTON, 
 DELAWARE, VA MEDICAL CENTER, REPRESENTING AMERICAN FEDERATION 
  OF GOVERNMENT EMPLOYEES, AFL-CIO, AND THE AFGE NATIONAL VA 
                            COUNCIL

    Ms. Washington. Chairman Murray, Ranking Member Burr, and 
Members of the Committee, thank you for the opportunity to 
testify before you on behalf of AFGE.
    As the coordinator of PTSD services and evidence-based 
psychotherapy at Wilmington VA, my role is to provide specialty 
care to veterans with severe and complex PTSD as well as the 
new onset.
    Due to chronic short staffing at my facility and the 
inability to manage my patients appointments based upon their 
individual needs, I am frequently frustrated in my ability to 
provide that care.
    Why do I work at the VA? For me, it is very personal. My 
father is a Korean War veteran as where my uncles. My brothers 
are veterans, and my niece and her husband are both veterans, 
and my nephew just recently returned from Iraq.
    Timely treatment is critical in evidence-based 
psychotherapies including two methods I frequently use to treat 
PTSD. First, with prolonged exposure, the patient reexperiences 
rather than avoids the trauma.
    The second approach, cognitive processing therapy, treats 
PTSD as a disorder of non-recovery where we address erroneous 
beliefs about the traumatic events so that the patient can 
better process the trauma memory.
    These treatments have been demonstrated to be highly 
effective in treating trauma through a limited number of 
sessions, but patients must be seen weekly during the treatment 
period which is very difficult at my facility.
    When I determine that a patient is suitable for this type 
of treatment and motivated to receive it, I ask the scheduling 
clerks to book out 10 to 12 weekly appointments at a regular 
time.
    Too often, I am told that that the patient will have to 
wait as long as 6 weeks for the first appointment. But after 
waiting that long, many patients lose the motivation for 
treatment or their PTSD worsens while they are waiting. So, 
sometimes I find it better not to start evidence-based 
psychotherapy because the harm of waiting outweighs the benefit 
of treatment.
    Also, because scheduling clerks are under great pressure to 
bring new veterans in within 14 days, they may take one of my 
PTSD patients regular appointments for a new patient 
appointment which hurts the effectiveness of my patient's 
treatment.
    It is also extremely difficult to make timely referrals for 
ongoing mental health services. So, these patients stay on my 
caseload even though they do not need specialty treatment any 
longer. This, in turn, further delays for speciality treatment 
for veterans who could benefit from it.
    Even though the Uniform Mental Health Services Agreement 
and the PTSD handbook clearly state that PTSD treatment should 
be reserved for veterans with severe PTSD and complex cases and 
new onset, I am frequently assigned patients with only minor 
forms of PTSD or only a history of PTSD with no current 
symptoms; and I have no means of referring them back to general 
mental health because they are booked solid. So, those patients 
stay with me indefinitely.
    As long as scheduling continues to be driven by clerks 
pressured by management to make the numbers look good and as 
long as mental health providers have little or no say about 
where and when to best serve their patients, this will keep 
happening.
    Patients are also harmed by the pervasive shortage of 
primary care providers at my facility. Even though assignment 
to a primary care provider is a requisite treatment to a mental 
health provider and the DSM clearly states that you rule out a 
medical condition first, some of the patients end up with me or 
in general mental health when they actually need medical 
treatment.
    For example, Graves' disease, a hyperthyroid condition, 
sometimes mistaken for ADHD, similarly patients with dementia 
with Lewy Bodies that include a symptom of visual 
hallucinations, HIV medication can cause a brief period of 
psychosis at the onset.
    When these patients are referred to mental health treatment 
without a comprehensive primary-care assessment, the mental 
health provider is forced to carry out treatment without 
critical information.
    Also, the patient could end up worse because his medical 
condition is not treated, or he may receive antipsychotic 
medication he does not need.
    The Wilmington VA has not filled a vacant primary care 
physician designated for OEF/OIF/OND veterans since March. As a 
result, OEF/OIF/OND staff cannot get primary care appointments 
for these patients, and no one is doing poly-trauma consults or 
related-injury referrals or monthly treatment review of poly-
trauma veterans.
    When veterans cannot get appointments with their primary 
care provider they sometimes end up in the ER to get their 
medication, which is not the best way to treat them or the best 
use of resources.
    The VA would also make better use of its resources by 
timely treatment. Research shows that patients more effectively 
get better at the outset with fewer mental health or medical 
services in the long run when they received treatment early.
    Another barrier to comprehensive care is the absence of a 
full PTSD treatment team. I developed and proposed a PTSD 
clinical team; but due to lack of staff, among other 
requirements, the program has not been implemented. Instead, 
management creates the appearance of a team by counting staff 
located at CBOCs.
    What else do I think would help the medical conditions or 
the mental health conditions, first, it would be true that 
treatment teams that include regular meetings with mental 
health, medical, and nursing, panel sizes for mental health 
providers which are long overdue, and we have been waiting 
several years for VA central office to establish parameters for 
maximum number of patients for each mental health provider to 
carry.
    Finally, as I noted, mental health providers must have a 
say in when their patients need to be seen and to ensure that 
our patients receive integrated care so all their medical and 
mental health conditions are treated as a whole.
    That is good care. That is good resource allocation, and 
that is the way to get the most care for veterans and which is 
our goal every day.
    Thank you very much.
    [The prepared statement of Ms. Washington follows:]
  Prepared Statement of Michelle Washington, Ph.D., Coordinator, PTSD 
Services and Evidence Based Psychotherapy, Wilmington VA Medical Center 
 on Behalf of American Federation of Government Employees, AFL-CIO and 
                      the AFGE National VA Council
    Chairman Murray, Ranking Member Burr and Members of the Committee: 
Thank you for the opportunity to testify on behalf of the American 
Federation of Government Employees (AFGE) and the AFGE National VA 
Council (NVAC) (hereinafter ``AFGE'') about VA mental health care wait 
times and access to care. AFGE represents more than 205,000 VA 
employees, including roughly 120,000 Veterans Health Administration 
(VHA) employees providing direct services to veterans.
    My testimony addresses mental health access at the Wilmington VA 
Medical Center, where I work as the Coordinator of PTSD Services and 
Evidence Based Psychotherapy. My testimony also includes reports from 
other AFGE members providing mental health services. Please note that 
at the request of these employees, none of the reports are identified 
by name or location. All these employees expressed serious concerns 
about job loss or other workplace retaliation for speaking up for 
patient care and employee rights. In fact, several employees turned 
down AFGE's request to testify because of the risk of retaliation.
    I also fear retaliation by management for participating in this 
hearing. Nonetheless, I took the risk of testifying today because of 
the importance of speaking out about the growing barriers to providing 
mental health care to my patients. Like my colleagues, I work at the VA 
because of an intense dedication to serving this unique patient 
population, and their service-connected mental health conditions.
    I have reviewed the VA's survey questions about access and sadly, 
my own experiences confirm that my facility lacks adequate staff to 
allow me to treat patients on a timely basis in order to maximize the 
effectiveness of treatment.
    I was hired as a specialist in Post-Traumatic Stress Disorder 
(PTSD) to treat veterans with severe and complex PTSD as well as 
veterans newly diagnosed with PTSD. However, due to staffing issues I 
am called upon to treat veterans with any mental health condition. As a 
result, there are significant time delays in my ability to provide 
requested PTSD assessments and services including evidence-based 
psychotherapies for PTSD.
    Additionally, once specialty services have been provided, poor 
staffing in the general mental health clinic makes it difficult if not 
impossible to refer veterans for ongoing general mental health 
services. Consequently, veterans remain on my caseload for extended 
periods of time causing delays in providing treatment to other veterans 
in need of specialty PTSD care.
    More specifically, veterans in need of new and established patient 
appointments usually have to wait far longer than fourteen (14) days 
and often as long as two months before they can begin evidence-based 
trauma-focused treatments. Often after such a delay, patients have lost 
the motivation for treatment and therefore cannot benefit from these 
highly effective treatments. In addition, without clinicians having 
control of their schedules, scheduling consistent weekly 60-120 minute 
appointments is difficult and especially harmful for patients receiving 
various evidence-based psychotherapies.
    As previously stated, these treatments have been demonstrated to be 
the most effective treatment approaches I use to treat Post-Traumatic 
Stress Disorder (PTSD) and depression. The mental health community, 
both inside and outside the VA, is very excited about these forms of 
treatment because they are so highly effective in treating trauma and 
other disorders within fairly short timeframes.
    Timely treatment is critical for both evidence-based 
psychotherapies for PTSD: Prolonged Exposure and Cognitive Processing 
Therapy. Prolonged Exposure therapy (PE) is a form of cognitive 
behavioral therapy designed to treat Post Traumatic Stress Disorder, 
characterized by re-experiencing the traumatic event through 
remembering it and engaging with, rather than avoiding, reminders of 
the trauma (triggers). Cognitive Processing Therapy (CPT) 
conceptualizes PTSD as a disorder of ``non-recovery'' in which 
erroneous beliefs about the causes and consequences of traumatic events 
produce strong negative emotions and prevent accurate processing of the 
trauma memory and natural emotions emanating from the event. Patients 
in evidence-based psychotherapies must be seen at least weekly, in 
order to effectively treat PTSD. If patients have to wait longer 
between appointments, the treatment loses its efficacy.
    Recently, the new Chief Psychologist mandated that all 
psychologists set up a ``new patient clinic'' and see four new patients 
per week in order to meet the fourteen (14) day requirement. However, 
no provision has been established to see these new patients for follow-
up care. They will have to wait four to six weeks for a follow-up 
appointment. In addition, taking away four clinical hours per week 
further delays follow-up care for established patients.
    The Wilmington VA does not currently have a full PTSD treatment 
team despite the VA's current commitment to patient-centered, team-
based care. As the coordinator of PTSD services, my duties include 
development of a PTSD Clinical Team (PCT). I have in fact developed and 
proposed such a program but due to a lack of staff, among other 
requirements, the program cannot be implemented. Instead, management 
claims to have a PTSD program by including staff located at CBOCs, even 
though a clear requirement of a PCT is that team members be co-located 
at a separate and distinct location. AFGE has reported this to the 
Office of the Inspector General.
    Mental health access is also impacted by a shortage of primary care 
providers in the hospital and CBOCs. Even though assignment to a 
primary care provider is a prerequisite to assignment to a mental 
health provider, our hospital has not filled a primary care position 
designated for OIF/OEF/OND veterans that has been vacant for since 
March of this year, and previously, was only covered two days a week 
intermittently. OIF/OEF/OND staff was sending consults to primary care 
for appointments, but were recently told the consults did not go 
anywhere.
    The previous provider in this position had a panel of 1,038 
veterans to cover with two days per week in a variety of shielded and 
different named panels. These veterans are still assigned to that 
provider even though she no longer has clinical privileges or access to 
CPRS. Since March, no provider is been doing polytrauma consults, War 
Related Injury referrals, or monthly treatment review of polytrauma 
veterans.
    One of our CBOCs does not have any primary care provider, causing 
even longer waits for mental health treatment at the other CBOC.
    Veterans who cannot get timely assignments to primary care provider 
sometimes end up in the emergency room to obtain medication.
    Access to primary care is also essential for detecting medical 
conditions, such as a thyroid disorder, that may be contributing to a 
veteran's mental health problems. While patients wait many months for 
their first primary care appointment, we try to proceed with treatment 
even though we are missing a ``big piece of the puzzle * * *.''
    Evening and weekend appointments should be available at the medical 
center and the CBOCs, but additional clinic hours are simply not 
possible due to chronic short staffing.
    At the Wilmington VA, space shortages interfere with our ability to 
provide appropriate care. Mental health services are not all provided 
on the same floor, making it more difficult for clinicians to consult 
with each other regarding patient needs.
    The chronic shortage of medical clerks at our facility also hurts 
the ability of our mental health clinics to run smoothly. Management is 
unwilling to hire more clerks, consequently, the clerks we have are 
always getting pulled away to work in other short staffed areas, 
without management consulting the affected BH providers.
    The clerks have been told that if a patient does not arrive by one 
minute before the scheduled appointment time, that they should cancel 
the appointment; they are disciplined if they fail to do so and have 
more than three ``no shows.''
    Sadly, new measures for timeliness have encouraged more, not less, 
management gaming. When a veterans asks for the first available 
appointment that week, he or she is told that the first available date 
is ``X'' and when they ask for date ``X,'' it is recorded as a desired 
appointment.
    Social workers at my facility universally feel extremely overworked 
and overwhelmed. When a new position is posted, such as HUD VASH or 
SUD, the position is only posted internally, and instead of hiring 
additional staff, social workers are simply transfer from one critical 
area to the new position.
    Our new social work chief has created a very negative work 
environment, and recently, more than a dozen social workers resigned 
after being unfairly targeted and being admonished for speaking up for 
patients.
    The new social work chief recently instituted thirty minute therapy 
sessions, and is ordering social workers to cease providing more time 
with patients, unless he has been notified. The clerks have been 
directed to change all appointments to thirty minutes; social workers 
were never consulted.
    The chief has not informed staff of the guidelines he will apply to 
determine whether longer sessions are appropriate. Our social workers 
feel as if these major changes are being made based only on anecdotal 
evidence, rather than a solid justification for reducing patient access 
to therapy, resulting in a lower quality of care.
    Workplace morale is also harmed by management's practice of passing 
over existing social work staff for internal promotions, and, instead, 
hiring new clinicians with no VA experience for higher positions and 
chief positions. When internal promotions do occur, management does not 
backfill the vacant position, yet they expect other fully assigned 
social workers to take over other one or two vacated positions in 
addition to their own full time responsibilities.
    Our social workers report that there is an overreliance on group 
therapy for substance abuse treatment, noting that some veterans have 
more intense needs or are too introverted for group treatment but are 
not offered other options.
    Social workers at our CBOCs are forced to place patients on long 
wait lists. At the CBOCs, one social worker may have to handle all 
therapy, including substance abuse treatment, as well as case 
management--a growing need in communities that have lost other 
resources for veterans and their families.
    Our patients also face long waits for substance abuse treatment. 
Our clinicians are very frustrated; a two month wait for services does 
not work for these patients. If a veteran is ready to quit, we have to 
get them into the VA now or the window may close!
                    reports from other va facilities
Psychiatrist in general mental clinic:
    This clinician recently transferred to Comp & Pen because he could 
no longer handle the stress and frustration of trying to provide BH 
treatment with severe staff shortages. He feels as if staffing levels 
will ``never catch up'' with the growing demand for services, and that 
at his medical center, trying to keep up with patients' needs is like 
``a finger in the dike.''
    His panel sizes were enormous, and he and other psychiatrists had 
to carry the entire onus of developing suicide prevention plans and 
working with Suicide Prevention Coordinators. He felt pressured to care 
more about deadlines than patients
    This psychiatrist's patients had to wait two months for new 
appointments. Although he preferred setting up frequent appointments 
(within a month) for his established patients, they usually had to wait 
at least six months. He was ``absolutely'' unable to make timely 
specialty appointments for his patients with PTSD; he would do a 
consult and get no response.
    When medical school residents stopped covering overnight calls a 
few years ago, VA clinicians were required to cover weekend rounds 
without any compensatory time. Compensatory time was restored only 
after AFGE filed a grievance.
    This psychiatrist also noted although many residents want to work 
at the VA, new hires frequently quit the VA because of poor human 
resources practices and heavy caseloads.
    He sees his former colleagues rushing around as if in a ``rat 
race'' with thirty minute visits that leave no room for emergencies or 
walk-ins. As he noted, ``a walk-in is never quick.'' (As other 
clinicians noted, management is pressuring clinicians to cancel 
patients with non-urgent needs, and advise them to come in on a walk-in 
basis instead.)
    He could no longer handle intense pressure of having to squeeze too 
many patients into shorter sessions. ``I am not a 30 minute 
psychiatrist,'' he noted; ``lots of veterans don't tell you they are 
suicidal until minute 41!'' He felt that his only choice if he ended up 
with a suicidal emergency was to take time away from next patient.
    He had too little time to write adequate notes after each session; 
the ``smart'' clinicians survive by seeing patients for only twenty 
minutes and then writing up quick notes by hand.
    In his view, a shortage of clerical and scheduling staff also 
contributes to mental health access limitations, but Central Scheduling 
for Psychiatrist ``just doesn't get it.'' It is the clinician who knows 
whether a patient needs to come back sooner. He felt strongly that 
patients need localized attention for proper scheduling.
CBOC Psychologists:
    Report #1: As the only mental health provider in her CBOC, this 
psychologist reported that she has to ``do it all because you are it'' 
including all individual and group appointments, walk-ins, call-ins, as 
well as some C&P exams.
    She is ``overbooked every day.'' Her caseload of more than 200 
patients, including many high risk patients, is simply ``unrealistic.''
    She has no control over new patient appointments but is always 
``booked out solid two to three months ahead.'' This provider feels 
strongly that fifty minutes for intake is simply ``not enough.''
    Management has repeatedly pressured her to go into CPRS and change 
the ``desired date'' even though doing so would be a clear violation of 
VHA directives.
    She is also usually booked two months out for established patient 
appointments. Even though she has patients that she should be seeing 
weekly, ``there are no openings.''
    This psychologist struggles to keep up with her charting because of 
her caseload. If she takes even one day of annual leave, it puts her 
further behind. Management has refused her repeated request to assign a 
social worker to her CBOC. Yet, when her charting fell behind because 
of her patient caseload, management invoked the threat of not assigning 
a social worker!
    She never takes her fifteen minute breaks because she is booked 
back to back, and her supervisors regularly take her lunch hour to meet 
with her. She does not complain because ``I am here for the vets'' but 
it is demoralizing when management responds by failing to support her 
and refusing to approve the compensation time she rightfully earned.
    This provider agrees that C&P exams hurt access by pulling clinical 
staff away from routine patients. To perform a C&P exam properly takes 
time. ``They are like forensic exams'' and she likes to do 
psychological testing and go through the C file to provide what VBA 
needs.
    The workplace environment at this psychologist's facility is 
extremely unsupportive, and often hostile to providers already under 
great stress for carrying extremely heavy caseloads that include many 
high risk patients. When a patient attempts suicide or other at-risk 
behavior without warning, management routinely blames the provider and 
refuses to recognize that the provider also is under stress. It seems 
as if ``all management cares about is numbers because that's what their 
bonuses are based on.''
    The CBOC's psychiatrist recently quit because the work environment 
was too stressful and management wore her down with false allegations, 
and by refusing to let her order sleep studies. Management has refused 
to fill that vacancy.
    Veterans in her area wanted evening and weekend appointments. When 
a psychiatrist was still at the CBOC, this would have been possible. To 
find a way to accommodate veterans, this psychologist proposed to 
management that an alternative work schedule be instituted to provide 
evening and weekend appointments. Sadly, her request was denied, even 
though it would have complied with the Uniform Services mandate and the 
recovery model for veterans in school or working.
     A disabled veteran herself, this provider states that she will 
continue to speak up every time patients are not getting the care they 
need. Her patients give her a great deal of positive feedback. However, 
she is seriously considering jobs outside of the VA and only stays 
because she really wants to work with veterans.

    Report #2: Another clinical psychologist working at a CBOC 
concurred that it is very difficult to see patients on a more frequent 
basis. Four years ago, he could see his established patients twice a 
month, but the standard is now once a month. While he can make 
exceptions for some crises and evidence-based treatment for weekly or 
bi-weekly appointments, this can only occur for a short time period. 
Even if patients want to go through evidence-based weekly psychotherapy 
(an intense experience that not all veterans want to go through), he 
simply could not keep up with a weekly schedule, even though it is 
dangerous to space it out more infrequently. As he noted, ``One time a 
month is simply not quality of care.''
    More generally, he felt that resources are not properly 
distributed; his county has a large number of veterans and too few 
providers, whereas the adjoining county is far better staffed. He 
acknowledges that it is hard to fill vacancies in rural areas and 
recommends rotating staff to less desirable locations to cover these 
gaps.
    He also felt that the C&P exams pull clinicians away from direct BH 
care. At his facility, C&P exams are now performed at a different 
location so he and other clinicians who do C&P on a part-time basis 
have to spend more time traveling, further diminishing therapy time.
    He agrees that there is a shortage of clerical and scheduling staff 
and that when new providers were hired, there was no corresponding 
increase in support staff.

    Report #3: This provider stated that her work environment is so 
stressful that ``everyone I work with is trying to leave and we are 
losing really good people who could be an asset to the VA.''
    She is usually able to make new patient appointments within 14 
days, and the next two follow up appoints within three weeks. Patients 
have to wait from about four to six weeks for subsequent appointments.
    Her managers regularly manipulate the wait list numbers in numerous 
ways, including requiring veterans to choose between being on a wait 
list for two week appointments and taking a four week appointment.
    This clinician is very frustrated that she cannot set appointments 
based on her own clinical judgment, even though management assured her 
that she could. It concerns her that she is required to see some OIF/
OEF/OND patients for eight weekly sessions when older veterans with 
more serious BH problems have to wait longer between appointments.
    Management also regularly pressures providers to give up their 
administrative days to see patients.
    This provider is worried about keeping her job because she insists 
on maintaining her own wait list to get her patients in sooner. She 
noted: ``If you see some patients only four to five times a year, they 
don't get better and there is a greater chance they will get 
suicidal.'' In her view, therapy every five weeks ``is like fake 
therapy.'' She feels that current limitations on access prevent BH 
providers from ``keeping up with our veteran's lives much less their 
coping skills.''
Clinical Nurse Specialist at a Domiciliary
    Homeless veterans typically have not accessed VA BH services in the 
past, despite rampant problems with depression and anxiety. Thus, 
getting them a timely initial appointment is critical.
    Sadly, this clinician, a 26 year veteran herself, is extremely 
frustrated that the homeless veterans she works with have to wait 45 to 
60 days for their initial BH evaluation. In addition, access at her 
facility has deteriorated since the psychiatrist who split his time 
between the domiciliary and substance abuse clinic left; that had been 
a ``wonderful, wonderful arrangement.''
    Because she is a veteran who ``does not take no for an answer,'' 
she tries to get her clients intake appointments sooner, by calling 
scheduling clerks daily, despite her own heavy caseload. Sometimes, she 
has to send homeless veterans to the emergency room instead for short 
term medication needs. (An emergency room doctor at another facility 
recommends that all ERs follow the example at his facility of having 
24/7 psychiatrist coverage.)
    In urgent cases, she goes to the acting Chief of Psychiatry, who 
may make an exception but often tells her there are simply no available 
appointments.
    Her facility has lost eight psychiatrists recently because 
management interfered with their work assignments. Management's 
solution was to pull psychiatrists from other units to cover inpatient 
vacancies. But many inpatient staff vacancies remain, and many 
patients, including those at risk of suicide and homicide, have to be 
diverted to non-VA hospitals.
    More generally, the new OIF/OEF/OND initiatives are good and new 
veterans are receiving better debriefings on MH issues. She is 
concerned that the veterans already in the VA system are the ones not 
getting the help they need.
    In closing, I again thank the Committee for the opportunity to 
testify on behalf of AFGE and share the perspective of BH clinicians on 
the front lines. I hope that in the future, our members can share their 
suggestions about ways to improve patient care with the Committee 
without fearing for our jobs or experiencing other forms of 
retaliation.
                        Summary of AFGE Concerns
     The inability to make timely new patient, established 
patient and specialty appointments is rampant and directly related to 
provider short staffing: In all VA behavioral health (BH) settings 
(inpatient, outpatient, domiciliary), the lack of providers has 
resulted in widespread failure to provide timely appointments, 
including specialized care where frequent sessions are critical, such 
as evidence-based psychotherapies.
     Providers are regularly required to ``rob Peter to pay 
Paul.'' In order to see higher risk patients more frequently, BH 
providers must shorten sessions with other patients, delay care for 
other patients, and cut into time needed for preparation of patient 
notes and other administrative responsibilities.
     Residents and other potential new hires who are very 
interested in working at the VA are deterred by poor H.R. practices 
including delays and lost applications.
     BH providers with valuable experience are leaving the VA 
due to management pressure to cover up delays in treatment, failure to 
promote from within, unsupportive, stressful and hostile work 
environments and interference with clinical judgment about what 
patients need.
     Central scheduling results in ``one size fits all'' 
appointments that fail to take into account provider recommendations 
and individual patient needs.
     Rural CBOCs lack sufficient BH staff to provide the 
growing number of rural veterans with clinical care and case management 
who depend on the VA because of a severe lack of other resources in 
their communities for veterans and their families.
     Short staffing of clerical and scheduling personnel 
diverts clinical time away from patients. The VA's failure to hire more 
medical support staff to back up recent expansions in its clinical 
staff also interferes with providers' ability to focus on patient 
needs. AFGE strongly opposes VA's ongoing campaign to downgrade medical 
support personnel without a thorough analysis of the duties of impacted 
employees.
     Greater management flexibility could expand BH access, 
such as alternative work schedules to cover evening and weekend 
sessions, and rotation of staff to rural CBOCs, as mandated by the 
Mental Health Uniformed Services Act of 2008.
     Managers should be held accountable for violations of laws 
and regulations, including through the application of the Title 38 
Table of Penalties, for instances of wait list data manipulation, 
pressuring providers to change appointments, and for retaliating 
against employees who use appropriate avenues to advocate for patient 
needs.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
  Michelle Washington, Ph.D., Coordinator, PTSD Services and Evidence 
     Based Psychotherapy, Wilmington, Delaware VA Medical Center, 
      representing the American Federation of Government Employees
    Question 1. We have heard some concerns about the transition to 
mental health care teams occurring as part of the Department's 
implementation of the Patient Aligned Care Team (PACT) model. The 
Department tells us that this is a more appropriate model and one the 
private sector uses. They also say that the veteran will need to 
establish good relationships with each of the providers on the team, 
and we discussed the importance of truly establishing those 
relationships. Can you please explain how providers decide which team 
member is most appropriate to see a veteran seeking care?
    Response. According to the Patient Centered Medical Home Model 
Concept Paper from the VA Patient Centered Primary Care Implementation 
Work Group, the core team of the Veteran patient is his/her provider, 
an RN care manager, a clinical staff assistant, and an administrative 
staff member who are responsible for the central functions of a medical 
home model. Although care management functions reside within the core 
team, specialized services are provided on an episodic basis when the 
Veteran patient can benefit from additional expertise such as that of 
mental health providers, medical/surgical specialties, pharmacists, 
dieticians, chaplains, etc.
    Some VA facilities have a mental health provider (not including a 
social worker who may serve solely as a case manager) as part of that 
team. On those teams, if mental health services are needed the veteran 
would be sent to that team's provider (for example, psychiatrist for 
medication, psychologist/social worker for psychotherapy). On teams 
that don't have mental health providers such as here at Wilmington 
VAMC, the team sends a consult (requesting evaluation for services) to 
the Behavioral Health Service. The veteran is randomly assigned to a 
provider to collect background information. Following that appointment 
the veteran is assigned to the next available mental health provider.
    The ``team'' approach in behavioral health is not functioning 
because the teams do not have all of the people needed to make it 
multidisciplinary per the original design. It never did. Therefore, on 
paper the idea looks great but in practice it is failing. So the 
administration simply tells everyone we have teams but never reveal 
that they are not functioning (same for PACTs).

    Question 2. Dr. Washington, in your experience, has VA been able to 
schedule appointments in a way that encourages those personal 
relationships to develop?
    Response. My training and experience has taught me that for mental 
health treatment to be most effective you start with weekly sessions 
and taper off as the patient improves and hopefully eventually no 
longer needs mental health services. Heavily loading treatment at the 
front end encourages good treatment rapport which leads to better and 
often faster treatment outcomes. Since coming to the VA, it has been 
difficult to follow this process. Seeing people every four to six weeks 
means that rapport takes longer to build and progress in treatment is 
substantially slower if it occurs at all. Please also note that in 
behavioral health, clerks will schedule any new patient in any open 
slot. (In contrast, existing patients are scheduled with their usual 
provider.)
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
                       Michelle Washington, Ph.D.
    Question 1. In your testimony, you state that veterans at the 
Wilmington, Delaware VA Medical Center usually have to wait much longer 
than 14 days for an appointment. Has the mental health clinic at 
Wilmington used other options, such as fee-basis care, to ensure 
veterans get the care they need? If not, why?
    Response. For mental health services we will refer to the Vet 
Centers if the veteran meets their criteria for treatment. Otherwise, 
they are scheduled with the next available provider. To my knowledge, 
fee basis is not used because we can provide the service at our 
facility. Therefore, the veteran will have to wait for the next 
available provider appointment. For emergency inpatient mental health 
care only, we have contracts with two community hospitals.
    Please note that Vet Centers have access to our records but we are 
not able to view theirs. So when patients are seen there as well as 
here we don't know how they are doing in treatment. Also, related to 
the social worker/veteran who was recently terminated, her PTSD group 
will be taken over by a Vet Center employee and will be held at the 
Wilmington VAMC. Vet Center employees cannot document in our medical 
record (CPRS), so we will cannot see how our patients are doing in that 
setting.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
                    IV to Michelle Washington, Ph.D.
    Question 1. How can we meet the overwhelming demands for mental 
health care among all our veterans, in this climate of cuts and calls 
for spending caps?
    Response. a. One suggestion would be to start psychotherapy first, 
and then refer for psychiatric medications once the therapist has been 
able to conduct a proper assessment of the patient's condition. This is 
what is frequently done in private practice psychotherapy offices. Here 
at Wilmington, the practice is frequently the opposite which often 
serves to discourage patients from engaging in psychotherapy. The 
veteran ``feels better'' with the medication and thus, the cause of the 
problem is never addressed. Please note that this is not a universal 
statement; some patients with acute/urgent issues, chronic conditions, 
etc. may need immediate psychiatric assistance.
    b. Engage veterans in treatment with weekly sessions earlier and 
taper off as they improve. This encourages good treatment rapport which 
leads to better and often faster treatment outcomes.
    c. Another suggestion would be to have mental health imbedded in 
primary care. That provider could conduct the initial assessment and 
determine if more in depth mental health services are needed. Please 
note also that when the administration talks about integration of 
mental health into primary care they cite that we have a health 
psychologist. However, the scope of duties for that position is limited 
and not true mental health/primary care integration.

    Question 2. How do we encourage and recruit VA nurses and mental 
health professionals in times of pay freezes and calls for overall cuts 
in our Federal Government?
    Response.  a. Reallocate funds from administration to direct care 
staff. By shrinking the size of the administrative staff, those funds 
could be used to hire additional direct care staff. In addition, you 
would not have one direct care staff member doing three jobs. 
Therefore, more patients can be seen.
    b. Accountability of administration's use of time and distribution 
of resources.
    c. Communication with direct care staff regarding patients' needs 
when developing performance measures and/or compliance with these 
measures.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
                       Michelle Washington, Ph.D.
    Question 1. When servicemembers are separating from the military 
and DOD has identified them as being in need of behavioral health care, 
is there any formal communications between DOD and VHA behavioral 
health care providers with regards to continuity of behavioral health 
care for those veterans after separation from active-duty?
    Response. Once there is a discharge date, the DOD's Military 
Treatment Liaison sends a referral packet to the OIF/OEF/OND program 
manager at the facility.

    Question 2. Is there any effort by DOD to set up an initial 
interview with local VHA behavioral health providers for 
servicemembers, who DOD has identified in need of behavioral health 
care, prior to separation from active-duty?
    Response. Not prior to discharge but once the referral packet is 
received, we are mandated to set up an appointment within 30 days of 
discharge.

    Question 3. Is there any effort by DOD providers to collaborate 
with local VHA providers with regard to servicemembers, who DOD has 
identified in need of behavioral health care, after separation from 
active-duty?
    Response. No. VHA providers may get a referral packet but there is 
generally no direct communication with DOD providers.

    Question 4. Are servicemembers, who DOD has identified in need of 
behavioral health care, discharged from active-duty prior to 
successfully completing behavioral health treatment coming to VHA for 
additional behavioral health services?
    Response. The only information VHA gets is what is in the referral 
packet. Therefore, the status of their mental health care may not be 
clear.

    Chairman Murray. Thank you very much, Dr. Washington.
    Dr. Hoge.

              STATEMENT OF CHARLES W. HOGE, M.D., 
                   COLONEL, U.S. ARMY (RET.)

    Dr. Hoge. Good morning, Chairman Murray, Ranking Member 
Burr, Members of the Committee, thank you for the honor of 
allowing me to be here today to talk with you about access, 
which is a very critical issue.
    I kind of in my testimony, my written testimony, I sort of 
broaden the discussion a little bit to look a little bit beyond 
appointment access and to consider other barriers to care and 
barriers to recovery because it is not just about appointments.
    We know that the majority of veterans and servicemembers 
who need mental health care do not come in initially or upwards 
of half come in to see us and another half do not.
    And then of those who come in, a large percentage drop out 
of care after they touch mental health care one or two times 
and then they drop out of care. There are a variety of factors. 
There are a variety of considerations in why this occurs some 
of which has to do with appointment availability or follow-up 
availability.
    Sometimes it has to do with negative perceptions of mental 
health care or interactions within, you know, at the first 
session in which the veteran felt as if their needs were not 
met and they leave care.
    I have been involved in studying stigma and barriers to 
care since the beginning of the war, and one of the things that 
we learned more recently is that there are negative perceptions 
of mental health care that actually drive utilization of 
services or drive the willingness to come in to see us in the 
mental health clinic and that some of those perceptions are 
actually stronger than some of the traditional stigma concerns 
that we have had for a long time.
    Those are things, perceptions that mental health care does 
not work, or that it is not going to be effective for me, or it 
is a last resort, for instance, or some of the things that 
veterans voice.
    In terms of, I want to echo a few of the comments that were 
made. Treatment is 70 to 80 percent effective for combat-
related PTSD. If the veteran comes in to get care and receives 
a sufficient number of sessions for recovery to occur, and 
clearly early treatment, as Mr. Tester mentioned, is a very 
important factor in that.
    I also want to echo the comments that Dr. Washington 
mentioned about the importance of integration with primary care 
because PTSD is really not solely an emotional or psychological 
condition.
    I really view it as a physical condition that has 
generalized health effects. It affects the endocrine system. It 
affects the autonomic nervous system, the part of the nervous 
system that controls automatic functions like heart rate, 
breathing, and so forth.
    A lot of veterans--there are a number of studies showing 
that veterans with PTSD have significantly higher rates of 
physical health problems in almost all categories of physical 
health problems compared with veterans without PTSD.
    So, the coordination of care in primary care and having 
access both to mental health care within primary care and 
having good coordination of services with the primary care team 
is really critical in the treatment of veterans.
    Some of the other things that I mentioned in my testimony 
have to do with the stigmatizing PTSD, combat- related PTSD by 
considering it from the occupational perspective and not always 
from the medical perspective, and that is, to understand how 
some of the reactions that servicemembers and veterans have 
after coming back from a combat deployments are, in fact, very 
adaptive for the combat environment.
    So, many of the reactions that individuals have that we 
label symptoms were, in fact, beneficial and adaptive in the 
combat environment.
    Talking about it this way can sometimes help to reassure 
veterans that, you know, they are not crazy and that, you know, 
their condition, their reactions have a physiological basis. 
They are not something in their head, and that, you know, the 
medical system is there to do something to help them with those 
physiological reactions.
    The other thing that I mentioned in my testimony has to do 
with the importance of peer-to-peer support. I think that there 
is a real critical role, because a lot of veterans are very 
reluctant to speak with civilians, including civilian mental 
health professionals who have not been deployed, and sometimes 
they need that veteran peer-to-peer connection in order to kind 
of encourage them to come in to get the help that they need.
    And finally, I just want to put in a plug for research. 
There are a number of areas where we could improve the research 
particularly in primary-care interventions, particularly in 
understanding more about why veterans, why there is still a 
reluctance to seek care and drop out of care and what specific 
interventions we might be able to do to improve retention in 
treatment.
    Thank you very much.
    [The prepared statement of Dr. Hoge follows:]
 Prepared Statement of Charles W. Hoge, M.D., Colonel (Ret.), U.S. Army
    Chairman Murray, Ranking Member Burr, and Members of the Committee, 
thank you for the honor of addressing the Senate Committee on Veterans' 
Affairs. I served on active duty for 20 years as an internist and 
psychiatrist. My experiences have included deployment to the war zone, 
treating servicemembers and their families at Walter Reed, and 
directing research to improve post-deployment mental health care. I 
also wrote a book for veterans and their families titled Once a 
Warrior--Always a Warrior: Navigating the Transition from Combat to 
Home, which Max Cleland described as ``the guide to surviving the war 
back here.''
    Ensuring that veterans have access to quality mental health 
treatment is a high priority. Of veterans who experienced direct combat 
in Afghanistan or Iraq, an estimated 10-20% struggle with PTSD, similar 
to rates after Vietnam. Depression, alcohol/substance abuse, suicidal 
behaviors, and other mental health concerns are also prevalent. In 
addition, large numbers of veterans experience readjustment challenges 
of a less severe nature (sometimes this is referred to as ``PTS''). 
These problems can affect the veteran's spouse, children, and other 
family members, and can impact the ability to find meaningful work and 
enjoy life.
    Access to care has been defined in various ways, and it is helpful 
to distinguish between an organization's ability to provide medical 
services, and the many barriers to care and recovery experienced by 
individuals in need of these services. In other words, even when an 
organization makes care accessible in the form of readily available 
appointments with qualified personnel and short wait times, this does 
not mean that individuals will be able to utilize these services or 
that the quality of care will be adequate to achieve recovery. My 
interest has increasingly been focused on the veteran's perspective and 
the many barriers veterans encounter navigating the transition home 
from the combat environment.
    Mental health treatments have improved dramatically over the last 
two decades, and there are many more resources now that were not 
available to veterans of previous conflicts. Studies have shown that 
treatment for PTSD can be 70-80% effective, as long as individuals are 
able to access the care and continue with treatment long enough for it 
to be effective.
    Unfortunately, the marked improvements in evidence-based treatments 
have been offset by continued gaps in access and other barriers to 
recovery. Despite extensive stigma-reduction efforts over 10 years of 
war, it is estimated that only approximately half of servicemembers and 
veterans in need of mental health treatment seek these services out; of 
those who do begin treatment, many receive less than optimal care or 
leave before achieving recovery. The actual effectiveness of PTSD 
treatment is estimated to be closer to 40%, not 70-80%, because of high 
rates of withdrawing from care.
    Stigma, negative perceptions of mental health care, and other 
barriers influence whether a veteran will initially access or continue 
to utilize services. Stigma is pervasive in society, not just in the 
military, and involves concerns of how others might view the veteran 
who seeks mental health care. Negative perceptions include lack of 
trust or confidence in mental health professionals, or considering 
mental health treatment ineffective, unhealthy, or a ``last resort.'' 
Other barriers include difficulty obtaining appointments, lack of 
availability of the same provider over time, poor coordination of care, 
distance from the treatment facility, transportation costs, or work or 
child care responsibilities that interfere with appointments.
    The question is, how do we meet veterans where they are, and foster 
a climate that minimizes the many barriers they face to recovery? Here 
is a partial list of considerations grouped into broad categories:
                           appointment access
    Appointments for veterans (initial and follow-up) need to be 
readily available at convenient times and locations, with options to 
assist veterans with evening or weekend appointments to minimize 
interference with work. This includes addressing any specific barriers 
that impede getting to appointments (e.g., transportation availability 
and costs). Outreach is essential to ensure that veterans are aware of 
available resources.
                  stigma and willingness to seek care
    More research is needed to better understand and guide 
interventions to improve willingness to seek care when needed. There 
are numerous potential opportunities to affect change in this area, and 
I will comment on two that I have been particularly interested in: (a) 
fostering greater understanding of PTSD from the warrior's perspective 
to reduce stigmatizing attitudes, and (b) veteran peer-to-peer 
initiatives to enhance transition and readjustment.
    Considering PTSD from the warrior's perspective within the military 
occupational context, rather than always from a medical perspective, is 
an important normalizing step for everyone (veterans, family members, 
health care professionals, and society at large). Warriors are 
professionals trained to work in some of the most inhospitable 
environments and they respond to combat events according to their 
training as part of cohesive teams. This is similar to other first 
responders (e.g., police, firefighters), and very different than the 
experiences of civilian victims of trauma. There is a paradox that 
responses that sometimes interfere with functioning back home (and may 
be labeled ``symptoms'') can also be beneficial in the military 
occupational context, reinforced through rigorous training and 
deployment. For example, ``hypervigilance'' can equate to sharply tuned 
threat perception in combat. Anger and numbing of emotions can stem 
from skills the warrior developed in channeling anger and controlling 
other emotions to focus on accomplishing combat missions. These 
responses have a physiological basis. They are not ``psychological'' or 
``emotional'' per se.
    I think there is also a critical role for veteran peer-to-peer 
counseling, mentoring, readjustment, and outreach efforts, partnered 
with traditional mental health services, since many veterans report 
feeling much more comfortable talking with peers about their war-
related concerns than with others.
      negative perceptions of mental health care and willingness 
                       to continue with treatment
    No matter how good evidence-based treatments may be, they will not 
be effective if offered in ways that drive veterans away. Mental health 
care needs a makeover to correct negative perceptions which appear to 
be pervasive. Research is needed to better understand veterans' 
perceptions of their health care experiences, with feedback to ensure 
the health care system is responsive. Veterans frequently report 
dissatisfaction with care, and disconnect between their experiences as 
warriors and situations they encounter when they access the medical 
system. This can take many forms, such as: ``I'm tired of answering the 
same questions over and over to different providers.'' ``The doctor 
kept looking at the computer screen.'' ``I felt misunderstood and 
judged.'' ``The doctor only offered medications.'' ``The doctor told me 
she understands what I went through, but never deployed.'' ``The doctor 
said there were only two talk therapy options for PTSD supported by the 
VA, neither of which I want.'' ``The doctor told me that I have to 
think differently about something that happened in combat that I don't 
want to see differently.''
    When a veteran takes the difficult step to overcome obstacles and 
seek mental health care, they are looking for a professional who is 
accessible, caring, competent, non-judgmental, and attentive to their 
concerns. Patient-centered care is important. Veterans should be 
provided with as wide a range of evidence-based treatment options as 
possible, and actively participate in selecting those they are most 
comfortable with.
    Clinicians must know how to tailor the core components of evidence-
based treatments to individual patient preferences. For example, in 
PTSD treatment, narration is one of the most therapeutic components, 
and research indicates that narration can be conducted in many 
different ways, including oral (past or present tense), written, as 
part of a life narrative review, or combined with specific eye-
movements (as is done in a therapy called Eye Movement Desensitization 
and Reprocessing or EMDR). Clinicians must also have sensitivity and 
knowledge in attending to difficult military-specific topics, such as 
grief, survivor's guilt, ethical dilemmas from combat, and other unique 
transition and readjustment concerns. The bottom line is that one size 
does not fit all, and policies aimed at standardizing care across 
health care systems must not lose sight of this.
               structure and coordination of health care
    I am encouraged by efforts in both the DOD and VA to enhance mental 
health treatment in primary care, and build collaborative patient-
centered systems within primary care that address all deployment health 
concerns. However, more research, particularly clinical trials, is 
needed in this area.
    Health care should be structured with an understanding of PTSD as a 
physical condition that affects physical, cognitive, psychological, and 
emotional functioning, and co-exists with other health concerns. There 
is an unrealistic expectation that the physiological effects of combat 
can quickly reset upon return home, which is not how the body 
functions. The extreme physical stress of combat, sleep deprivation, 
injuries (including concussions/mild TBIs) and PTSD can all interact to 
affect health, including the functioning of the endocrine and autonomic 
nervous systems (the part of the nervous system that controls heart 
rate, breathing, digestion, and other automatic or reflexive 
functions). Veterans with PTSD have significantly higher rates of 
physical health problems compared with veterans without PTSD, including 
chronic pain, headaches, sleep problems, concentration/memory problems, 
fatigue, cardiovascular problems, hypertension, and other concerns. 
Several of these problems are also linked to ``self-medication'' with 
alcohol or other substances.
    This means that PTSD (and other war-related health concerns) cannot 
be treated in isolation or strictly within specialty clinics. Treatment 
needs to attend to all post-war health effects holistically, with 
careful coordination of services through primary care to avoid 
problems, such as adverse interactions between medications prescribed 
by different providers.
    I believe there is also a role for complementary and alternative 
medicine modalities to help, for example, with modulating physiological 
reactivity, improving sleep, and assisting with pain control. Program 
evaluation and research is needed in all these areas.
                          support for families
    Last, more attention needs to be given to supporting spouses, 
partners, and other family members who are the most important and 
healing connections that veterans have. Family members should be 
actively involved in the treatment process. Sometimes the most 
effective intervention the medical system can provide to veterans is to 
simply support and strengthen their connections with others.
    Once again, I thank you for inviting me to share my perspective and 
for your attention to the critical topic of access to care, and I look 
forward to your questions.
                          selected references
Hoge CW. Once a Warrior-Always a Warrior: Navigating the Transition 
            from Combat to Home, Including Combat Stress, PTSD, and 
            mTBI. Globe Pequot Press, Guilford, CT 2010.
Hoge CW. Interventions for war-related Post Traumatic Stress Disorder: 
            meeting veterans where they are. Journal of the American 
            Medical Association 2011; 306:549-551.
Hoge CW. The paradox of PTSD: bridging gaps in understanding and 
            improving treatment. VVA Magazine, 9/2011 (http://
            digitaledition.qwinc.com/article/The+ Paradox+Of+PTSD/
            835300/0/article.html)
Kim PY, Britt TW, Klocko RP, Riviere LA, Adler A. Stigma, negative 
            attitudes about treatment, and utilization of mental health 
            care among soldiers. Military Psychology 2011;23:65-81.
Brown, MC, Creel AH, Engel CC, Herrell RK, Hoge CW. Factors associated 
            with interest in receiving help for mental health problems 
            in combat veterans returning from deployment to Iraq. 
            Journal of Nervous and Mental Diseases 2011;199:797-801.
Tanielian T, Jaycox LH (eds.). Invisible wounds of war: psychological 
            and cognitive injuries, their consequences, and services to 
            assist recovery. RAND Corp, Santa Monica, CA, 2008.
Seal KH, Maguen S, Cohen B, et al. VA mental health services 
            utilization in Iraq and Afghanistan veterans in the first 
            year of receiving a new mental health diagnosis. Journal of 
            Traumatic Stress 2010;23:5-16.
Harpaz-Rotem I, Rosenheck RA. Serving those who served: retention of 
            newly returning veterans from Iraq and Afghanistan in 
            mental health treatment. Psychiatric Services 2011;62:22-
            27.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
             Charles Hoge, M.D., Colonel (Ret.), U.S. Army
    Question 1. In your testimony you list a number of barriers to a 
veteran seeking mental health care such as scheduling issues, 
continuity of providers, poor coordination of care, travel and 
transportation issues, and responsibilities such as work or child care 
that keeps the veteran from getting to appointments.

    a. In your opinion, what role can the private sector play in 
helping to ease some of these barriers veterans face?
    Response. There are many ways that the private sector can help, 
particularly in the areas of outreach, clinical treatment, and 
research. In terms of outreach, I am particularly encouraged by peer-
to-peer programs that involve fellow veterans reaching out to other 
veterans in need of services. Veterans are often more willing to talk 
with their peers, and I think there is an important role for peer-to-
peer outreach partnered with traditional mental health services. In 
terms of treatment, many veterans access civilian health care systems, 
and there is a need for better education of civilian providers on how 
to effectively communicate with and provide treatment to the veteran 
population. The private sector is also important in conducting research 
to improve evaluation and treatment of war-related mental health 
problems.

    b. What immediate steps would you suggest VA take to help veterans 
needing mental health care today?
    Response. To expand on the recommendations provided in my 
testimony, I believe that enhancing willingness to engage in and 
continue with mental health treatment is the most important thing that 
can be done to improve the overall effectiveness for care for veterans. 
Research and program evaluation in this area is a very high priority. 
Strategies that I believe are particularly important to consider 
include: (1) better integration of mental health services in primary 
care, given the strong association of combat-related mental and 
physical health problems; (2) establishing peer-to-peer outreach 
programs partnered with traditional mental health services; (3) having 
strong marital and family therapy capability within treatment 
facilities; (4) integrating PTSD and other mental health services, 
given the high co-existence of conditions (e.g., depression, alcohol/
substance misuse); (5) ensuring that all veterans with PTSD have access 
to a wider range of evidence-based trauma-focused psychotherapy options 
than just Cognitive Processing and Prolonged Exposure therapies, 
following the current VA/DOD Post-Traumatic Stress (PTS) Clinical 
Practice Guideline (2010); (6) better education and support for 
clinicians in delivering evidence-based trauma-focused psychotherapy in 
a patient-centered manner; (7) evaluation and dissemination of 
strategies to improve negative perceptions of mental health care, such 
as incorporating immediate patient feedback into treatment sessions; 
and (8) enhancing research and dissemination of adjunctive treatment 
modalities, including complementary and alternative medicine 
approaches, following the current VA/DOD PTS Clinical Practice 
Guideline. Please also review my written testimony for additional 
information regarding these recommendations.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
          IV to Charles Hoge, M.D., Colonel (Ret.), U.S. Army
    Question 1. Dr. Hoge, your testimony talks about the stigma of 
seeking mental health care, and I agree this is a huge challenge and 
one I hear about at private veteran's roundtables. But seriously how do 
we change military culture and public understanding about mental health 
care and veterans?
    Response. Stigma is pervasive in society, and I'm not sure stigma 
perceptions will change very much until there is broader acceptance and 
understanding of mental health issues. However, I think we can still 
make a significant difference in veterans' willingness to utilize 
mental health services by looking beyond stigma at the many factors 
that influence veterans' decisions to access care or stay in treatment, 
as well as the key factors that predict recovery. These include, for 
example, how care is structured and delivered, the specific treatment 
strategies that are most acceptable to veterans, the rapport between 
the veteran and provider, and negative perceptions of care. Please see 
my responses above and written testimony for additional comments.

    Question 2. Getting a job is an important part of the transition, 
but how do we educate employers that a veteran has transferable skills 
and is a good hire, rather than a mental health risk?
    Response. This is such an important issue. Veterans have unique 
professional skills and values that they developed through their 
military training and deployment experience, and even PTSD symptoms can 
sometimes be considered adaptive and beneficial skills in certain 
professional situations (e.g., military, law enforcement, other first 
responders). There needs to be an active effort to combat negative 
stereotypes and improve general understanding of what it means to serve 
in the military, including the many benefits of military service and 
positive qualities that military training and experience bring to the 
civilian workplace.

    Question 3. How can we meet the overwhelming demands for mental 
health care among all our veterans, in this climate of cuts and calls 
for spending caps? How do we encourage and recruit VA nurses and mental 
health professionals in times of pay freezes and calls for overall cuts 
in our Federal Government?
    Response. I'm not sure I have a ready answer for this, but I know 
that there is nothing more rewarding than working with veterans, and 
that this sentiment is universally shared by my colleagues devoted to 
providing outstanding care. It is very important that funding 
priorities continue to be directed toward ensuring that there are 
sufficient mental health personnel and resources to support the growing 
demand for services resulting from over a decade of war (in addition to 
the demand from prior wars). It is important that health care policy 
decisions be strongly informed by feedback from mental health 
professionals who are working every day ``in the trenches'' with our 
veterans, even if this feedback is not what the organization wants to 
hear. It is important that mental health professionals have healthy 
work environments that are conducive to wanting to stay in those 
positions, and that health care leaders strive to protect mental health 
professionals from unnecessary or burdensome policies or administrative 
requirements that may be well intentioned but actually detract from 
patient care. For example, there needs to be a serious relook at the 
multiple existing screening processes in terms of whether they are 
truly patient-centered with potential benefits outweighing risks.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
             Charles Hoge, M.D., Colonel (Ret.), U.S. Army
    Question 1. Do active-duty servicemembers, who are identified with 
behavioral health care needs, have greater access to effective 
treatment and fewer barriers to receiving treatment, while still on 
active-duty?
    Response. Some studies have suggested that active duty 
servicemembers have more ready access to care than Reserve/National 
Guard servicemembers, who may be living in locations distant from 
military or VA treatment facilities. However, this is a question that 
may be best asked directly to the military services.

    Question 2. Do active-duty servicemembers receiving behavioral 
health care treatment have similar withdrawal rates to veterans in VHA 
treatment programs?
    Response. The rate of dropping out of treatment has not been 
studied as extensively in active duty servicemembers as it has in the 
VHA, but the limited data that are available suggest that dropping out 
of mental health care is also a critical problem for active duty 
servicemembers.

    Question 3. Are you aware of any peer-to-peer counseling, 
mentoring, readjustment and outreach efforts currently underway in DOD 
for active-duty servicemembers and National Guard personnel?
    Response. A program that immediately comes to mind is the Army 
Embedded Behavioral Health program, which received a very favorable 
program evaluation. It would be best to ask the Army directly for 
information on this and other programs.

    Chairman Murray. Thank you very much.
    Dr. Van Dahlen.

            STATEMENT OF BARBARA VAN DAHLEN, PH.D., 
        FOUNDER AND PRESIDENT, GIVE AN HOURTM

    Ms. Van Dahlen. Thank you. Good morning, Chairman Murray, 
Ranking Member Burr, and Members of the Committee. Thank you 
for this opportunity to provide testimony regarding veterans 
access to care through the Department of Veterans Affairs.
    It is an honor to appear before the Committee, and I am 
proud to offer my assistance to those who serve our country. As 
the founder and president of Give an Hour, a national nonprofit 
organization providing free mental health services to our 
returning troops, their families, and their communities, I am 
well aware of the mental health issues that now confront our 
military and veterans community.
    As a licensed clinical psychologist who has practiced for 
over 20 years, I am certain of the importance of ensuring that 
those in need are able to access effective care, care that fits 
their needs, care that fits their schedules, care that 
guarantees the opportunity to develop a relationship with a 
provider that they can trust.
    As the daughter of a World War II veteran, I share your 
commitment to ensure that all veterans in need of mental health 
services receive the care that they deserve.
    The Department of Veterans Affairs is the principal 
organization in our Nation's effort to ensure that all of those 
who wore the uniform receive the mental health services they 
require.
    But no organization, agency, or department can provide all 
of the education, support, mental health treatment that every 
veteran and family need.
    Indeed, I would argue that it is more helpful to those who 
serve and their families to see numerous endeavors coordinated 
on their behalf so that they understand that our country, not 
just our government, supports them and is committed to their 
health and well-being.
    Give an Hour is one example of a community-based effort 
designed to complement the work of the VA. We are honored to do 
our part.
    The idea behind Give an Hour is really quite simple. Ask 
civilian mental health professionals to provide an hour each 
week of mental health support or treatment to any OEF/OIF 
servicemember, veteran, or family member in need free of 
charge.
    Give an Hour provides mental health care and support to 
those that are active duty, members of the Guard, reservists, 
veterans, and their families. We define family members as 
anyone who loves someone who has served since 9/11.
    Our clients find their way to us through a number of 
channels. Many find us on the web and contact our providers 
directly. We have excellent relationships with other nonprofits 
and VSOs, all of which make regular use of our services.
    Further, we have very good relationships within the 
Department of Defense and often receive referrals from our 
colleagues there. And although we do not have an official 
relationship with the Department of Veterans Affairs, we 
received many referrals from the VA.
    Our mental health professionals remain in our network for 
at least 1 year. They are required to be licensed in good 
standing and to carry their own malpractice insurance.
    We have developed excellent relationships with all of the 
major mental health associations. Our network includes 
psychologists, psychiatrists, social workers, psychiatric 
nurses, pastoral counselors, licensed professional counselors, 
substance abuse counselors, and marriage and family therapists.
    Give an Hour has over 6000 professionals in our network. We 
are in every State and territory. Our providers offer face-to-
face direct care. They provide phone support to those who are 
unable to attend a session in person. And this month, we began 
offering telehealth capability first in Virginia and North 
Carolina and then to the rest of our network in 2012.
    Give an Hour providers offer a wide range of options with 
respect to available appointments including evenings, weekends, 
and home visits. In addition, they bring a wealth of treatment 
options and areas of expertise to their work.
    We know that one size does not fit all with respect to this 
population or any. Flexibility and treatment based on 
individual needs are critical elements if we are to 
successfully address the mental health needs of veterans and 
their families.
    There is no limit to the number of sessions the client 
receives and all of our services are free. Give an Hour 
providers have provided over 42,000 hours of care, and we have 
reason to believe that many more hours have actually been 
given. Regardless, we are pleased that we can count $4.2 
million in mental health services provided to those who have 
served our country.
    Our capacity for providing care has not yet been reached. 
We can currently offer 6,000 hours of care each week to provide 
support, education, information, and assistance. Our goal is to 
enlist 40,000 professionals to assist in this effort so that 
someday we hope to offer 40,000 hours which translates to $4 
million of mental health care per week.
    Give an Hour is a virtual organization. Because we are not 
a bricks and mortar operation, we have minimal overhead and are 
able to provide our services efficiently and inexpensively. We 
are currently able to provide 1 hour of care for $17.88.
    Give an Hour cannot provide all of the services that our 
veterans and families need. But neither can the VA. Working 
together, we have a much greater likelihood of ensuring that no 
veteran in need suffers or fall through the cracks of a poorly 
coordinated and overly burdened system. Thank you.
    [The prepared statement of Ms. Van Dahlen follows:]
      Prepared Statement of Dr. Barbara Van Dahlen, Psychologist, 
           Founder and President of Give an HourTM
    Thank you for this opportunity to provide testimony regarding 
veterans' access to mental health care through the Department of 
Veterans Affairs. It is an honor to appear before the Senate Committee 
on Veterans' Affairs, and I am proud to offer my assistance to those 
who serve our country.
                      effective mental health care
    As a psychologist and the Founder and President of Give an 
HourTM, a national nonprofit organization providing free 
mental health services to returning troops, their families, and their 
communities, I am well aware of the mental health issues that now 
confront the men, women, and families within our military and veterans 
community. As an American I share your commitment to ensure that all 
veterans in need of mental health services receive the care and 
treatment they deserve.
    Many issues affect our ability to effectively and successfully 
deliver mental health treatment and support to our military and 
veterans communities. While we are here to focus specifically on the 
critical elements of wait time and access to care, our efforts must 
address all of the factors that enhance or interfere with the delivery 
of services if we are to ultimately succeed with our mission. First, we 
must have adequate numbers of mental health professionals appropriately 
prepared and available in all communities to serve those in need. In 
addition, we must effectively educate military personnel, veterans, and 
their families so that they understand the full range of mental health 
issues that can affect those who serve our country. Education is 
critical if we are to prevent the development of disabling and costly 
conditions and disorders. Finally, and most important, we must work 
together across organizations and agencies to ensure that our messaging 
is consistent and our approaches are complementary.
    The failure to provide effective mental health education, support, 
and treatment to military personnel, veterans, and their families will 
have dire consequences for generations to come. As a mental health 
professional I have witnessed the impact on the families of Vietnam 
veterans of the failure to provide effective and appropriate care to 
those in need. Many of these veterans--who returned from an unpopular 
war to an unsupportive Nation--were never properly identified as having 
significant mental health concerns. As a result, they and their 
families suffered for years--some for decades--from the invisible 
wounds of war.
    Indeed, we are already seeing the consequences of the failure to 
identify and provide treatment to those OIF/OEF veterans in need as 
they come home from war. Over the last 10 years we have seen a rise in 
suicide among our servicemembers and veterans from the current 
conflicts. This generation of veterans is entering the homeless 
population at an alarming rate. And we need only look at the rise of 
divorce within the military community as well as an increase in mental 
health services being delivered to children of our warriors to 
understand the far-ranging and significant consequences of the mental 
health issues affecting those who serve.
    Without a doubt, the Department of Veterans Affairs is the 
principal organization in our Nation's effort to ensure that all of 
those who wore the uniform and their families receive the mental health 
care they need to ensure they are able to lead healthy and productive 
lives once they complete their service. Clearly the VA has worked hard 
to keep up with the changing landscape and the growing demands over the 
last decade as a result of the wars in Iraq and Afghanistan. The VA has 
increased the number of mental health professionals providing services 
since 2006. It now employs 21,000 clinicians. It has increased the 
number of Vet Centers across the country to 292 and has added 70 mobile 
Vet Centers in its effort to serve those who live in rural communities. 
Similarly, the VA has expanded its call centers to help connect 
veterans in need with counseling services and launched the Veterans 
Crisis Line, which allows veterans and their families to call 24 hours 
a day, seven days a week for assistance. Finally the VA has begun 
integrating mental health care into its primary care settings.
    But no organization, agency, or department can provide all of the 
education, support, and mental health treatment that every veteran and 
his or her family needs. Indeed, I would argue that it is more helpful 
to those who serve and their families to see numerous endeavors 
coordinated on their behalf so that they understand that our country--
not just our government--supports them and is committed to their health 
and well-being. Give an HourTM is one example of a 
community-based effort to complement the good work of the Department of 
Veterans Affairs. We are honored to do our part.
                       give an hourTM
    I founded Give an HourTM in 2005. As the daughter of a 
World War II veteran, I became concerned about the stories coming home 
about those who were serving. Although the Departments of Defense and 
Veterans Affairs were doing more than ever before in their efforts to 
care for the invisible injuries of war, servicemembers were clearly 
struggling and their families were suffering. Early studies by Charles 
Hoge and others indicated that significant numbers of servicemembers 
would continue to come home with post-traumatic stress, Traumatic Brain 
Injury, depression, anxiety, and other understandable consequences of 
exposure to the brutality of war.
    The idea behind Give an HourTM is really quite simple: 
ask civilian mental health professionals across the country to provide 
an hour each week of mental health support and/or treatment to any OIF/
OEF servicemember, veteran, or family member in need, free of charge. 
Our plan continues to be to organize the civilian mental health 
community so that we might offer additional critical mental health 
services to the Departments of Defense and Veterans Affairs to aid them 
in our Nation's efforts to assist returning troops and their families.
    Give an HourTM provides mental health care and support 
to those who are active duty, members of the National Guard, 
Reservists, veterans, and their families. We define family members very 
broadly--as anyone who loves someone who has served since 9/11.
    Our clients find their way to us through a number of channels. 
Servicemembers and veterans tend to be technologically skilled, and 
many find us on the Web and contact our providers directly. We have 
excellent relationships with a number of nonprofits and VSOs, all of 
which make regular use of our services by referring individuals to our 
providers. In addition, we have a successful marketing campaign, with 
frequent articles about our efforts appearing in numerous magazines and 
newspapers. And we have been fortunate to receive free advertising from 
publications such as Time magazine and USA Today. I am also a frequent 
guest on local and national television and radio programs. Further, we 
have very good relationships within the Department of Defense and often 
receive referrals from our colleagues there. Finally, although we do 
not have an official relationship with the Department of Veterans 
Affairs, we have received many referrals from the VA.
    Our mental health professionals commit to remain in our network for 
at least one year. Mental health professionals accepted into our 
network are required to be licensed in good standing in their state and 
to carry their own malpractice insurance. We have developed excellent 
relationships with all of the major mental health associations, and we 
accept mental health professionals from all of the major disciplines. 
Our network includes psychologists, psychiatrists, social workers, 
psychiatric nurses, pastoral counselors, licensed professional 
counselors, and marriage and family therapists. Though not required, 
servicemembers, veterans, or family members who receive care through 
GAH are asked to give back by volunteering in their own communities. We 
currently have great relationships with a number of organizations--
including The Mission Continues and Service Nation--that assist us with 
this element of our model.
    Give an HourTM has over 6,000 mental health 
professionals in our network. We have providers in each of the 50 
states and U.S. territories. Our providers offer face-to-face direct 
care to servicemembers and/or their families, they provide phone 
support to those who might be unable to attend a session in person, and 
this month we will begin offering tele-health capability first in 
Virginia and North Carolina and then to the rest of our network in 
2012.
    Give an HourTM providers offer a wide range of options 
with respect to available appointment times to those who seek services 
including evenings and weekends. In addition, they bring a wealth of 
treatment options and areas of expertise to their work. We know that 
one size does not fit all with respect to this population or any. 
Flexibility and treatment based on individual needs and preferences are 
critical elements if we are to reach and successfully support the 
mental health needs of veterans and their families. There is no limit 
to the number of sessions that servicemembers receive, and all services 
are free.
    In addition to providing direct service, GAH also offers free 
mental health consultation to other organizations that provide services 
to the military community. For example, we have enjoyed a long-standing 
relationship with organizations such as TAPS (the Tragedy Assistance 
Program for Survivors) and SVA (Student Veterans of America), providing 
direct assistance with referrals and assisting at their events. We are 
also regularly asked to participate in Yellow Ribbon events and similar 
community gatherings across country. Our staff members present at 
conferences and are key members of advisory groups addressing the needs 
of those in our Armed Forces. We are proud that Give an 
HourTM is successfully harnessing the knowledge, wisdom, 
skill, and compassion of our civilian mental health professionals and 
offering these resources to those who serve, our veterans, and their 
families in communities across the country.
    Give an HourTM surveys our mental health professionals 
quarterly to determine the specific services they have provided. 
Typically about 25% of our mental health professionals respond to our 
surveys. Our last survey was completed at the end of August 2011: those 
who have answered our surveys over the last five years report having 
given 42,000 hours of care since we began providing services. Given 
that only a quarter of our respondents provide information, we can 
assume that many more hours have actually been given. Regardless, we 
are pleased that we can count $4.2 million in mental health services 
provided to the men, women, and families who serve our country.
    And we know that our capacity for providing care has not yet been 
reached. We can currently offer 6,000 hours of care each week, to 
provide support, care, education, information, and assistance. Our goal 
is to enlist 40,000 mental health professionals--approximately 10% of 
the 400,000 mental health professionals in our country--to assist in 
this effort. Someday we hope to offer 40,000 hours, which translates to 
$4 million, of mental health care per week.
    Give an HourTM is a virtual organization. Although most 
of our 12 staff members live and work in the Washington, DC, area, we 
also have employees in Virginia, New Jersey, North Carolina, and 
Pennsylvania. Five of our staff members are either veterans themselves 
or military family members. Because we are not a bricks and mortar 
operation, we have minimal overhead and are able to provide our 
services efficiently and inexpensively. In addition to our 6,000 mental 
health volunteers, we also appreciate the efforts of approximately 300 
general volunteers, who assist us throughout the country with a variety 
of tasks and efforts. Because of our organizational efficiency and the 
generosity of the mental health professionals who have stepped up to 
assist with this critical effort, Give an HourTM is able to 
provide one hour of care to servicemembers, veterans, their families, 
and their communities for $17.88.
    As a clinical psychologist I am aware of the importance of proper 
training for the members of our network. Indeed focus groups conducted 
with our mental health volunteers indicate their interest in being well 
prepared to serve those in the military community. Since our inception, 
Give an HourTM has been dedicated to providing a variety of 
training opportunities--both online and through conferences and 
workshops--to those who offer their services to assist returning troops 
and their families. We are fortunate to have collaborative 
relationships with a variety of organizations and associations, many of 
which have provided training tools and opportunities. Indeed, because 
of our knowledge and commitment to training and education, Give an 
HourTM has also been commissioned to create training tools 
for educators and employers. We look forward to continuing to explore 
and offer new and creative tools to assist our talented mental health 
professionals with their important work.
    And we look forward to working with our colleagues at the 
Departments of Defense and Veterans Affairs as we continue to develop 
opportunities to offer the considerable resources available within the 
civilian mental health community to returning troops, veterans, their 
families, and their communities.
                       beyond mental health care
    As critical as effective and accessible mental health care is to 
servicemembers, veterans, and their families, these men, women, and 
families who serve our Nation need and deserve much more as they return 
to our communities. And while good mental health forms the basis for 
every other aspect of a satisfying and productive life, without a good 
job or a quality education, it is difficult to imagine how those who 
serve can move forward and carry on.
    Over the past six years through my work and travel with Give an 
HourTM, I have had the pleasure of meeting numerous 
community leaders--leaders who care deeply for our military families. I 
have also had the honor of working with many leaders within the 
nonprofit community as well as leaders from a variety of Veterans 
Service Organizations, all of whom work tirelessly to support 
servicemembers, veterans, and their families. And I am pleased that I 
now have many good friends and respected colleagues in the Department 
of Defense who are committed to providing opportunities and care to 
servicemembers.
    I have had numerous conversations and frequent discussions with 
these colleagues regarding the importance--and indeed the necessity--of 
creating a comprehensive and integrated system of care for those who 
serve and their families. These conversations consistently focus on the 
need for collaboration, coordination, and communication among all 
organizations, agencies, and departments. And while everyone seems to 
agree that a concerted effort is required to coordinate Federal, state, 
local, and community-based efforts, implementation of such an effort 
has been difficult to achieve.
    Fortunately, several efforts seem to be under way across the 
country to tackle this most difficult challenge, and many of the 
leaders of these efforts are now working to connect these critical 
models to one another. I am proud of my association with and 
contribution to one of these efforts, the Community Blueprint Network.
                      community blueprint network
    As Adm. Mullen noted so many times during his tenure as chairman of 
the Joint Chiefs of Staff when he coined the phrase ``The Sea of 
Goodwill,'' there is universal public support for veterans, 
servicemembers, and their families. Federal, state, and local 
governments, as well as nonprofit, private, and philanthropic resources 
and services, have grown and improved in communities across America. 
But supporting veterans, servicemembers (active duty, Reservists, and 
National Guardsmen), and their families is about ensuring that 
communities are prepared to organize the resources, services, and 
support that help those in the military community lead healthy, 
successful lives. There remain significant gaps in services and a great 
deal of untapped potential for providing effective and sustainable care 
through focused planning and coordination.
    To address these needs by leveraging the combined experience and 
expertise of collaborating organizations, volunteers from several 
leading nonprofits created an initiative and an online tool called the 
Community Blueprint, which is already helping local community leaders 
assess and improve their community's support for veterans, 
servicemembers, and their families. The initiative is now formally 
being administered as the Community Blueprint Network Initiative by 
Points of Light Institute and is being implemented in several 
communities across the country. Plans for a national launch of the 
initiative are currently under way.
    The Community Blueprint Network Initiative includes several key 
components:

     The Blueprint assists each community in assessing and 
fulfilling its role in supporting those who have borne the price of 
battle--veterans, servicemembers, and their families.
     The Blueprint helps community leaders and citizens gain a 
more precise and locally focused understanding of how they can 
contribute to an improved support matrix including offering 
opportunities for civilians, veterans, servicemembers, and their 
families to volunteer and serve alongside each other.
     The Blueprint provides community leaders with information 
about the primary challenges returning veterans, servicemembers, and 
their families may face.
     The Blueprint offers advice based on practices worthy of 
replication and experience about setting priorities, adopting 
strategies that work, and building coalitions to implement those 
strategies.
     The Blueprint is user-friendly and focuses on eight key 
areas: Behavioral Health, Education (both K-12 and higher education), 
Employment, Family Strength, Financial Management and Legal Assistance, 
Housing Stability and Homelessness Assistance, Reintegration, and 
Volunteerism. Under each of these impact areas the Blueprint offers up 
to six topics that stakeholders (community leaders, civic leaders, 
VSOs, etc.) can address. For example, under Higher Education, 
stakeholders will find the topic ``Welcome and Integration: Strategies 
to identify and support military-connected students and families.'' 
Each topic will have tabs for additional information and resources.
     The Blueprint provides communities with a forum to learn 
and share best practices and to bring key stakeholders and community 
leaders together to collaborate behind the common goal of assisting our 
Nation's veterans, servicemembers, and their families.

    In the summer of 2010, the Bristol Myers-Squibb Foundation (BMSF) 
approached Give an HourTM with an interest in funding our 
efforts to provide free mental health care to returning troops and 
their families. After learning of our involvement in the Community 
Blueprint Network Initiative--and the need for a more comprehensive and 
integrated system of care to support those who serve in communities 
across the country--BMSF agreed to fund Give an HourTM to 
develop a model that can be used to assist communities in their efforts 
to organize support for military personnel, veterans, and their 
families. The result was a two-year grant for a demonstration project 
in two communities: Norfolk, VA, and Fayetteville, NC. This grant is 
enabling GAH to support, assist, coordinate, and convene community 
stakeholders as we develop a model that will be shared with the 
national Community Blueprint Network Initiative and with communities 
across the country involved in this critical endeavor.
    Thus far, we have been impressed with and pleased by the response 
to our efforts in Norfolk and Fayetteville. Multiple community-based 
organizations have joined our meetings and our working groups, and we 
have received assistance from colleagues at the Department of Defense 
so that we now have developing relationships with installations and 
military partners in each of these communities. We have begun 
implementing programs and events in each community to highlight what we 
are doing in each of the eight areas of focus within the Blueprint.
    On November 17 Give an HourTM joined with the consulting 
firm Booz Allen Hamilton to host a summit in Fayetteville, on the needs 
of women veterans. The event was well attended by stakeholders and 
community leaders, including the mayor and officials from the local VA. 
This summit resulted in the development of three initiatives focused on 
ensuring the health of women veterans in Fayetteville and the 
commitment of those who attended to ensure the implementation of these 
initiatives. Give an HourTM will continue to work with Booz 
Allen Hamilton over the coming months to support and coordinate these 
and other initiatives in this community as part of our work on the 
Community Blueprint demonstration project.
    Clearly, the development of the Community Blueprint Network 
Initiative provides an unprecedented opportunity for all Federal and 
state agencies and departments to coordinate with community-based 
organizations and efforts to ensure that military personnel, veterans, 
and their families receive the type of comprehensive and coordinated 
care they need and deserve as they move forward in their lives as 
healthy Americans. We look forward to joining our efforts with those of 
the Department of Veterans Affairs in this worthy effort.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
       Barbara Van Dahlen, Ph.D., founder and President, Give an 
                           HourTM
    Question 1. We often hear that VA is the best place to treat 
veterans because VA providers better understand the veterans' 
experiences. Dr. Hoge's testimony echoed that sentiment when he says 
that the experience of a veteran with PTSD is very different from a 
civilian's experience with trauma. How does your organization make sure 
your providers understand the effect military service has on the course 
of treatment for PTSD?
    Response. Indeed, it is very important to ensure that all mental 
health professionals working with servicemembers, veterans, and their 
families are properly trained and prepared for the critical work with 
this population. Many of our providers join Give an HourTM 
because they have expertise in treating those who have experienced 
trauma, but they may not be familiar with the military culture. Others 
join because they are in some way connected to the military through 
family members or their own service, but they may not have experience 
in treating trauma victims. All seem to join because they are patriotic 
Americans, with excellent clinical skills, who want to do their part 
even though they may not be skilled in the treatment of trauma or have 
experience with the military culture.
    Fortunately, there are many good training tools currently available 
to assist civilian mental health professionals who are interested in 
learning more about this population and the issues they bring home. I 
am regularly asked to review these programs and frequently make our 
providers aware of good programs. Sometimes workshops or conferences 
are available in specific geographical regions, so we send out notices 
to our providers in those areas. Often we are notified about online 
training tools that have become available and we pass on this 
information to all of our providers. In addition, we have worked with 
our mental health association partners to provide information through 
Webinars and we have created and collected tools and primers that can 
be downloaded from our Web site.
    Give an HourTM is also working with a number of partners 
to identify--and when needed--create training tools and opportunities. 
We are also crafting a project with one of our VSO partners to bring 
servicemembers/veterans together with GAH providers in communities 
across the country so that both groups can better understand each 
other.
    Finally, we would welcome the opportunity to partner with the VA to 
provide training to our providers. I was recently approached by some of 
my colleagues at the National Center for PTSD to participate in a 
research study to train civilian mental health professionals. We 
provided a letter of support for this DOD-funded project and are 
hopeful that the project will go forward and that Give an 
HourTM providers will become part of the study. I will be 
meeting with Deputy Sec. Gould on January 12 and look forward to 
discussing how Give an HourTM and the VA might work together 
to provide training to the community-based mental health professionals 
in our organization and elsewhere who will be treating our Nation's 
veterans for decades to come.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
    IV to Barbara Van Dahlen, Ph.D., founder and President, Give an 
                           HourTM
    Question 1. How can we meet the overwhelming demands for mental 
health care among all our veterans, in this climate of cuts and calls 
for spending caps? How do we encourage and recruit VA nurses and mental 
health professionals in times of pay freezes and calls for overall cuts 
in our Federal Government?
    Response. The current demand for mental health services for 
veterans and their families will certainly continue to increase over 
the coming months and years. We can successfully meet this growing 
demand if we create a comprehensive and integrated system of care--one 
that incorporates all of the excellent services available through the 
VA system but also goes far beyond what the VA can provide. Such a 
system must include community-based mental health resources, primary 
care physicians, and other professionals in our communities who 
interact with veterans and their families. Such an approach must 
coordinate the efforts of state, Federal, and local governmental 
agencies in addition to nonprofit and VSO initiatives and resources. 
Mental health professionals from all involved organizations can and 
must play a primary role in educating our civilians--our physicians, 
our faith-based leaders, our first responders, our educators, and our 
employers--about the issues affecting those who serve and their 
families. Such a public health approach will ensure that those in need 
of treatment will be identified early and that all who can play a role 
in the healing and support of those who are suffering are knowledgeable 
and well prepared for the task at hand.
    There is no silver bullet when it comes to treatment and healing. 
During this time of budget cuts and limited resources we must look for 
creative and innovative approaches to address the mental health needs 
of our returning warriors. For some veterans, a stable and meaningful 
job is as important--if not more so--to their mental health as a weekly 
session with a mental health professional. Increasing community 
awareness and increasing options for care and support increase the 
likelihood of success in ensuring that all military personnel, 
veterans, and their families receive the care and support they need and 
deserve. By creating an ``all hands on deck'' approach to this problem, 
we increase the number of potential supports in a community, despite 
the fiscal challenges of our era, and we create opportunities for 
skilled professionals to join the effort through volunteer work even if 
funding is cut or limited.
    The awareness that no one organization, no one profession, and no 
single approach can meet all of the needs of our servicemembers, our 
veterans, and their families led to the development of the Community 
Blueprint Network Initiative. As I described in my written testimony, 
volunteers from several leading nonprofits created the Community 
Blueprint, which is already helping local community leaders assess and 
improve their community's support for veterans, servicemembers, and 
their families. The initiative is now formally being administered as 
the Community Blueprint Network Initiative by the Points of Light 
Institute and is being implemented in several communities across the 
country. Plans for a national launch of the initiative are currently 
under way.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Senator Sanders to 
       Barbara Van Dahlen, Ph.D., founder and President, Give an 
                           HourTM
    Question 1. Do you and your volunteers provide servicemembers and 
veterans you provide behavioral health services to documentation that 
they can submit to VA in support of a service-connected disability 
claim?
    Response. Give an HourTM provides confidential free 
mental health services to servicemembers, veterans, and their families. 
As an organization we do not collect information about the clients who 
make use of our provider network. However, all of our mental health 
professionals keep records just as they would when seeing any client in 
their practice. Therefore any veteran can request documentation of the 
services they receive--just as any client can from any mental health 
professional. They are entitled to those documents when and if needed.

    Chairman Murray. Thank you very much.
    Mr. Roberts.

  STATEMENT OF JOHN ROBERTS, EXECUTIVE VICE PRESIDENT, MENTAL 
     HEALTH AND WARRIOR ENGAGEMENT, WOUNDED WARRIOR PROJECT

    Mr. Roberts. Thank you, Chairman Murray, Ranking Member 
Burr, and Members of the Committee. Thank you for allowing me 
the time to come before you today on this important issue and 
provide testimony.
    As the Executive Vice President of the Wounded Warrior 
Project, I interact daily with wounded warriors. Not only am I 
an executive with WWP, a former VA supervisor, but I am also a 
wounded warrior myself who has struggled with PTSD since my 
injuries in 1992.
    Every day I come across men and women that served this 
country. Their stories echo the story that I once told. They 
are very similar in nature. The stories have not changed from 
one generation to another.
    Earlier this month, Wounded Warrior Project sent out a 
survey to our alumni or our warriors we serve. We got 900 
responses back. Out of those 900, 62 percent of those 
individuals had attempted to obtain treatment through the VA. 
Half of those individuals have had difficulties getting that 
treatment, and one out of three of those individuals got no 
treatment at all.
    You know, these are real-life individuals that have served 
their country proudly and are struggling to get the care that 
they need and deserve. But I want to share a couple of 
statements from three of those individuals that wrote in 
written comments.
    ``I cannot get an appointment for 3 months, and then they 
canceled and rescheduled three times. Once I was able to see a 
counselor, I was told I cannot get repeat care in a group 
setting more frequently than once a month. Even though group 
counseling was not ideal for my situation, I was told that they 
would not pay for me to see a private counselor even though 
they could not fill my appointments at the frequency they said 
I required. That is when I gave up on the VA health care. As a 
result, I put off getting treatment for almost 2 years until I 
got private insurance from my new job.''
    The second statement is, ``In Columbia, South Carolina, 
there is one doctor, two counselors. I have been off active 
duty since July 2011 and I have had one appointment for PTSD. 
They are so short staffed it is like trying to put a Band-Aid 
on an amputation.''
    And the last statement is, ``While it would be great to 
have the ability to have more frequent visits than every two to 
3 months, I am actually limited to the frequency anyways due to 
the limited sick leave from work and the VA CBOC not offering 
evening counseling.''
    All the stories are different. They have a very similar 
theme, and unfortunately, they are very troubling. Warriors may 
be able to get in for their initial appointment and screening; 
but when a veteran who is struggling with PTSD, with 
depression, substance abuse, and is coming to the VA for help 
and is told that the next available appointment is months away, 
why are we surprised when somebody kind of loses hope and turns 
to more desperate measures--suicide, for example.
    Let me ask some questions. Why, after 10 years, do warriors 
have to struggle to get effective care for the signature wound 
of this war? Why has not the Undersecretary for Health and the 
Secretary moved beyond measuring baseline access to initial 
mental health evaluations to systematically tracking access to 
sustained follow-up care?
    In fact, if leaders spent more time speaking with the 
veterans and their own clinicians, they would realize that the 
problems with the VA's mental health system run far deeper than 
even their data suggests.
    In that regard, why have not those leaders instituted 
concrete medial measures rather than offering so-called action 
plans that promise nothing more than the possibility of future 
plans.
    And when will VA leaders actually enforce central office 
policies and end the disconnect between national directives and 
what is actually taking place in the medical centers across the 
country?
    I recently spoke to a VA psychologist in a large urban VA 
medical center. He described the VA's ability to handle the 
current caseload as completely inadequate.
    VA has placed great emphasis on providing evidence- based 
mental health care to include sessions of cognitive behavioral 
therapy. The clinician I spoke with is trained in this 
technique and thinks it is effective for veterans with PTSD.
    Unfortunately, he is not able to provide this time- 
consuming treatment. This individual talked to me about working 
10 to 12 hour days just to keep up. So, the veterans that he 
treats are not able to get that treatment that they deserve.
    This clinician operates a crisis center which currently has 
a waiting list for veterans who need care and then he indicated 
to me that there are other clinicians in his medical center 
that have caseloads up to 300 veterans.
    I am not the smartest math guy around but I did a little 
calculation. If one doctor had 300 patients, never took lunch, 
phone calls, breaks, went to the bathroom or went to meetings, 
they could give 30 minutes a month to each patient.
    To me, as was said, I am the civilian up here. I do not 
know if 30 minutes a month is actually adequate or quality 
care. I will leave that up to the professionals.
    These caseload levels result in many veterans being seen no 
more than once every 4 weeks; and when they go to those 
appointments, the sessions often are focused on medication 
management but not much of the needed therapy.
    Appointments to manage medication may check the box and 
fulfill access to timeliness standards but this is not the type 
of care that will ultimately lead veterans to successfully 
manage their mental health conditions.
    Meeting numerical benchmarks is not good enough if the care 
the warriors receive is of poor quality. VA's recent action for 
improving timeliness and mental health care does not reflect 
the urgency needed to address the situation.
    While the issues of impact and access to care are complex, 
this is also a leadership issue. It is time to move beyond 
characterizing these issues as perceived challenges and 
acknowledge them head on.
    VA's insistence on studying these issues is simply 
unacceptable. Veterans need a meaningful, aggressive strategy 
the same way that they are currently tackling homelessness 
which is often a direct result of an underlying mental health 
issue.
    While there is a lot to be done, WWP as three 
recommendations. First, better utilize VA's Vet Centers and 
allocate more resources to those centers. Second, mount a 
meaningful peer support program to help engage and retain 
veterans in mental health treatment. And last, utilize the fee-
basis care in situations where VA resources do not allow a 
veteran to be seen in a timely manner.
    VA officials speak of transforming the VA mental health 
care system, but a real transformation must dramatically 
improve the timeliness and access to effective quality mental 
health care.
    In our view, VA leadership has fallen short in meeting that 
challenge, short on urgency, short on commitment, short on 
vision, and short on action. We urge the Committee to demand 
more.
    Thank you, Chairman Murray, Ranking Member Burr, and the 
other Members of this Committee. Your continued oversight is 
essential in getting Secretary Shinseki and Undersecretary 
Petzel to embrace this challenge. Too much is at stake to move 
forward with business as usual. Thank you.
    [The prepared statement of Mr. Roberts follows:]
 Prepared Statement of John Roberts, Executive Vice President, Mental 
          Health and Family Services, Wounded Warrior Project
    va mental health care: addressing wait times and access to care
    Chairman Murray, Ranking Member Burr and Members of the Committee: 
Wounded Warrior Project (WWP) applauds this Committee's continued focus 
on Department of Veterans Affairs (VA) mental health care. Thank you 
for conducting this hearing as a follow-up to your July 14th hearing. 
During that hearing you heard testimony from Daniel Williams, a wounded 
warrior, and Andrea Sawyer, a caregiver for her husband Loyd. Chairman 
Murray, the survey of VA mental health professionals you requested 
during that hearing clearly shows that Daniel's and Loyd's struggles 
are not isolated anecdotes but representative of a systemic gap in 
care. More does need to be done.
    The survey's findings should serve as a stark call-to-action. 
Instead, the Veterans Health Administration provided the Committee an 
``Action Plan'' (dated November 7th), which outlines a series of timid 
half-steps for improving VA mental health care. This vague plan-to-
develop-plans falls far short of the immediate, aggressive action that 
is needed to assure that warriors receive timely, effective mental 
health care. Our experiences in working with wounded warriors 
overwhelmingly verify the fact that access to appropriate mental health 
care is a real and dire issue that warrants immediate, aggressive 
action. Admittedly, the factors impacting access to care are complex, 
but this is also a leadership issue--and that leadership is failing.
                  timeliness of va mental health care
    Earlier this month we asked wounded warriors to participate in a 
survey that asked about their experiences with VA mental health care. 
Of more than 935 respondents, 62% had tried to get mental health 
treatment or counseling from a VA medical facility; some 2 in 5 of 
those indicated that they had difficulty getting that treatment. And of 
those reporting that they had experienced difficulty, more than 40% 
indicated that they did not receive treatment as a result. Getting 
timely appointments was a frequent problem.
    The following comments from warriors responding to the survey were 
not unusual:

          ``I could not get an appointment for 3 months, and then they 
        canceled/rescheduled me three times. Once I was able to see a 
        counselor, I was told I could not get repeat care [in a group 
        setting] more frequently than every month, even though group 
        counseling was not ideal for my situation. I was also told they 
        would not pay for me to see a private counselor, even though 
        they couldn't fill my appointments at the frequency they said I 
        required. That's when I gave up on VA health care. As a result, 
        I put off getting treatment for almost two years until I got 
        private insurance through a new job.''
          ``The wait time to see my mental health provider is way too 
        far between appointments and I am tired of having to go 
        inpatient to have my immediate needs met. I just think that the 
        VA is overwhelmed.''
          ``Timeliness of my appointments with my primary care provider 
        and psychologist can be 3-6 months depending on how busy they 
        are. The providers are grossly understaffed. How can veterans 
        receive quality care if they only schedule a visit with their 
        providers 2-3 times a year?''
          ``I felt the care provided by the caregivers was top notch. 
        However through no fault of their own, the system has set them 
        up for failure in that they have too many people to see in such 
        periods of time.''
          ``While it would be great to have the ability to have more 
        frequent visits than every two to 3 months, I am actually 
        limited to this frequency anyways due to limited sick leave 
        from work and my VA [CBOC] not offering evening counseling.''
          ``It took over 6 months from retirement date to even be 
        scheduled for mental health treatment. The local VAMC has only 
        one mental health provider for ALL OIF/OEF veterans.''

    WWP outreach and alumni support staff routinely assist in referring 
warriors who have combat stress issues to Vet Centers and VA medical 
facilities. Our staff often encounter difficulties in securing timely 
mental health appointments for warriors. That experience certainly led 
us to question the reliability of VA data indicating near-uniform 
adherence to its 14-day scheduling policy, and VA's recent clinician-
survey findings were not altogether surprising. Unfortunately, VHA's 
response to those findings suggest little real action. The operative 
words describing VHA's plans--``reviewing,'' ``exploring possible 
barriers,'' ``working with other offices,'' ``engaging leadership and 
staff,'' and ``developing policies''--suggest a response that amounts 
to little more than studying the problem. As we advised Secretary 
Shinseki in an October 6th letter that urged him to take bold 
leadership, VHA's emphasis on studying and discussing issues at a time 
when veteran suicides continue at alarming rates, suggests a plodding 
bureaucracy out of touch with a very real crisis.
    Consider how just three warriors describe their own mental health 
status:

          ``I've been dealing with PTSD/Depression for many years now 
        and it just seems to never go away. It affects my day to day 
        activities. I seem to have lost my self-purpose and interest.''
          ``My main problems are being emotionally numb, isolation, 
        freezing up in social environments, drugs and not having the 
        desire or energy to put toward changing my situation any more. 
        It has been over 5 years, and I am still just as bad as and 
        even worse than when I came back.''
          ``My greatest challenge is the feeling of uselessness and 
        helplessness.''\1\
---------------------------------------------------------------------------
    \1\ Franklin, et al., ``2011 Wounded Warrior Project Survey 
Report,'' (July 2011) pp. 83-4.

    Warriors facing such serious mental health problems need timely, 
effective mental health care. But we routinely encounter very different 
experiences with VA mental health care. Some of the very common 
---------------------------------------------------------------------------
problems warriors experience are the following:

     Delays in obtaining appointments;
     Inability to have input on appointment times, and 
resultant inability to attend a scheduled appointment because of work 
or school commitments;
     Lack of available mental health providers;
     Having to go to an emergency room because a therapist 
wasn't available to see the veteran;
     Not seeing the same therapist twice;
     Overmedication or inability to have meds adjusted when 
needed;
     Lack of support or understanding;
     Distance to available VA clinics or hospitals.
                              quality care
    VA mental health care should not only be of exceptional quality but 
should be tailored to meet the unique needs of our warriors. Ten years 
of war have taken a toll on the mental health of American fighting 
forces. Too many warriors are still battling demons. WWP is somewhat 
encouraged that the Veterans Health Administration, in responding to 
the survey of its mental health providers, acknowledged with respect to 
its mental care delivery system that ``important gaps remain, and VHA 
has not yet fully met its aspirational goals.''
    But we are also concerned that VA is highlighting a recent RAND 
assessment suggesting that its mental health care is as good as or 
better than that reported in the literature by other groups or by 
direct comparisons.\2\ In our view, veterans suffering from the stress 
of combat deserve timely, effective mental health care--not just ``as 
good as.'' In 2006, an Institute of Medicine panel assessing mental 
health care in this country, observed that despite what is known about 
effective care for mental-health/substance-use conditions, numerous 
studies have documented a discrepancy between mental-health/substance-
use care that is known to be effective and care that is actually 
delivered. Reviewing studies assessing the quality of care for many 
different behavioral health conditions, IOM found that only 27 percent 
of the studies reported adequate rates of adherence to established 
clinical practice guidelines.\3\ Pointing to departures from known 
standards of care, variations in care in the absence of care standards, 
failure to treat mental health and substance use conditions, and lack 
of care-coordination, IOM found that poor behavioral health care in 
this country hinders improvement and recovery for many.\4\
---------------------------------------------------------------------------
    \2\ Katherine E. Watkins and Harold Alan Pincus, ``Veterans Health 
Administration Mental Health Program Evaluation,'' RAND Corporation, 
2011.
    \3\ Institute of Medicine, ``Improving the Quality of Health Care 
for Mental and Substance-use Conditions,'' The National Academies Press 
(2006), 5-6.
    \4\ Id., 35-6.
---------------------------------------------------------------------------
    For veterans confronting such problems, the observation that VA 
mental health care may be ``better'' than poor care elsewhere offers 
little comfort.
    Consider, in that regard, the experience of a veteran named Angie, 
who was medivaced back from Iraq in 2003, developed PTSD, and soon 
after spiraled into a deep depression. After an 8-month wait to get 
care at the St. Louis VA medical center, Angie turned to TRICARE. But 
complicated medical problems led to her becoming dependent on pain 
medication. Finally, feeling suicidal, she again sought VA help, going 
to a VA medical center emergency room. She credits a dedicated VA 
physician's response to her crisis to her finally being admitted for 
care and to successful recovery. In this case, the care provided was 
apparently excellent. But that care almost came too late. For a 
facility or system to provide good care that cannot be readily accessed 
can hardly be classified as an achievement.
                             access to care
    It is not enough, in our view, for VA to assure this Committee that 
it is providing veterans access to mental health care. ``Access'' must 
mean more than simply that a veteran can get ``through the door'' or 
can ``be seen.'' Important questions include ``access to what?'' and 
``how is that access maintained?''
    We know that many veterans are being helped by dedicated clinicians 
at VA medical facilities, but others have had less positive encounters. 
Too often OEF/OIF veterans cite experiences reflected in a recent 
response to a WWP survey, ``the VA is overwhelmed at this point and [it 
is] discouraging for young troopers seeking care. Too much medicine 
gets thrown at you. Each provider thinks they can solve the complex 
issue of PTSD/Combat Stress with meds.''\5\
---------------------------------------------------------------------------
    \5\ Franklin, et al., 2011 Wounded Warrior Project Survey Report, 
(July 2011), 90.
---------------------------------------------------------------------------
    We must move beyond the ``access to care'' paradigm to a standard 
of ``access to effective care.'' It is not clear that VA has genuinely 
identified the critical elements of what constitutes effective mental 
health care, particularly as it relates to treating our returning 
warriors. Notwithstanding the recent extensive RAND Corporation attempt 
to evaluate VA mental health care, RAND's study seems ultimately to 
pose as many questions as it is able to answer in terms of meaningful 
qualitative judgments regarding VA mental health care. As RAND notes, 
the current state of quality assessment in mental health is still 
limited by many barriers.\6\
---------------------------------------------------------------------------
    \6\ ``Veterans Health Administration Mental Health Program 
Evaluation,'' RAND Corporation, 149.
---------------------------------------------------------------------------
    RAND's acknowledgement that VA outperformed private plans on seven 
of nine quality measures should also be tempered, in our view, by the 
fact that those quality measures all relate to reliance on medication. 
In contrast, RAND found that VA clinicians fall far short in providing 
a range of evidence-based practices, many of which involve talk-
therapy. RAND specifically cited the low percentage (20%) of veterans 
receiving cognitive-behavioral therapy for PTSD. A relatively recent 
comprehensive study found even lower rates in that regard among OEF/OIF 
veterans. There VA researchers found that of nearly 50,000 OEF/OIF 
veterans with new PTSD diagnoses, fewer than 10 percent appeared to 
have received evidence-based VA mental health treatment for PTSD 
(defined by researchers as attending 9 or more evidence-based 
psychotherapy sessions in 15 weeks).\7\
---------------------------------------------------------------------------
    \7\ Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas 
Metzler, Li Ren, Daniel Bertenthal, and Charles Marmar, ``VA Mental 
Health Service Utilization in Iraq and Afghanistan Veterans in the 
First Year of Receiving New Mental Health Diagnoses,'' Journal of 
Traumatic Stress, 2010.
---------------------------------------------------------------------------
    But even if VA adherence to evidence-based practices were greater, 
applying tested treatment models and techniques do not necessarily 
ensure effective treatment.\8\ Treatment must also be ``culturally 
competent''--that is, it must be responsive to the values, experiences, 
and language of the patients it serves.\9\
---------------------------------------------------------------------------
    \8\ Sandra J. Tanenbaum, ``Evidence-Based Practice as Mental Health 
Policy: Three Controversies and a Caveat,'' Health Affairs, vol. 24, 
No. 1 (January/February 2005).
    \9\ The President's New Freedom Commission on Mental Health, 52.
---------------------------------------------------------------------------
    In our experience, the success that Vet Centers have in counseling 
warriors stems in significant part from their staff's understanding of 
both the combat experience and warriors' ethos and language. A high 
percentage of Vet Center staff are themselves combat veterans; they and 
their clients share a common ``culture,'' so to speak. Many warriors 
also report that they feel understood when seen at Vet Centers and that 
their traumatic experiences and responses are viewed as normal 
responses to the combat experience rather than being pathologized.\10\
---------------------------------------------------------------------------
    \10\ See Charles W. Hoge, ``Once a Warrior Always a Warrior: 
Navigating the Transition from Combat to Home,'' Globe Pequot Press 
(2010).
---------------------------------------------------------------------------
    While the RAND's report lacks all the answers, one of the leading 
clinician-researchers in the field, Dr. Charles Hoge, has it right, in 
our view, in offering the following perspective with respect to helping 
veterans with war-related PTSD:

          ``Improving evidence-based treatments * * * must be paired 
        with education in military cultural competency to help 
        clinicians foster rapport and continued engagement with 
        professional warriors * * * Matching evidence-based components 
        of therapy to patient preferences and reinforcing narrative 
        processes and social connections through peer-to-peer programs 
        are encouraged. Family members, who have their own unique 
        perspectives, are essential participants in the veteran's 
        healing process and also need their own support.'' \11\
---------------------------------------------------------------------------
    \11\ Charles W. Hoge, MD, ``Interventions for War-Related 
Posttraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA, 
306(5): (August 3, 2011) 551.

    There is much to this advice, and it illustrates the gaps in VA's 
approach. With a dogged adherence to a medical model, VHA leaders seem 
insistently and narrowly focused on evidence-based treatments--closing 
the door to promising practices or even veterans' preferences. As 
discussed in WWP's testimony before the Committee on July 14, VA 
insisted on pursuing evidence-based practice as a rationale for 
disbanding a group-therapy program at the Richmond VA Medical Center 
over the objections of the veterans who had not only been actively 
participating in their treatment but also benefiting from the therapy. 
While promoting tested practices may seem laudatory, the rigidity of 
VA's approach has tended to ignore the veteran and what ``works'' for 
him or her.
    In striking contrast, Hoge wisely emphasizes that reliance on 
evidence-based treatments alone is not enough. As he notes, VA must 
also work to improve its clinician's cultural competence--their 
understanding of, and rapport with, warriors. And success is not solely 
about clinician-patient relationships. Peer-support has a critical role 
to play, as he advises. It is noteworthy that when WWP surveyed our 
alumni, nearly 30% identified talking with another OEF/OIF veteran as 
the most effective resource in coping with stress--the highest response 
rate of all the resources cited, including VA care (24%), medication 
(15%) and talking with non-military family or friend (8%).\12\
---------------------------------------------------------------------------
    \12\ Wounded Warrior Project Survey, p. 54.
---------------------------------------------------------------------------
    Finally, greater attention should be given to the metrics being 
employed to gauge the effectiveness of VA care. The goal should not be 
simply to alleviate or manage symptoms or to have the veteran complete 
a 14-session evidence-based therapy program. Rather, the goal should be 
to help these wounded warriors rebuild their lives.
                             the way ahead
    Given the urgency of the issues raised during the Committee's 
July 14th hearing and VA's clinicians' survey, WWP asked Secretary 
Shinseki to take three immediate steps to improve timeliness and access 
to care: better utilize VA's more than two hundred Vet Centers and 
allocate more resources to those centers, integrate peer-to-peer 
support to help sustain warriors in mental health treatment, and cover 
private-care options if VA resources are so limited and taxed that a 
warrior in need cannot be seen within a reasonable timeframe.\13\
---------------------------------------------------------------------------
    \13\ According to the RAND evaluation report, only 1.3% of FY 2008 
mental health encounters were paid for by VA but not provided by it.
---------------------------------------------------------------------------
    Immediate action is imperative. VA has embraced an all-out effort 
to end homelessness; they must do the same to address the growing 
mental health crisis before it is too late. Our newest generation of 
veterans must not be allowed to fall into the gaps that lead to 
addiction, homelessness, or suicide.
    Congress has already specifically mandated or authorized several 
steps in law, directing VA to provide needed mental health services to 
OEF/OIF family members whose own stress may diminish their capacity to 
provide emotional support for returning warriors as well as to 
implement a peer-support program at VA medical facilities.\14\ The VA 
is capable of providing ``the best care anywhere.'' That care needs to 
include timely, effective mental health care.
---------------------------------------------------------------------------
    \14\ See sections 304 and 401 of Public Law 111-163.
---------------------------------------------------------------------------
    Thank you Chairman Murray, Ranking Member Burr, and the other 
Members of this Committee--your continued oversight is essential in 
getting the Department to embrace this challenge. Too much is at stake 
for business-as-usual to be the watchword.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
   John Roberts, Executive Vice President, Mental Health and Warrior 
                  Engagement, Wounded Warrior Project
    Question 1. You recommend that VA better utilize Vet Centers to 
improve timeliness and access to care. One of the key factors in the 
success of Vet Centers has been the strict privacy protections they 
have in place. How do you believe VA can effectively expand the use of 
Vet Centers while maintaining these protections?
    Response. We would not anticipate any diminution in the strict 
confidentiality afforded veterans who receive Vet Center services as it 
relates to our recommendation that VA expand Vet Center services.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
   John Roberts, Executive Vice President, Mental Health and Warrior 
                  Engagement, Wounded Warrior Project
    Question 1. John, your remarks highlight some disturbing instances 
of individual veterans not getting timely mental health care. Are these 
isolated instances unique to a relatively limited number of facilities, 
or something more?
    Response. The responses to our survey strongly suggested that, with 
isolated exceptions, the problems veterans encountered regarding access 
to timely care and getting the right type of care, for example, were 
widespread and existed at many facilities across the country. Those 
survey responses were in alignment with the observations and 
experiences of WWP staff at our field offices who work closely with 
warriors. The troubling pattern documented by our survey raises a 
related issue--VA's relative lack of transparency regarding its 
provision of mental health care. For example, while VA has been eager 
to share data that highlight the number of OEF/OIF veterans who have 
been seen for mental health conditions, there has been little to no 
transparency regarding other important issues and indicators--how 
extensive has been VA facilities' use of fee-basis mental health care, 
how long on average have VA mental health position-vacancies gone 
unfilled, what are VA's mental health staffing criteria, etc. Rather 
than exhibiting openness and candor as it relates to providing mental 
health care to returning veterans, the Department has been too quick to 
assert that ``all's well,'' and to reject suggestions for improvement.

    Question 2. Your testimony contrasts the experience veterans have 
at Vet Centers with their encounters at VA medical centers and clinics. 
How different are those experiences, and are there lessons the VA 
medical centers can take from the Vet Centers?
    Response. Wounded Warriors who are experiencing problems associated 
with combat stress or readjustment consistently report having very 
different experiences at Vet Centers than at medical centers and 
clinics. Wounded Warrior Project explored this issue with warriors in-
depth over the course of a three-day ``Warrior Empowerment Summit'' in 
September 2010. Despite the Summit participants' varied backgrounds and 
unique personal journeys, they reached remarkable agreement on what VA 
assistance had ``worked'' for them and what hadn't, and what needs to 
change to help those warriors coming behind them. What was strikingly 
evident was how helpful Vet Centers have been to participants, and, 
with only limited exceptions, the frustrating and even negative 
experiences many had at other VA medical facilities. Several important 
themes--and avenues for change (already either authorized or required 
by law)--emerged from these discussions, relating to key differences 
between Vet Center services and those provided at other VA facilities. 
What is significant about these observations is that other VA 
facilities can adopt and incorporate into their operations critical 
features that make the Vet Center experience attractive to, and 
successful for, warriors. In particular, the Summit participants 
identified the following Vet Center elements as important to them: (a) 
peer-to-peer services; (b) working with clinical staff who understood 
the military and combat experience; (c) the availability of family 
services; and (d) outreach.

          Peer-to-peer support: In describing highly positive 
        experiences at Vet Centers, warriors emphasized the importance 
        of being helped by peers--combat veterans on the Vet Center 
        staff who (in their words) ``get it''--something too seldom 
        encountered at other VA facilities. Given the inherent 
        challenges facing a patient in an acute-care setting, it is all 
        the more important to have the support of a peer who, as a 
        member of the treatment team, can be both an advocate and 
        support. Section 304 of Public Law 111-163 requires VA to 
        provide peer-support services to OEF/OIF veterans at its health 
        care facilities along with mental health services, a 
        requirement it was to have implemented within 180 days of 
        enactment. It is very troubling that VA has not implemented 
        that long-overdue requirement.
          Cultural competence: Health care providers, to be effective, 
        must be ``culturally competent''--that is, must understand and 
        be responsive to the diverse cultures they serve. Our Summit 
        participants expressed frustration with VA clinicians and staff 
        who, in contrast to what most have experienced in Vet Centers, 
        may appear not to understand the experience of combat, or the 
        warrior culture. In essence, these warriors found that VA 
        health care often was not ``culturally competent.'' Rather than 
        winning trust and engaging warriors in treatment, some 
        clinicians and staff were perceived as ignorant of military 
        culture. Warriors reported frustration with clinicians whose 
        only experience with PTSD was in treating patients whose trauma 
        was a vehicular accident or domestic violence, but who were 
        inexperienced with PTSD stemming from combat. Warriors can 
        accept the explanation that their PTSD is a normal human 
        (physiological) response to extreme stress, but may not trust a 
        clinician who pathologizes them or characterizes PTSD as a 
        ``disorder'' rather than an expected reaction to combat.\1\ 
        Moreover, VA health facilities are in many respects ``foreign'' 
        to warriors, who complain of difficulty navigating the system 
        and lack of information regarding their health or treatment 
        plans. It is not surprising, given warriors' frustrations with 
        VA staff insensitivity and difficulty in navigating or 
        understanding their VA care, that very high percentages of OEF/
        OIF veterans fail to complete the recommended 15-session 
        evidence-based treatments for PTSD.\2\ Dramatically improving 
        the cultural competence of clinical AND administrative staff 
        who serve OEF/OIF veterans through training, standard-setting, 
        etc.--and markedly improving patient-education--would be a 
        valuable step.
---------------------------------------------------------------------------
    \1\ C.W. Hoge, Once a Warrior Always a Warrior: Navigating the 
Transition from Combat to Home, (Globe Pequot Press, 2010) 5, 51.
    \2\ Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas 
Metzler, Li Ren, Daniel Bertenthal, and Charles Marmar, ``VA Mental 
Health Service Utilization in Iraq and Afghanistan Veterans in the 
First Year of Receiving New Mental Health Diagnoses,'' Journal of 
Traumatic Stress, 2010.
---------------------------------------------------------------------------
          Family mental health services: Research indicates that one of 
        the strongest factors that help warriors in their recovery is 
        their level of support from loved ones.\3\ Yet the impact of 
        lengthy, multiple deployments on those loved ones may diminish 
        their capacity to provide the depth of support the veteran 
        needs. One survey of Army spouses, for example, found that 
        nearly 20 percent had significant symptoms of depression or 
        anxiety.\4\ While Vet Centers have provided counseling and 
        group therapy to family members, VA medical facilities have 
        long offered little more than ``patient education'' despite 
        broad statutory authority to provide not only counseling but 
        mental health services. It took nearly two years for VHA to 
        disseminate information on section 301 of Public Law 110-387, 
        which requires VA to provide marriage and family counseling to 
        family members of veterans under treatment for a service-
        connected condition (though we are finding that such services 
        are, in fact, not widely available).\5\ Section 304 of Public 
        Law 111-163 directs VA to go further--requiring VA (within 180 
        days of enactment) to provide support, counseling and mental 
        health services to members of the immediate family of veterans 
        when such services would assist in the veteran's readjustment, 
        the family's readjustment, or the veteran's recovery from an 
        injury or illness. WWP finds it troubling, particularly given 
        its durational ``window,'' that this provision--covering the 
        three year period beginning on return from an OEF/OIF 
        deployment--has still not been implemented.
---------------------------------------------------------------------------
    \3\ Hoge, Once a Warrior, 28.
    \4\ Hoge, 259.
    \5\ Veterans Health Administration, IL 10-2010-013, ``Expansion of 
Authority to Provide Mental Health and Other Services to Families of 
Veterans,'' August 30, 2010.
---------------------------------------------------------------------------
          Outreach: Warriors reported that VA's general ``outreach'' 
        was not particularly helpful as related to their combat stress 
        issues. Post-deployment briefings that encourage veterans to 
        enroll for VA care tend to be ill-timed, or too general and 
        impersonal to address the warrior's issues. While generally 
        aware of the existence of a treatment option, many Summit 
        participants cited a reluctance to seek VA care, often 
        attributed to a perception (or experience) that pursuing VA 
        treatment would be more stressful than helpful. Several 
        acknowledged self-medicating; others sought isolation as their 
        ``drug of choice.'' Warriors identified VA health care 
        facilities as ``passive''--as placing the burden on the warrior 
        to seek treatment rather than reaching out to engage the 
        veteran in his or her community, and providing little or no 
        support, encouragement, or helpful information for navigating 
        that system. While a significant percentage of OEF/OIF veterans 
        have enrolled for VA care, an almost equally large percentage 
        has not. Given the prevalence of PTSD among OEF/OIF veterans 
        and the implications of its going untreated, Web sites and 
        public service announcements are insufficient to get warriors 
        to seek help. Section 304 of Public Law 111-163 now directs VA 
        to carry out such one-on-one peer outreach, though VA has not 
        implemented that peer-outreach directive.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
IV to John Roberts, Executive Vice President, Mental Health and Warrior 
                  Engagement, Wounded Warrior Project
    Question 1. How can we meet the overwhelming demands for mental 
health care among all our veterans, in this climate of cuts and calls 
for spending caps?

    Question 2. How do we encourage and recruit VA nurses and mental 
health professionals in times of pay freezes and calls for overall cuts 
in our Federal Government?
    Response. We appreciate the concern underlying those questions, and 
would highlight that the deep and immediate concern is that today those 
returning from often multiple deployments with war-related mental 
health conditions are not getting timely effective mental health care 
at many VA health care facilities. Rather than tight budgets, VA has in 
recent years enjoyed significant budget increases, but it appears to be 
doing a poor job of managing those resources to meet veterans' needs 
for mental health care. Our experience mirrors the Committee's findings 
that veterans are experiencing unreasonably long waits for needed 
mental health treatment. But the Department has failed to be at all 
transparent about these problems. What has become increasingly clear is 
that VA performance measures are fueling pressures to ``see'' 
increasing numbers of OEF/OIF veterans. But VA has not established 
performance measures to assess treatment outcomes. Moreover, VA's 
failure to deploy its resources to ensure that OEF/OIF veterans are 
actually receiving the timely effective treatment they need is 
resulting in too many veterans falling through the cracks. Under such 
circumstances, it is not surprising that some VA clinicians have 
expressed frustration and that VA finds it difficult to recruit. In 
sum, we are justifiably concerned that VA has not made a sufficient 
priority of ensuring timely effective care of those bearing the psychic 
wounds of war.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
   John Roberts, Executive Vice President, Mental Health and Warrior 
                  Engagement, Wounded Warrior Project
    Question 1. In your testimony, the Wound Warrior Project 
recommended to VA, ``* * * that Secretary Shinseki better utilize VA's 
more than two hundred Vet Centers.'' Could you elaborate on how Vet 
Centers could be ``better utilized''?
    Response. It has been our experience that VA medical centers do not 
necessarily have close working relationships with Vet Centers, and that 
veterans who are seen at either Vet Centers or other VA facilities 
cannot necessarily rely on what should be easy, reliable referral 
patterns to and from VA medical centers. One step toward better 
utilization of Vet Centers, therefore, would be to establish more 
consistent coordination and collaboration between the two. And, given 
that veterans generally report highly positive experiences at Vet 
Centers and have generally encountered greater difficulty accessing 
timely, effective mental health at other VA medical facilities, we see 
benefit in expanding the number of Vet Centers, and in that sense, 
better utilizing those services.

    Question 2. Could you discuss what happens when DOD identifies an 
active-duty servicemember is in need of behavioral health services 
before the servicemember is either separated from active-duty or 
determined to be fit for duty?
    Response. In our experience, if a servicemember is referred to a 
treatment facility and is found to need behavioral health treatment, 
that individual would often receive treatment. This is the expected 
action. But such a hypothetical servicemember might mask or minimize 
symptoms out of fear that getting needed treatment might result in 
ending a military career, or might be given only a superficial 
assessment resulting in the judgment that no treatment is needed. That 
servicemember might be referred to a Medical Evaluation Board and in 
some instances rushed through a process where needed treatment is 
deferred for later treatment under VA auspices.

    Question 3. How much collaboration is there between DOD and VA with 
regard to addressing the behavioral health needs of wounded warriors 
prior to and following separation from active-duty?
    Response. We have seen little evidence of significant collaboration 
between the military services and VA in terms of meeting warriors' 
behavioral health needs prior to and following separation.

    Chairman Murray. Thank you very much, Mr. Roberts. I think 
every Member of this Committee agrees with you that we need an 
aggressive strategy; and hopefully, this hearing will highlight 
that and our second panel will be able to really begin to talk 
to the VA about that.
    So, thank you to all of you.
    Dr. Washington, I wanted to start with you. As I mentioned, 
the survey that I requested of mental health providers really 
highlight the disconnect between VA policies and practice.
    The VA claims that about 95 percent of our veterans get an 
appointment within that mandated 14-day window. The survey from 
VA staff found that only 63 percent of providers can schedule 
patients for mental health appointments within 14 days.
    So, I wanted to ask you as the provider, and I am sure you 
talk with other providers throughout the system, how often have 
you and those you talk to been able to really schedule 
appointments for patients within that 14-day window?
    Ms. Washington. I would agree with probably the survey's 
findings. It is fairly inconsistent. It is very low numbers, 
meaning that they may be able to come in for the initial 
consultation which is just getting background information 
within the 14 days; but then actually getting a face-to-face 
physical appointment to start actual therapy could be a month, 
6 weeks easily.
    Chairman Murray. So, the disconnect then could possibly be 
what that initial appointment actually is about?
    Ms. Washington. Yes, because initially when a consult is 
sent in, usually from primary care or sometimes the individual 
is self-referred; they come in and then we just get their 
background history, and it could be anyone who actually takes 
that.
    So, I think what is happening is sometimes they are 
accounting that as the initial appointment when, in reality, it 
is really just getting the background information, getting 
their history versus an actual appointment to sit with a 
counselor to then determine what a good treatment plan will be 
for that person.
    Chairman Murray. Because I think most of us think when 
somebody is seen within the first 14 days, they are actually 
seeing you or another provider who is beginning treatment.
    Ms. Washington. That is not the case.
    Chairman Murray. But that counts under the VA's 14-day 
window if they just get that.
    Ms. Washington. Yes.
    Chairman Murray. OK.
    Dr. Hoge, you recently wrote an article in the Journal of 
the American Medical Association and found that a very high 
percentage of veterans dropped out of their PTSD treatment, and 
you found that VA efforts at providing PTSD therapy was only 
reaching about 20 percent of the veterans who needed it.
    I am really troubled by that finding that only about half 
of our veterans actually complete a full course of mental 
health treatment. From where you sit, what do wait times and 
scheduling problems play in veterans dropping out of care and 
not getting their full treatment?
    Dr. Hoge. I think that is one of many factors because there 
is not good research to really tell us exactly, you know, how 
important that is versus other factors. But it is clearly a 
critical and important, one critical and important factor along 
with others.
    Sometimes it is stigma. Sometimes it is, you know, sort of 
structural or physical barriers like transportation or distance 
from the treatment facility or appointment times, not being 
able to get appointment times that conflict with work, work 
priorities and so forth.
    And then I have been very interested recently in the sort 
of new domain of perceptions, negative perceptions of mental 
health care. I was actually surprised by some of the recent 
research that has looked at that and the high percentage of 
individuals who report having negative perceptions of mental 
health care, not trusting mental health professionals, feeling 
as if mental health care is not going to be effective.
    And so, I do not know what to do about it exactly but I 
think that it opens the question of, you know, how do we better 
market mental health care.
    And I think that some of the answers to that lie within the 
domain of integration with primary care, better peer-to- peer 
support because veterans are very responsive to their peers, in 
communication with peers, and family support also because the 
family also is critical often in helping the veteran get into 
care. So, it is not just peers but family members.
    Chairman Murray. I think that the stigma issue that you 
talk about plays into the wait time. If you are reluctant to 
call anyway and ask for help and then you call and you cannot 
get help right away or you cannot get an appointment at a time 
that works for you, that just plays right into your own thought 
that this is not something that is acceptable.
    Dr. Hoge. I agree completely.
    Chairman Murray. Dr. Van Dahlen, first of all, thank you 
for everything your organization has done and continues to do 
for our veterans. Give an Hour and a lot of other organizations 
played really an important part in making sure that our 
veterans get access. So, we really appreciate what you do.
    You mentioned that you do not have a relationship or you do 
have a relationship with the DOD but not with the VA.
    Ms. Van Dahlen. Yes.
    Chairman Murray. What is the barrier in establishing a 
relationship with them?
    Ms. Van Dahlen. I do not really know. We have had many 
conversations and meetings; but unlike with the Department of 
Defense where there has really been an openness and an interest 
toward collaborating with community-based resources, there is 
clearly a belief in DOD that I have watched evolve over the 
last 6 years since founding Give an Hour that, a recognition 
that we cannot do it all from the military perspective, the 
military organizations. It has to be coordinated effort in 
communities because many of these veterans go home to 
communities where there may not be a VA or Vet Centers nearby.
    And so, why not coordinate with the community mental health 
professionals whether it is fee-for-service or, in our case, 
mental health professionals who do not want to be paid. They 
want to give their time.
    So, the Department of Defense seems to have moved in a 
cultural way, in a perspective that we need to look at and they 
are doing a lot of work. I have not had that experience in 
conversations with the VA.
    Chairman Murray. Thank you very much. I am out of time. So, 
I will have to go to my second round.
    Senator Burr, I will turn it over to you.
    Senator Burr. Thank you, Chairman, and I am going to be 
brief and focus just with Dr. Washington but I would ask 
unanimous consent that all Members be allowed the opportunity 
to send questions to our witnesses today as part of the record 
because I think we could spend a half a day here quite 
honestly.
    Chairman Murray. Absolutely. We will do that.
    Senator Burr. Dr. Washington, very quickly, what are you 
told when you raise the barriers that you have painted for us 
to your management? What do they tell you?
    Ms. Washington. They tell me we are working on it. We are 
developing a new blueprint for services, and that is usually 
the response. There is nothing really substantive given to me 
other than they are looking at it. They are aware of certain 
things, and then in some cases, there is flat out denial that 
there is an issue.
    Senator Burr. You testified that there are mental health 
positions that, at the Wilmington Medical Center, have not been 
filled.
    Ms. Washington. Yes.
    Senator Burr. Let me ask you. In the last 2 years, how many 
positions have been filled?
    Ms. Washington. The exact number? I could not tell you. But 
I know some positions once they were vacated were then 
eliminated. So, the exact number of how many are left vacant--
--
    Senator Burr. Do you have any idea right now how many are 
open and how long they have been open?
    Ms. Washington. I could not give you exact numbers.
    Senator Burr. I think these are all things that we will 
follow up in detail. Again, I think it gets at the heart of the 
level of commitment to structurally solve the problem, and I 
hear from each one of our witnesses the most disturbing thing 
is that appointments still are the most difficult thing for a 
veteran, whether they are seeking mental health treatment or 
primary care. The actual appointment is the toughest thing for 
them to accomplish. Forget the fact that it may only be for the 
purposes of collection of records, and I think the Chairman and 
I will get into that with the Secretary if, in fact, we have 
got a little scam going on.
    I thank the Chair.
    Chairman Murray. Senator Akaka.
    Senator Akaka. Thank you very much, Madam Chairman.
    Dr. Washington, first, thank you for testifying before us 
today despite your fear of retaliation. Enacting stronger 
protections so whistle blowers can come forward without fear of 
retaliation is one of my top priorities. I believe it is 
important to have many viewpoints so that we can continue to 
improve the services we are providing to our veterans.
    In your opinion, what are the top two priorities that 
should be addressed in order to better treat veterans who need 
mental health care services?
    Ms. Washington. I would say the top two from my perspective 
would be, first of all, getting them into care much more 
quickly. That seems to me, as I said in my testimony, that if 
you get them into services quickly and you get them in 
intensive services quickly, you can get the treatment, they can 
get the treatment that they need and then they can go on with 
their lives because ideally, I mean, that is the goal is for 
them to get better and to live their lives rather than having 
to come to the VA constantly for the rest of their lives.
    So, it is definitely, you know, getting access to both 
mental health and medical care. Numerous, many numbers of my 
patients have extensive medical conditions because their PTSD 
was the result of a physical trauma as well.
    I have had people who have serious back injuries and they 
are in chronic pain and they are not able to get the 
medications that they need to treat those chronic conditions or 
any other treatments without a long delay.
    So, I would say my top two things would be helping them to 
get quick appointments for both medical and mental health care.
    Senator Akaka. Thank you.
    Dr. Hoge, left untreated many health conditions can lead to 
an increased risk of unemployment, homelessness, and suicide. 
Stigmas prevent some from seeking the mental health treatment 
they need. This has been a huge problem over the years.
    DOD has also faced this issue; but according to the leaders 
I have spoken to, the situation is improving. My question to 
you is is the stigma situation improving amongst the veterans 
and can the VA leverage some of the DOD's successes to help 
further break down the stigma in the veteran community?
    Dr. Hoge. I think stigma has improved; but because that is 
not the whole story, it has not led to the robust numbers that 
we would like to see in terms of utilization of services and 
access. So, it is not the whole story but they are clearly has 
been improvements in perceptions of stigma.
    I think that looking at things, looking at PTSD, for 
instance, from the physiological and physical perspective and 
its relationship to combat physiology, how combat changes the 
way the body functions is important in destigmatizing this 
condition and treatment and also looking at it from the 
occupational warriors perspective so that when a veteran comes 
in for treatment or a servicemember comes in to treatment in 
DOD and they sit down with the health professional or mental 
health professional, they are not automatically, they do not 
automatically get the sense that they are being labeled as 
having a mental disorder when, in reality, their body is 
reacting the way it has been trained to react in a combat 
environment, if that makes sense.
    It is a little bit long-winded response.
    Senator Akaka. Thank you.
    Dr. Van Dahlen, I want to thank you and your staff for all 
that you do to support the mental needs of veterans. Your 
partnering with communities across the country to provide 
needed support is to be commended.
    From your viewpoint, if there is one thing that we in 
Congress could do better to support the needs of veterans and 
their families, what would it be?
    Ms. Van Dahlen. That is a big question. I really do believe 
that the answer, and there are some great efforts currently 
underway, the answer is in encouraging and sometimes perhaps 
using the power of the Congress to push where it is not 
happening.
    Integration, coordination, collaboration. That is the way 
we are seeing forward in many communities that we are now 
working in. There are some good efforts underway nationally to 
do just that. And it requires the VA and DOD and Department of 
Labor, those agencies have critical roles in those communities 
but it is at the community level because that is where people 
live.
    Senator Akaka. Thank you.
    Mr. Roberts, part of your organization's focus is to ensure 
injured servicemembers stay connected with one another through 
both a peer mentoring and robust alumni program. You mentioned 
peer-to-peer programs.
    How important is it for veterans in your programs to be 
able to connect with other veterans through peer-to-peer 
programs?
    Mr. Roberts. In the survey that I mentioned when I spoke, 
the biggest response I got back of what these individuals want 
and what they think is effective for them is that peer-to-peer 
support and it is easier. I have run a program called Project 
Odyssey since 2007 which is basically a peer-to-peer 
recreational outdoor retreat with a therapeutic aspect to it.
    And that Loyd, who is behind me, Loyd Sawyer, whose wife 
testified on the 14th, was a benefactor of that program. I 
think Loyd can to speak the fact that being around other peers 
and being able to talk openly and honest about what is going on 
back home and how they are affected by this PTSD and how their 
families are affected makes a great impact on it. It also 
encourages many of them to get that treatment to get better 
because we do put peers that we have trained that are being 
successful with their recovery, we train them, give than 8 
hours of training, put them into our programs, and they are out 
there basically to be that peer mentor for those young men and 
women who are still struggling.
    Senator Akaka. Thank you very much.
    Thank you, Madam Chairman.
    Chairman Murray. Thank you.
    Senator Isakson.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Mr. Roberts, thank you very much for your 
service to our country. Have you had any experience with the 
Federal Recovery Coordinator Program at VA that has been 
established for severely wounded warriors?
    Mr. Roberts. We have many experiences with them, yes, sir.
    Senator Isakson. Is it improving the coordination of care 
to veterans?
    Mr. Roberts. From the messaging I am getting, yes, it is. I 
think to the credit of the VA, the establishment of that 
program has begun to help. We are understaffed in terms of the 
number we need but that is a step, I think, in the right 
direction.
    Senator Isakson. Have any of you others had experience with 
the Federal Recovery Coordinator Program?
    Dr. Van Dahlen.
    Ms. Van Dahlen. Just from hearing that it is a positive 
experience for veterans who access that. So, I would say the 
same thing as Mr. Roberts.
    Senator Isakson. Dr. Van Dahlen, you mentioned the 
telemedicine or telehealth program you are initiating. Could 
you elaborate with regard to mental health how you deliver, 
what you are delivering? Are you delivering counseling? Are you 
delivering consulting? What are you delivering?
    Ms. Van Dahlen. Yes. We are using that capability to do all 
of the services that we are now providing, and one of the 
things that I would like to say is that one of the ways that I 
think organizations like ours can really work collaboratively 
with the VA is to have our professionals providing education 
and information.
    To the Dr. Hoge's point, the issue is to try to change the 
perceptions, change the stigma, change the expectations. If you 
harness the mental health professionals across the range--VA, 
community-based--you can help put information out to 
communities, to faith-based leaders, to schools about these 
issues, about the needs, about what is available.
    So, in terms of what we are going to telehealth we will be 
providing direct service for folks in rural communities who 
cannot access a clinic or mental health professional. We will 
be providing consultation to schools and to employers and to 
other primary care doctors or pediatricians who do not have 
access to a mental health professional.
    So, we plan to use that technology. It is not the answer, 
but it is another tool to provide information, support, and 
treatment where we cannot get live providers out to those 
areas.
    Senator Isakson. Yeah. That makes a very good point. 
Interestingly enough, on the stigma issue, which is a huge 
issue, and another national problem which is illiteracy, we 
found that by delivering via the Internet Web-based literacy 
training in the State of Georgia we have greatly improved the 
number of people coming in to learn to read and learn to write 
because the stigma is removed since they are dealing with a 
computer versus a human being. And I would think telecounseling 
would be somewhat the same thing.
    Ms. Van Dahlen. Actually, there have been some interesting 
initial reports that this generation of servicemembers, because 
they have grown up with technology, often feel more comfortable 
having that telehealth conversation.
    It is an issue of training some of the providers who are 
older that it is OK to engage in that kind of relationship. But 
I think we are moving again toward finding no one-size-fits-all 
solution, but for this generation I think that can be a very 
important tool to add.
    Senator Isakson. I am a little bit miffed with the fact 
that DOD is very engaged with your program and VA has been 
distant. I guess distant is the right word; perhaps not engaged 
any way.
    Ms. Van Dahlen. There have been, I would say at the local 
levels there had been some wonderful folks through the VA who 
have found out about what we do, and we work together. But on 
the national conversation, it is not happening yet; and 
hopefully that will come. It is what we want.
    Give an Hour was built to offer those services in whatever 
way they make sense to assist the efforts with the VA and DOD. 
That is the purpose.
    Senator Isakson. Madam Chairman, I think we ought to have 
an engagement with the VA on that very subject because if there 
are community-based free services, mental health services for 
veterans, with the number of veterans coming back from Iraq and 
from Afghanistan we can use every professional available for 
our veterans, and coordination of that would be very helpful.
    Thank you, Madam Chairman.
    Chairman Murray. Thank you very much.
    Senator Tester.
    Senator Tester. Well, thank you, Madam Chairman, and I want 
to thank all of the folks for testifying today. We will start 
with you, John. I, too, want to echo my thanks for your service 
to the country, and you are an incredible asset in this 
particular unit because you have been there and done that, and 
obviously had some successes. I think that your perspective is 
critically important.
    I want to talk about peer-to-peer for a second and vet-to-
vet.
    Mr. Roberts. Yes, sir.
    Senator Tester. From your perspective, you talked about the 
retreat that was done. There is a program in Montana called 
Healing Waters. We take fishermen out and do a little fly 
fishing. It is a little different than what you visualize 
sitting in a room and talking.
    But how can we enhance peer-to-peer or vet-to-vet stuff? 
But more importantly, how can VA enhance it?
    Mr. Roberts. I have got to tell you that most of my 
comments probably sounded very negative toward the VA. I was a 
VA supervisor. I know there are a lot of good people in that 
system that want to do the right thing.
    One of them, Dr. Batres, with the Readjustment Counseling 
Services, actually partnered with me on Project Odyssey when we 
started in 2007, which provided culturally competent counselors 
from the Vet Centers to go on these retreats.
    Because it is a little bit out-of-the-box--not sitting in a 
room around, you know, a circle with a bunch of chairs pouring 
out your feelings--it was actually taking the counselors out, 
being engaged with the warriors on an active level where they 
were doing an activity, whether physical or whatever we were 
doing, and then at night having that trust built up where you 
could sit around the fire and just kind of talk about 
everything.
    And the individuals did not know they were actually in a 
group session, but they were. I think it is being creative. I 
think it is engaging in these warriors that are being 
successful.
    Myself, I am very proud of the fact that I overcame PTSD; 
and if my wife was here, she could testify how bad I was. Just 
like Andrea could testify how bad Loyd was or is. It impacts 
the families.
    Honestly, it is doing something more than my experience 
with the VA. I went for one appointment. I got screened, and 
the doctor sat me in a room. He had no military experience and 
had a very short time to talk to me; he did not want to know 
what was going on.
    My marriage at that time was falling apart. I was self-
medicating like many of the warriors I treats or I help today. 
And quite frankly, he wanted to teach me how to breath. And I 
thanked him kindly, left the room, and never went back for 
treatment.
    I was lucky. I had another Marine reach out to me that I 
was injured with and kind of pulled me out of the gutter. I 
think that it is a critical part of the recovery process, 
having that support and having those individuals that have been 
successful dealing with it.
    And not every treatment is perfect. You cannot put 
everybody in a box and expect one treatment to fit everybody.
    Personally, I am not a believer in medication. That may 
work for others--I cannot say what works or does not work--but 
I think the treatment has to be tailored to the individual, so 
they are going to go through trials and errors. Sometimes 
things are going to work, but if it does not work they have to 
try something else.
    Senator Tester. I appreciate the perspective. I can tell 
you that I do not think any of us around here think the VA are 
bad people. They are doing the best I think they can do but 
there are some areas they can do better.
    You actually made some comments during your opening remarks 
that I hope the VA can respond to, access to follow-up care, 
the fact that we are doing medication management.
    I mean, the days of warehousing folks who have mental 
health problems should have been long, long, long gone. When I 
see that kind of structure, sure there needs to be some 
medication management, but that should not be the entire 
emphasis of the visit.
    I want to talk with either one of the two docs. In the 
private sector, and I do not know if you guys can answer this 
or not, but as far as highly qualified mental health 
professionals that are out there, the information that I have 
got is that there is not a lot of folks out there, not enough, 
let us put it that way.
    And if that is your own opinion, do you have any ideas on 
how we can enhance it so that we can get more highly qualified 
folks out there from your perspective being in the business?
    Dr. Hoge. I mean, clearly, there is a shortage of mental 
health professionals nationally that is also in DOD and VA. And 
so, you know, more training of mental health professionals, 
more programs to train mental health professionals might be of 
benefit.
    I think there are ways also in the discussion, for 
instance, of peer-to-peer counseling to leverage the skills of 
mental health professionals in ways that have partnerships with 
lay peer-to-peer counselors that may extend mental health 
professionals.
    And so, for instance, there may be ways to incorporate 
peer-to-peer mentoring and counseling into traditional mental 
health clinics within the VA structure, within DOD and other 
clinics.
    So, short of going out and training and hiring more mental 
health professionals, there may be ways to extend the treatment 
in other ways through other types of professionals that work 
with the mental health professionals.
    Ms. Van Dahlen. I completely agree, and there are several 
programs now underway that Give an Hour is partnering with that 
are peer-based programs and what someone taught me very early 
on who is a vet, who had developed a peer-to-peer, you know, 
peer-lead, clinician-guided, to have a clinician involved to 
assist, to provide the mental health information can really 
facilitate the delivery of peer-to-peer support. So that is 
one.
    And what we are finding in the communities we are very 
involved in--Fayetteville, NC, and the Hampton Roads area of 
Virginia in a community-based effort--the mental health 
professionals want to be trained. And there are so many great 
tools; the VA has many, as do others, like DOD.
    It is working, again collaboratively, to create systematic 
programs to offer the kinds of training online, in workshops. 
It is out there. It is poorly coordinated. There are good tools 
but they are not available.
    But clinicians want it. Our providers when we surveyed them 
they do not want to join TRICARE. They do not want to be paid 
but they want training. They want the cultural information they 
need, the appropriate training to give the good services.
    So, they are there but it is packaging them and providing 
them.
    Senator Tester. Thank you.
    Thank you, Madam Chair.
    Chairman Murray. Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Madam Chairman. And we 
appreciate you all being here very much.
    Mental health is just a huge problem. We can go to, I 
think, county jails all over the country where you have people 
who have tried to commit suicide, that literally there is no 
room in the State hospitals. It is just a tremendous problem.
    We can look at the suicide among our youth, and then we 
have this significant problem among the military. You know, we 
have created this problem. So, it is just something. It is just 
a very, very difficult problem.
    I would like to talk a little bit more about the peer- to-
peer in the sense that, you know, your testimony is such that, 
you know, the Marine helped you and where would you be without 
that.
    So let us talk a little bit about how, you know, how we can 
do a better job of instituting that. I am familiar with the 
Rivers to Recovery Program. We actually have a dog training 
bill in the sense that we have a lot of dogs that need to be 
trained, using veterans to interact with that, and, you know, 
the fact that you are caring about something else.
    And I heard a story of a guy that had amputations, was 
laying in a hospital, and a golf pro told him that he was going 
to teach him how to play golf, and the guy who was actually 
suicidal laughed at that thought inside. And sure enough, it is 
very frustrating because, you know, he could thrash me without 
any problem at all now.
    So, I think those are great things. The question is, from 
your perspective, you know, recognizing that again this is not 
just a problem with the VA. I mean, we have got, you know, this 
tremendous mental health problem going on throughout the 
country especially in rural areas which is a great concern.
    Much of Arkansas, much of our country, you know, especially 
the National Guardsmen, you know, come from small communities, 
go back. They do not have the resources even of being with 
their buddies.
    You know, it is not like being overseas or, you know, being 
theater. You come back as a group. These people come back and 
they are just dispersed to the small towns they are from.
    But I guess what I would like is some suggestions. Most of 
the studies that we have seen are based on medication and, you 
know, how do we think outside the box perhaps and maybe do 
things a little differently.
    Go ahead, sir.
    Dr. Hoge. If I could make a comment. One of the most 
feeling components of what happens inside that mental health 
office, mental health treatment office is narration, the 
ability to narrate the events that happened downrange in combat 
and really talk through the details and connect with the 
emotions.
    Often times, there is underlying issues of grief, for 
instance, and the loss which have never been dealt with, just 
as one example.
    And there are also some interesting data on that narration, 
as you mentioned, one size does not fit all. Each individual, 
you know, each individual has a distinct way in which they need 
to go through their readjustment process.
    Sometimes there are some good data, for instance, on 
written narration. There is some very interesting data from 
European investigators working with war-torn refugee 
populations where they train lay counselors to go in and do 
narrative therapy, life-narrative therapy, and achieve 
essentially equivalent results in recovery from PTSD.
    So, I think that opens the door for narrative, you know, 
treatment strategies done by peer-to-peer, you know, lay peer 
counselors but supervised and coordinated and done in 
conjunction with traditional mental health professionals.
    So, I think that would be one area that we could think 
outside the box among others. The other big area would be 
primary care, really integrating care within that primary care 
structure in a collaborative way.
    Ms. Van Dahlen. Another piece that we should put out here 
is we know from studies, a really excellent study that was done 
a few years ago by civic enterprises that our veterans and 
their families, they volunteer at a higher rate. They come home 
and take continue to serve.
    And I think we are not taking advantage of their desire to 
continue to serve, to take care of their own. So, if you want 
to think about thinking outside the box, here we have a 
population that those who are coming through programs like 
ours, like the VA, like others, if we, from the beginning, 
create almost an expectation but a need that they understand 
that if they make it through, then we want them to join an 
effort to become a peer support person.
    I think we have a pool of ready-made folks who we could ask 
to engage in that kind of help for those who are coming behind 
them.
    Mr. Roberts. It is hard to argue with both their comments. 
I think these young men and women do have still that service 
desire; and once they do come through the recovery and they are 
successful, do want to give back and want help others that are 
struggling still.
    I like the peer-facilitated group that has to be 
supervised. That is kind of the key, that supervision is key to 
it.
    Senator Boozman. The Marine that you mentioned.
    Mr. Roberts. Yes.
    Senator Boozman. What was his role? Was he a friend or an 
acquaintance, or how did you come into contact him?
    Mr. Roberts. We served together. We were blown up together, 
and he was actually, at that time, being successful in his 
recovery. I, at that time, was more severely injured and quite 
frankly struggling and not doing very well. And he happened to 
reach out to me and pulled me back up and got me on the right 
path.
    Senator Boozman. Which would be hard to replace.
    Mr. Roberts. It is very hard to replace. I had more trust 
in that individual than I did in a VA mental health clinician. 
So, yeah, there was a lot of trust built up and somebody I knew 
I could talk to and not be judged for what I was doing.
    Senator Boozman. Thank you, Madam Chairman.
    Chairman Murray. Thank you to all of our panelists. I think 
your insight is very helpful to our Committee as we continue to 
move forward on this critical topic.
    I do have a number of Senators who want to ask additional 
questions. They will commit them to you in writing; and if we 
could get your responses that way, I would appreciate it.
    We do have a vote that is coming up shortly. So, I want to 
get our second panel up here. Again, thank you to all of you. 
Would our second panel please come forward.
    The vote has just been called so as the second panel comes 
up I would like all of us to go vote. We will come back and 
then we will hear the testimony and have a chance to ask 
questions.
    [Recess.]
    Chairman Murray. I am going to bring the Committee back to 
order here. Our Senators will be returning but I want to get 
this panel started. I appreciate everybody's patience.
    I want to welcome representing the VA, Dr. Mary Schohn. She 
is the Director of the Mental Health Operations, Veterans 
Health Administration, Department of Veterans Affairs. She will 
be testifying today and is accompanied by Dr. Zeiss and 
Dr. Kemp.
    So, Dr. Schohn, if you want to go ahead and begin your 
testimony.

   STATEMENT OF MARY SCHOHN, PH.D., DIRECTOR, MENTAL HEALTH 
OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; ACCOMPANIED BY ANTONETTE ZEISS, PH.D., CHIEF 
 CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES; AND JANET KEMP, 
   R.N., PH.D., NATIONAL DIRECTOR, SUICIDE PREVENTION PROGRAM

    Ms. Schohn. Chairman Murray, Ranking Member Burr, and 
Members of the Committee, thank you for the opportunity to 
appear before you to day to discuss the Department of Veterans 
Affairs' commitment to providing responsive, accessible, and 
effective mental health services that meet the needs of our 
Nation's veterans.
    I am accompanied by my colleagues, Dr. Antonette Zeiss, 
Chief Consultant for Mental Health; and Dr. Jan E. Kemp, the 
National Mental Health Director for Suicide Prevention.
    I also want to thank the first panel. We are pleased to 
hear of their recommendations to improve VA's mental health 
services. We agree with their suggestions and, in fact, have 
begun implementing many of them.
    VHA takes seriously our responsibility for meeting the 
mental health care needs of veterans. For the past several 
years, we have focused on enhancing this care by improving both 
the availability and quality of our services.
    As Chairman Murray noted in her October letter, we have 
written state-of-the-art policies, begun integrating mental 
health into primary care, and created groundbreaking new 
programs to meet the needs of veterans.
    Moreover, we have expanded our mental health staffing 
levels by almost 50 percent since fiscal year 2006. During this 
same time, VHA saw a 34 percent increase in the number of 
veterans receiving mental health care.
    To extend our reach to veterans in rural or hard-to-reach 
places, we have expanded and continued to expand the use of 
technology, including the use of telemental health and mobile 
apps most recently.
    We have recognized the essential role family members and 
friends play in each veteran's personal support network. To 
help spouses and other family caregivers address the many 
challenges associated with the transition from active duty, VHA 
has launched a spouse telephone support intervention and we 
have implemented the Coaching into Care Program to help family 
members in supporting veterans in accessing needed care.
    The VHA's efforts to improve mental health care have been 
many and yet we are aware that there is still much more for us 
to do. To this end, we have implemented a set of near-term 
actions informed by the August 2011 query of field staff 
requested by this Committee.
    Respondents to the query perceived deficiencies in 
performance measurement and mental health staffing, and 
expressed concerns about space shortages for mental health 
care. They also mentioned inadequacy of off-hour services and 
the need to balance demand for C&P and IDES examinations with 
the delivery of mental health services. Our action plan 
addresses each of these areas of concerns.
    First, we are auditing mental health scheduling practices 
and using the findings from these to improve practices.
    To ensure that appointments reflect veterans' needs and 
scheduling desires, we are developing a team-based staffing 
model that enables VHA to carefully monitor mental health 
staffing levels at business and facilities and to assess 
efficiency and value across the system.
    We have strengthened the performance measures to provide us 
with information beyond timeliness. We have added measures to 
assess three additional things, access to follow-up care for 
veterans recently discharged from inpatient treatment, access 
to enhanced care for veterans at risk for suicide, and access 
to specialty appointments for the treatment of PTSD.
    We continue to reach out to providers for their perceptions 
on problems and solutions in delivering the best quality mental 
health care. By the end of January 2012, we will have completed 
10 focus groups on providers to help us better understand the 
concerns cited in the survey and to follow-up as needed.
    As more veterans seek and receive mental health care and 
VHA augments staffing to provide their care, we have 
encountered space challenges. We have asked sites to update 
their facility-based base plans to address these challenges in 
both the short and long-term.
    VHA's off-hour capability for mental health services 
depends on primary care availability, especially at our 
community-based outpatient clinics.
    The Undersecretary for Health has commissioned a workgroup 
to review and develop a systemwide policy for off-hours clinic 
times and to report on these findings by tomorrow.
    In addition, because C&P/IDES exams may be for many 
veterans their first introduction to VA, we want to ensure a 
positive experience and timely access to care.
    To that end, VHA's Office of Mental Health Services and the 
Office of Disability and Medical Assessment have partnered to 
identify facilities highly impacted by these exams, and we have 
begun pilot programs to mitigate the issues.
    We know that veteran demand for mental health care will 
continue to increase as our servicemembers return from 
deployment and discharge from service. We have done a great 
deal to address these needs and I promise you we will continue 
to do more.
    I thank you for the opportunity to discuss our efforts. We 
are now prepared to answer any questions you may have.
    [The prepared statement of Ms. Schohn follows:]
  Prepared Statement of Mary Schohn, Ph.D., Director of Mental Health 
Operations, Veterans Health Administration, U.S. Department of Veterans 
                                Affairs
    Chairman Murray, Ranking Member Burr, and Members of the Committee: 
Thank you for the opportunity to appear before you to discuss the 
Department of Veterans Affairs' (VA) commitment to providing responsive 
and effective mental health services that meet the needs of our 
Nation's Veterans. In particular, I will address wait times for mental 
health appointments and implementation of our mental health policies. I 
am accompanied today by my colleagues, Antonette Zeiss, Ph.D., Chief 
Consultant for Mental Health; and Jan E. Kemp, Ph.D., National Mental 
Health Director for Suicide Prevention.
    Let me state clearly at the outset that we take very seriously this 
Committee's concerns regarding needed improvements to VA's mental 
health care services. We are diligently and quickly working to make 
changes identified by this Committee and through our own review. We 
look forward to continued dialog and partnership with this Committee 
and Congress on our shared mission.
    The Veterans Health Administration (VHA) places a high priority on 
providing timely, quality care to our Nation's Veterans living with 
mental health issues. While we have made marked improvements in the 
mental health services available to Veterans, we continue to experience 
rapid increases in demand. We have seen a 34 percent increase in the 
number of Veterans using VHA mental health services, from 897,129 
Veterans in FY 2006 to 1,203,530 Veterans in FY 2010. During the same 
period, mental health staff levels increased by 47.8 percent, from 
14,207 to more than 21,000.
    In addition, VHA has been implementing major improvements for 
Veterans since 2006, including expanding the availability of telemental 
health services; establishing VA's National Center for PTSD 
Consultation Program available by toll free number (866-948-7880) or 
online to assist VA clinicians with questions about PTSD, its symptoms 
and treatment; developing, in collaboration with the Department of 
Defense (DOD), a mobile smartphone app for tracking and self-management 
of PTSD symptoms, the PTSD Coach, which has been downloaded over 30,000 
times in over 50 countries worldwide and has been awarded the 2011 
Federal Communication Commission's Chairman Award for Advancements in 
Accessibility; and launching a national messaging campaign, ``Make the 
Connection,'' designed to connect Veterans and their family members to 
the experiences of other Veterans, and connect them with information 
and resources to facilitate the transition from service to civilian 
life. VA appreciates Congress' support, which enabled enhancement of 
these important mental health services.
    In October 2011, the Government Accountability Office (GAO) issued 
a report on ``VA Mental Health: Number of Veterans Receiving Care, 
Barriers Faced, and Efforts to Increase Access.'' GAO made no 
recommendations to VA in the report, and recognized the extensive 
efforts VA is making to increase access. The report stated:

        VA has implemented several efforts to increase Veterans' access 
        to mental health care, including integrating mental health care 
        into primary care. VA also has implemented efforts to educate 
        Veterans, their families, health care providers, and other 
        community stakeholders about mental health conditions and VA's 
        mental health care.

    Moreover, VA recently received the results of a report for which VA 
had contracted with the RAND Corporation and the Altarum Institute to 
complete a ``Program Evaluation of Veterans Health Administration (VHA) 
Mental Health Services.'' These results indicate that across the 
country, as of FY 2009 (the last date of data collection) VHA 
facilities reported substantial capacity for treating Veterans with 
mental illness, with reported substantial increases between original 
measurement and 2007. Capacity has continued to increase since the 
RAND/Altarum data collection as VHA transitions toward full 
implementation of the Uniform Mental Health Services Handbook. For 
example, they reported after-hours availability of mental health care 
at VA medical facilities at 81 percent, and our internal data 
monitoring show 100 percent of facilities having this availability in 
2011.
    In October 2011, the journal Health Affairs published an article 
referencing the RAND/Altarum study. The study authors claim that this 
is the largest and most comprehensive assessment of a mental health 
system ever conducted. The report, which was based on a review of 
administrative data from 2007, concludes that most quality indicators 
showed good care compared to privately insured mental health patients 
not seen in VA. While there are numerous differences demographically 
between the private plan patients and VA patients, this is the most 
comparable data source available. The demographic differences would 
tend to work against VA, which has a generally older, sicker, poorer 
population. However, on nine administrative measures used to evaluate 
important processes in mental health care, VHA performance on seven of 
these performance indicators is higher than that reported in the 
literature for non-VA providers. VA is not as good as non-VA care on 
the other two, but these are measures of care for Substance Use 
Disorder care patients. The RAND/Altarum researchers point out ways in 
which the population differences could bias results against VA, for 
example, saying, ``Performance on the SUD indicators within VHA may lag 
private plan performance due to the significantly higher prevalence of 
SUD in our cohort (57 percent) than in the privately insured population 
(19.1 percent). The study's authors also noted that a major issue to 
further improve VA mental health services is to reduce variation across 
Veterans Integrated Service Networks (VISN) and facilities. VA agrees 
with this analysis and has made reducing such variation a major focus 
of our efforts. Despite the strengths and improvements noted in the GAO 
and RAND/Altarum study, we recognize we have much more to do. Put 
simply, our work to care for America's Veterans' mental and overall 
health can never stop and we must continually improve.
    I want to provide you with a brief summary of the results of the 
query of VA mental health staff requested by Chairman Murray at the 
July 14, 2011, hearing titled, ``VA Mental Health Care: Closing the 
Gaps.'' Then, I will discuss a set of actions VA is implementing to 
further determine what gaps still exist, and finally, the actions VA is 
taking to deliver measurable improvements in our mental health care for 
Veterans.
    After the request from Chairman Murray at the July hearing, VHA 
queried selected VA front-line mental health professionals for their 
perceptions on the adequacy of staffing and resources to serve Veterans 
with mental health needs. To meet the Committee's deadline, VHA 
developed a Web-based query that was administered from August 10, 2011, 
to August 17, 2011. VHA queried 319 general outpatient mental health 
providers from each facility within five VISNs selected by Senate 
Veterans' Affairs Committee staff. A total of 272 professionals 
responded (a response rate of 85 percent). Approximately one-third (31 
percent) of the respondents were social workers, about one quarter (25 
percent) were psychologists, and a similar percentage were 
psychiatrists and nurses (22 percent each).
    The Mental Health Query was not a formal survey, but rather an 
informal tool designed to provide a quick assessment of a small sample 
of provider perceptions. VHA views it as one step in its ongoing 
commitment to assessing and addressing providers' perceptions and 
needs. The survey recorded providers' perceptions relating to 
performance measurement, mental health staffing, space availability in 
medical and mental health facilities, off-hours mental health clinics, 
and balancing demand for Compensation & Pension/Integrated Disability 
Evaluation System (C&P/IDES) examinations. Specifically, many front-
line providers believe that Veterans' ability to schedule timely 
appointments as measured by the VA performance system does not match 
providers' experience and that mental health staffing at their facility 
is inadequate. They also believe that space shortages, inadequate off-
hour clinic availability, and competing demands for C&P/IDES 
examinations are barriers to providing access.
    Based on these perceptions, VHA leadership has already taken a 
number of actions. Since the query was completed, VHA has:

     Disbursed $13 million in funding to hire new mental health 
staff, which will provide telemental health psychotherapy services to 
areas where there is lower staffing, such as small community-based 
outpatient clinics.
     Hired additional staff for our Veterans Crisis Line and 
the Homeless Call Center, given that needs continue to expand for these 
services. In addition, VHA is aggressively filling existing vacancies 
for mental health staff.
     Implemented a Spouse Telephone Support Intervention as 
part of our Caregiver Support Program after Veterans participating in 
pilot programs reported decreased symptoms of depression and anxiety. 
The spouse support program builds spouses' ability to cope with the 
challenges that reintegration to civilian society can bring, helps them 
serve as a pillar of support for returning Veterans, and eases the 
transition for families post-deployment.

    In addition, to supplement the preliminary survey findings, VHA 
will continue to reach out to providers for their perceptions on mental 
health care. By the end of January 2012, we will have completed 10 
focus groups of providers to better understand their concerns. Based on 
the findings of the focus groups, VISN leadership will conduct a formal 
staff survey at every facility, and a sampling of their associated 
community-based outpatient clinics, to generate facility-based plans. 
Surveying will begin in the second quarter of FY 2012, and we expect we 
will complete the survey by the end of the third quarter of FY 2012.
    As always, VHA's goal and focus is to have mental health services 
closely aligned with Veterans' needs and tightly integrated with VA 
health care facility operations. To this end, VHA leadership has 
developed and is implementing an action plan with aggressive timelines 
for completion. Some of the actions outlined above are part of this 
action plan. The results-oriented action plan pursues five key 
objectives: (1) improve the accuracy of the mental health scheduling 
process to improve our performance measurement system; (2) measure the 
adequacy of mental health staffing through development of a consistent 
national staffing model; (3) systematically identify and address space 
shortages in mental health areas; (4) increase off-hours access; and 
(5) balance the demand for C&P/IDES examinations. These actions have 
already been initiated, with deliverables scheduled throughout FY 2012.
    To address mental health access, VHA has put in place a new four-
part mental health measure that will be included in the FY 2012 
performance contract for VHA leadership. This performance contract 
forms the basis for evaluation of VHA leadership, including VISN 
Directors. Thus, the measures in the performance contract define what 
leadership is accountable to accomplish, and the evaluation based on 
their performance defines various outcomes for them, including bonuses.
    The new performance contract measure holds leadership accountable 
for meeting the following objectives:

    (1) The percentage of new patients to mental health who have had a 
full assessment and started in treatment within 14 days of seeking an 
appointment.
    (2) Operation Enduring Freedom/Operation Iraqi Freedom/Operation 
New Dawn (OEF/OIF/OND) patients newly diagnosed with Post Traumatic 
Stress Disorder (PTSD) receive at least eight sessions of psychotherapy 
within a single 14 week period;
    (3) Follow-up by a mental health professional within seven days 
after discharge to the community; and
    (4) Four visits within 30 days for any patient flagged as a high 
suicide risk.

    We are combining these actions with the overarching mandate 
articulated in the VA strategic effort known as ``Improving Veterans 
Mental Health (IVMH) Major Initiative'' and VHA Handbook 1160.01, 
``Uniform Mental Health Services in VA medical centers and Clinics.'' 
VHA's actions prescribe mental health teams; staffing plans based on 
approved patient panel sizes; and measureable improvement of patient-
centered outcomes for depression, PTSD, suicide, substance use, and 
mental health recovery. In addition, VHA recognizes that accountability 
for delivering improved performance rests squarely with VA facility and 
VISN leadership. VHA is using its management and oversight processes to 
ensure that all facilities and VISNs have appropriately prioritized the 
improvement of mental health care and are making measureable progress. 
A critical function of VHA Central Office and VISN oversight includes 
identification of facilities with high performance on mental health 
access and dissemination of high performing practices to other 
facilities and VISNs.
    VA greatly appreciates Congress' continued support of VA's mission. 
VA has worked hard to increase Veterans' access to mental health 
services through non-traditional settings such as primary care and 
community living centers, community outreach programs, and telemental 
health services. We have made significant improvements in the range and 
quality of services offered by providing state-of-the-art psychotherapy 
and biomedical treatments to cover the full range of mental health 
needs. We are pleased that these efforts have been recognized in recent 
external reviews by GAO and separately by RAND/Altarum study. As I said 
earlier, our work is and will never be complete. We must be focused on 
constant improvement and excellence. VA continues to implement Veteran 
and family education and is training other community stakeholders about 
mental health conditions experienced by Veterans. We remain committed 
and will continue to provide all services to meet the needs of our 
Veterans and to provide them the quality care they so richly deserve.
    I appreciate the opportunity to discuss VA's ongoing efforts in 
delivering quality mental health care. My colleagues and I are prepared 
to answer any questions you may have.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
Mary Schohn, Ph.D., Director, Mental Health Operations, Veterans Health 
             Administration, Department of Veterans Affairs
    Question 1. Section 304 of Public Law 111-163 required the 
Department to establish a program providing OEF and OIF veterans with 
mental health services, readjustment counseling and services, and peer 
outreach and support. This provision also authorized the Department to 
contract with community mental health centers and other qualified 
entities in areas not adequately served by VA. When asked about the 
status of this provision's implementation, the Department did not 
sufficiently respond to the question.

    a. Please provide the Committee with an update on the Department's 
progress in implementing Section 304 of Public Law 111-163.
    Response. An internal Veterans Affairs (VA) group supplemented by 
external members from the Department of Health and Human Services 
(DHHS) Substance Abuse and Mental Health Services Administration 
(SAMHSA) and the Department of Defense (DOD) Office of Reserve Affairs 
is monitoring the implementation of this legislation. Please see 
Attachment A: Section 304 Elements, Plan, and Timeline; which provides 
the most recent update of each Section 304 element. Site visitor teams, 
comprised of a lead consultant from the Veterans Health 
Administration's (VHA) Office of Mental Health Operations (OMHO) and 
mental health subject matter experts from the Office of Mental Health 
Services (OHMS), Veterans Integrated Service Network (VISN) Mental 
Health Directors, Office of Homeless Programs, Program Evaluation 
Centers, Mental Health Research Centers, Centers of Excellence, mental 
health leadership from the field, and/or experienced mental health 
front-line providers are currently gathering site-by-site information 
on the implementation.
    Readjustment Counseling Service's Vet Center Program also has some 
involvement with Section 304 of Public Law (P.L.) 111-163. A portion of 
this section requires the provision of, ``readjustment counseling and 
services described in section 1712A of title 38, United States Code.'' 
The Vet Center Program has provided these services, without time 
limitation, to eligible Veterans since the program's inception in 1979. 
Furthermore, Vet Centers have been authorized, through the Secretary of 
Veterans Affairs approval, to provide the full range of readjustment 
counseling services, including working with families, to Operation 
Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/
OND) Veterans and families since April 2003 (OEF) and June 2003 (OIF/
OND).
         Attachment A: Section 304 Elements, Plan, and Timeline

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    b. According to Dr. Kemp, VA is in the process of providing 
training to train more ``peer type support counselors.'' Please provide 
more details regarding this effort.
    Response. For each of the past 3 years, VA has supported the 
certification process for VA Peer Support Technicians. In fiscal year 
(FY) 2012, OMHS and OMHO will be working with the VHA Business Office 
and the VHA Contracting Office to award a contract to train Veterans to 
be peer support specialists by a single not-for-profit organization, as 
directed by section 304(c) of Public Law 111-163. Contracting received 
the materials for the contract at the end of November. We anticipate 
being able to award the contract no later than the fourth quarter of FY 
2012. The Contractor shall provide the required labor and materials to 
develop and present a peer support specialist training and 
certification program for VA employees nationwide. The contract will 
require Peer Support Certification Training (including didactic, 
experiential, and multimedia modalities) covering the 34 competencies 
VHA has designated as required for peer support staff. The training for 
the competencies that do not require the face-to-face experiential 
modality may be provided through in-person training or through 
completion of workbook materials, manuals, or online learning conducted 
prior to the experiential training. The Contractor will also 
demonstrate that competencies and skills have been mastered through 
both demonstration and written testing.

    Question 2. According to the RAND study entitled ``The Cost and 
Quality of VA Mental Health Services,'' evidence-based practices were 
reported as being widely available throughout VA, but the Department's 
records did not demonstrate that they were being widely delivered to 
veterans. What should the Committee make of this disparity and what 
actions is the Department taking in response to the report?
    Response. There are straightforward explanations for the apparent 
discrepancy between the RAND study and VA self-reported data. VA survey 
and administrative data support the RAND study finding that evidence-
based treatments for mental health disorders are widely available 
throughout VA. VA survey and administrative data also agree with the 
RAND study finding that these treatments are not currently delivered to 
all of the Veterans who could potentially benefit from them.
    One reason for the apparent discrepancy between treatment 
availability and delivery is that delivery of evidence-based treatments 
for mental health requires substantial teamwork between a patient and 
his or her clinicians and health care system. Having an evidence-based 
treatment available is a first step, but for that treatment to be fully 
delivered, the patient must be made aware of the available treatment, 
be motivated to try it, and be able to navigate logistical barriers to 
attend or adhere to treatment. Moreover these conditions must continue 
to be met over the course of care to ensure that a full dose of 
treatment is obtained. For example, a patient might be motivated and 
logistically able to attend evidence-based psychotherapy sessions for 
major depression while suffering from severe depression and 
unemployment, but early treatment response and a job offer might reduce 
motivation and make it more difficult to continue attendance to obtain 
a full course of therapy.
    Studies of patient behavior within and outside VA indicate that, 
even when evidence-based treatments are available, only a subpopulation 
of patients with relevant diagnoses will use and complete these 
treatments. Even in carefully selected cohorts of interested patients 
in clinical trials, where patients are closely tracked and typically 
provided incentives and assistance to complete the trial treatments, 
patient adherence to evidence-based mental health treatments is far 
from perfect. For example, in a large randomized clinical trial of 
psychotherapy for depression, 23 percent of patients who began 
psychotherapy did not complete the 12 week treatment program (Arnow et 
al., 2007). Similarly, a detailed longitudinal study of patients 
receiving treatment for obsessive compulsive disorder found that among 
those whose clinicians recommended a course of evidence-based cognitive 
behavioral therapy, only 74 percent initiated treatment, and only 21 
percent completed a full course of the treatment (Mancebo et al., 
2001). Patients also do not consistently use their medications even 
after receiving prescriptions. For example, estimates of medication 
nonadherence for depression and bipolar disorders range from 10 to 60 
percent (median: 40 percent), and attitudes and beliefs have been shown 
to be as important as side effects for determining adherence (Pompili 
et al., 2009).
    Given these difficulties in motivating patients to use and adhere 
to evidence-based treatments, VA expects a disparity between available 
treatments and their use. Knowing that patients are likely to have 
difficulty with motivation and adherence to recommended treatments for 
mental health problems, VA recognizes the importance of creating care 
systems and encouraging patient-provider interactions that increase 
patient motivation and facilitate adherence to treatment. VA has 
designed programming to be more accessible (e.g., offering evening or 
weekend hours, care via telemedicine, providing transportation 
assistance), provided reminders or organizers for Veterans, and trained 
staff in communication techniques that improve motivation (e.g., 
motivational interviewing or message framing). VA has also created 
performance measures that assess success in 1) getting patients to try 
evidence-based psychotherapy and pharmacotherapy, and 2) getting 
patients to complete a substantial course of treatment.
    These measures have spurred projects across VA to improve use of 
mental health services and highlighted the need to address patient 
motivation and adherence in health care delivery. For example, VA Palo 
Alto implemented a program to train primary care providers in 
motivational interviewing techniques that have been shown to encourage 
behavior change and treatment engagement in numerous clinical trials, 
and VA Portland has implemented a telepsychiatry program to allow 
patients to follow up with mental health providers without leaving 
their homes. OMHO is currently identifying promising programs through 
their site visits and program evaluation and will disseminate these 
interventions to other facilities.
    Another significant issue that contributes to the low rates of 
documented delivery is a lack of standardized methods for recording 
information about use of evidence-based practices (EBP) in the VA 
electronic health record and administrative databases. The RAND report 
states ``Documented delivery of EBPs in the medical record and 
administrative databases is infrequent, even when they are reported to 
be available.'' Because of lack of standardized documentation methods, 
these services may not be accurately identified in program evaluations 
even when they do occur.
    VA administrative databases rely on clinician coding using 
standardized procedure codes. These codes indicate only that patients 
received, for example, some sort of psychotherapy. They do not indicate 
what was discussed during the session and whether the session utilized 
evidence-based procedures or content. Moreover, these codes may not be 
consistently entered. While clinicians consistently enter notes about 
patient encounters into the electronic health record, these notes often 
focus on patient symptoms or concerns and treatment plans and 
frequently do not include information about the techniques, processes 
or manual treatment content used during the session. To improve 
documentation of use of evidence-based psychotherapies in medical 
record and administrative data systems, HVA's OHMS is creating 
psychotherapy session note templates and information technology 
solutions to help clinicians consistently document their use of 
evidence-based psychotherapies and program evaluators accurately track 
use of these treatments.

Arnow BA, Blasey C, Manber R, Constantino MJ, Markowitz JC, Klein DN, 
            Thase ME, Kocsis JH, Rush AJ. (2007) Dropouts versus 
            completers among chronically depressed outpatients. Journal 
            of Affective Disorders 97 (2007) 197-202.
Mancebo MC, Eisen JL, Sibrava NJ, Dyck IR, Rasmussen SA. (2011) Patient 
            Utilization of Cognitive-Behavioral Therapy for OCD. 
            Behavior Therapy 42 (2011) 399-412.
Pompili M, Serafini G, Del Casale A, Rigucci S, Innamorati M, Girardi 
            P, Tatarelli R, Lester D. Improving adherence in mood 
            disorders: the struggle against relapse, recurrence and 
            suicide risk. Expert Rev Neurother. 2009 Jul;9(7):985-1004.

    Question 3. In the Department's query of mental health 
professionals almost half of the providers reported that the lack of 
off-hour appointments is a barrier to care. However, the Department 
claims that after-hours mental health care is available at all VA 
medical facilities and large CBOCs. The Department also claims that 
evening hours are less preferred by veterans compared to weekend or 
early morning availability.

    a. Please explain the disparity between the provider responses and 
the Department's assertions.
    Response. The sampling methodology of the query of mental health 
professionals was developed to identify concerns of frontline providers 
in response to the Senate Veterans' Affairs Committee (SVAC) request. 
However the methodology was not sufficiently rigorous to provide an 
estimate of the size of the problem, or to identify where access 
problems are occurring. VHA administrative data provides specific 
information about the location of off-hours care for mental health and 
shows that this is available as required at facilities and large 
community-based outpatient clinics (CBOC). The data also showed that 
medium to small CBOCs are not routinely offering off-hours care.
    VHA did not mandate off-hours care for these smaller CBOCs, as 
there is often limited logistical support for off-hours care. However, 
the newly developed Extended Hours Access for Patients policy, which 
requires facilities to use local data on utilization, no-show, and 
cancellation rates to determine which extended hour option(s) best meet 
the needs of the facility's patient population, strongly encourages 
both primary care and mental health to provide services in these 
clinics during extended hours.

    b. Additionally, please describe how the Department will ensure 
that the off-hours care it provides will be most responsive to the 
preferences of veterans.
    Response. Based on the query data and concerns, VA's Under 
Secretary for Health commissioned a workgroup to expand access to off-
hours care, including primary care. The workgroup looked at the 
administrative data of use of off-hours care and gathered additional 
information through discussions with Veterans. Data showed that in-
person extended hours were most heavily used in urban areas; extended 
telehealth hours were more frequently used in rural areas. No-show 
rates were highest for clinics schedule after 4:30 p.m. and were lower 
for clinics scheduled before 8:00 a.m. and on weekends. Veteran 
feedback was mixed, citing concerns about driving at different times of 
the day, the need for consolidating all visits into one trip, 
availability of parking, and so on. Given the wide variety of feedback, 
much of it site-specific, the new Extended Hours Access policy requires 
facilities to use ``local data on utilization, no show and cancellation 
rates to determine which extended hour option(s) best meet the needs of 
the facility's patient population.''

    Question 4. Testimony from the hearing's first panel indicated that 
scheduling evidence-based psychotherapy treatment sessions at short and 
regular intervals is necessary for it to be effective. Is VA able to 
schedule mental health appointments according to the frequency the 
treatments prescribe?
    Response. VHA Handbook 1160.01, Uniform Mental Health Services in 
VA medical centers and Clinics requires that facilities have capacity 
to provide these therapies and that Veterans have full access to 
evidence-based psychotherapy (EBPT) services ``as designed and shown to 
be effective.'' VA is not able to precisely track specific wait times 
for EBPTs and how they may influence Veteran dropout of therapy as the 
Current Procedural Terminology codes used for tracking health care 
services do not distinguish types of psychotherapy, nor do they provide 
information about the number of therapy sessions received as compared 
to the number recommended within a given therapy protocol. OMHS has 
developed and is nationally disseminating documentation templates for 
the EBPTs that enable precise tracking of EBPT delivery and treatment 
completion, as well as facilitate documentation of session activity, 
promote fidelity to therapy protocols, and capture data elements to 
help track more detailed information about participation in evidence-
based psychotherapy activities than is available through standard 
encounter form data. The templates have been piloted at several 
facilities and are scheduled for full system deployment in FY 2012.
    A national survey of VA facilities evaluating the extent to which 
these therapies are provided indicated that all facilities are 
providing Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) 
Therapy for PTSD, and 98 percent of facilities were providing both of 
these therapies, which have been found to be equally effective. Survey 
results further indicate that capacity to provide these therapies 
varies throughout the system. To address variations in capacity, OMHS, 
in coordination with OMHO, developed additional national guidance on 
how to deliver EBP with the appropriate level of intensity and session 
frequency that has been shown to be effective. In addition, VA's 
national competency-based staff training programs in CPT and PE Therapy 
implemented a targeted training approach this FY 2012, placing 
important focus on sites that have fewer trained staff to ensure 
adequate numbers of trained staff are available.
    VA also appointed a Local Evidence-Based Psychotherapy Coordinator 
at each VA medical center to serve as a champion for EBPTs at the local 
level and to help establish local clinical infrastructures necessary 
for successfully implementing EBPTs at the local level. VHA has also 
developed a performance measure that evaluates sites on their ability 
to deliver a minimum of 8 sessions of psychotherapy within a 14-week 
period for OEF/OEF/OND Veterans with PTSD.
    VA is promoting implementation of these therapies through 
telemental health. Evidence-based psychotherapy for PTSD using 
telemental health offers an opportunity to overcome physical and other 
access barriers (e.g., physical distance, transportation costs and 
difficulties, job responsibilities) to initial and ongoing 
participation in evidence-based psychotherapy. Funding has been 
provided to the field to place approximately 100 EBPT for PTSD 
Telemental Health Providers at carefully selected sites throughout the 
system. Moreover, VA has developed an EBPT for PTSD Toolkit to help 
program managers and front-line staff to implement these services. An 
all-day workshop on the delivery of CPT and PE via telemental health 
was conducted at VA's national mental health conference in August 2011.

    Question 5. What new quality assurance measures will VA implement 
regarding mental health appointments to account for wait times, 
appropriate types of care needed, and ability to see the same provider 
to encourage good patient-provider relationships?
    Response. VA is committed to developing quality measures to help 
ensure that Veterans are able to receive timely access to mental health 
care as well as to developing measures to ensure that Veterans have 
continuity in their same provider(s) throughout their course of mental 
health treatment. During FY 2012, the Network Director's Performance 
Plan added a composite of five measures of behavioral health access. It 
includes a measure to monitor timely access among Veterans initiating 
specialty outpatient care for PTSD. The measure will track the 
percentage of Veterans seen for a new appointment to initiate PTSD 
treatment within 14 days of their desired date. This measure 
complements the following other access measures in the composite (1) 
completion of a comprehensive mental health evaluation within 14 days 
of an initial visit, (2) follow-up within 7 days after discharge from 
an inpatient psychiatry hospitalization, (3) frequent contact and 
follow-up during the 4 weeks after identification of risk for suicide, 
and (4) engagement in sufficient intensity of evidence-based 
psychotherapy for PTSD among returning Veterans.
    During FY 2012, a major implementation effort continues to identify 
the Mental Health Treatment Coordinator (MHTC) for each Veteran 
receiving mental health services. Over the course of mental health 
treatment, Veterans may receive care from a variety of clinicians. The 
MHTC role is intended to ensure that each Veteran has continuity 
through his or her mental health care and its transitions. Having a 
MHTC assigned ensures that each Veteran can maintain an enduring 
relationship with a mental health provider who can serve as a point of 
contact, especially during times of care transitions. Planned release 
of software enhancements in the 2nd Quarter of FY 2012 will facilitate 
the process of identifying and tracking the assigned MHTC for each 
Veteran. Currently, implementation is being tracked through electronic 
record review, but the capacity to aggregate information electronically 
is anticipated later in the fiscal year as sites shift to utilizing the 
new software tool. Decisions about clinically appropriate care are also 
documented in the Mental Health Suite (MHS) Treatment Planning software 
being implemented nationally in FY 2012. The software will systematize 
individualization of care and facilitate comprehensive care planning.

    Question 6. Dr. Charles Hoge estimated that, in 2010, only 20 
percent of the veterans who needed PTSD specific treatments were 
effectively reached by VA.

    a. What role do waiting-times and scheduling difficulties play in 
veterans dropping out of treatment?
    Response. Dr. Hoge's estimate, in his article of August 3, 2011 in 
the Journal of the American Medical Association, estimates that, ``* * 
* current strategies will effectively reach no more than 20 percent of 
all veterans needing PTSD treatment.'' However, that estimate is based 
primarily on extrapolations from published, randomized, controlled 
trials, not from actual VA evidence. Further, he assumes that the 50 
percent of OEF/OIF/OND Veterans who seek VA care are representative of 
the larger population of Veterans. However, VA knows from data on those 
who have completed the Post Deployment Health Reassessment (PDHRA) 
process that Veterans who report mental health concerns on the PDHRA 
are much more likely to come to VA for health care than those who do 
not report mental health concerns. Thus, the 50 percent he cites 
(actually currently 53 percent) who come to VA include a majority of 
those who are likely to seek mental health care.
    This is supported in VA's data. For example, 28 percent of those 
who seek VA health care have at least a possible diagnosis of PTSD, 
compared to 15-20 percent estimated for all military personnel who have 
combat experience, in the study of OEF/OIF/OND Servicemembers and 
Veterans by RAND. Further, in VA's annual review of mental health 
services actually delivered, of the 408,142 OEF/OIF/OND Veterans who 
received some VA care in FY 2011, 99,610 had at least one visit 
recorded with a PTSD diagnosis. Of those, over 98 percent (a total of 
94,414 individuals) were actively involved in VA mental health care 
during FY 2011.
    At another level, VA shares Dr. Hoge's concern. Although VA is 
serving a large and increasing proportion of those Veterans who need 
PTSD specialty care, Veterans are not always able or willing to 
participate in a full course of evidence-based treatment. VA continues 
to strive to make such services more readily accessible, as detailed in 
the following responses. Such efforts will continue and expand in FY 
2012. For example, in addition to the scheduling efforts documented 
below, improved access through expansion of delivery of evidence-based 
psychotherapies for PTSD via telemental health is already underway. VA 
is fully committed to constantly striving to improve on the extensive 
mental health enhancement efforts already made in VA.
    In addition, waiting times and scheduling difficulties are two 
important considerations, among many, which could affect dropping out 
of treatment. Although there is no empirical basis to determine 
statistically what percent of drop out may be related to such issues, 
even one dropout because of such problems would be too many. Therefore, 
continued focus on ensuring that waiting times meet our policy 
requirements and that scheduling difficulties are minimized are a focus 
of VA efforts to improve mental health services. Certainly as a part of 
that, efforts are directed at waiting times meeting VA's timeliness 
standards, as lengthy waits can discourage Veterans from seeking 
treatment. Moreover, clinic hours outside normal business hours (8-4:30 
on weekdays) are essential for reducing difficulties in scheduling 
appointments. All VA facilities and CBOCs serving over 10,000 unique 
Veterans already have after-hour or other extended hour mental health 
clinics, and an expanded array of extended hour services is being 
planned.
    There are other considerations, as well, concerning simplifying 
scheduling to ensure delivery of a coordinated course of evidence-based 
psychotherapy, which are reviewed in the following paragraph.
    Scheduling practices must be appropriately flexible to enable 
clinicians to deliver full courses of any PTSD treatment, including 
EBPT. At some sites, less flexible scheduling practices have resulted 
in some challenges in implementing the weekly 60-90 minute sessions 
that EBPs typically require. As noted above, the OMHS, in coordination 
with the OMHO, has developed national guidance on fully implementing 
EBPs at the local level, which includes specific guidance and 
identified best practices related to meeting scheduling requirements 
for EBPs. A number of facilities have developed scheduling procedures 
that support EBPs, and that have included clinic profiles with a 
default time increment of 30 minutes. The 30-minute default increment 
allows the clinician to specify to the scheduler whether a 30-, 
60-, 90-, or 120-minute session is required. Another scheduling 
strategy that can be useful is to schedule an entire course of weekly 
EBP sessions (or a significant number of sessions for the therapy 
protocol) prior to the initiation of treatment (e.g., Cognitive 
Processing Therapy typically requires 12 weekly 60-minute sessions). 
This can be accomplished using the ``multibook'' (multiple appointment 
booking) function in the VistA scheduling package. This practice 
ensures that the weekly appointment time is not inadvertently scheduled 
with a different patient. The consistency of date and time from week to 
week increases the likelihood that the patient will remember the 
appointment, with fewer failures to show, and also supports the 
patient's commitment to completing the entire course of psychotherapy.
    As noted above, other factors also impact Veteran dropout rate, as 
emphasized by Dr. Hoge, including stigma about receiving mental health 
treatment or belief that mental health care is not required. VA also is 
addressing these issues and has a variety of outreach programs to 
address these issues. Most recently, VA launched a national messaging 
campaign called ``Make the Connection'' to provide Veterans with 
information from other Veterans about the benefits of treatment. Make 
the Connection helps Veterans and their family members to connect with 
the experiences of other Veterans--and ultimately to connect with 
information and resources to help them confront the challenges of 
transitioning from service, face health issues, or navigate the 
complexities of daily life as a civilian.

    b. What specific steps can VA take to improve adherence to 
treatment?
    Response. VA has taken specific steps to increase Veterans' access 
to mental health care in general, which can lead to improved adherence, 
beginning with specific attention to availability of evidence-based 
PTSD treatment and to support the receipt of specialized PTSD services. 
These steps are outlined below.

     VA has implemented, and keeps updated, a PTSD Program 
Locator that allows Veterans, their family, or other concerned parties 
to search for the availability of specialized PTSD programs in their 
geographic area. The locator is available on the Internet and provides 
information about the types of programs available (e.g., outpatient, 
residential care, etc.) and gives information about how to contact 
programs. The Web site is linked to the National Center for PTSD 
(www.ptsd.va.gov), which also has extensive information for Veterans 
and their families that can educate them about PTSD, treatment options, 
and the resources that VA has to offer Veterans. This information is 
designed to increase access to appropriate care for PTSD.
     VA has implemented extensive efforts to integrate mental 
health care into primary care. These services include screening, 
assessment, and treatment of PTSD in primary care settings. This helps 
reduce wait times for receipt of care for PTSD, reduces the stigma that 
may be associated with seeking care for PTSD symptoms, and ultimately 
improves adherence.
     Screening, referral, and follow-up care are the first 
important steps in providing care to those Veterans who need it. VA has 
set standards for these measures in several domains and monitors them 
quarterly.
     VA has set standards for the appropriate screening of 
Veterans for PTSD. Nationally, 99 percent of all Veterans who should be 
screened for PTSD are screened at appropriate intervals.
     Additionally, 97 percent of Veterans are screened for 
Military Sexual Trauma (MST), and more than half of the female Veterans 
who screen positive for a history of MST go on to receive MST-related 
treatment services.
     More than half (57 percent) of Veterans with a diagnosis 
of PTSD receive at least some psychotherapy care. VA has made EBPs such 
as Prolonged Exposure Therapy and Cognitive Processing Therapy widely 
available, in addition to a number of other treatment options for 
Veterans with PTSD. Evidence-Based Therapy coordinators are present in 
97 percent of VA medical centers to coordinate access to these types of 
care.
     Of those Veterans with a diagnosis of PTSD, 15.7 percent 
receive a full course of psychotherapy treatment, defined as at least 
eight psychotherapy visits within a 14 week period. A course of 
psychotherapy is not appropriate for every Veteran at every stage of 
his or her recovery.

    Question 7. What specific actions is VA taking to reduce variation 
in mental health services across VISNs and facilities?
    Response. Although mental health services and service utilization 
may vary across sites as a function of differences in population 
treatment needs, marked variation raises concerns regarding mental 
health access. On September 11, 2008, VHA defined essential elements of 
its mental health program, to be implemented to ensure that all 
Veterans have access to mental health services, wherever they receive 
VHA care.
    Recently, VHA has taken a number of specific actions to reduce 
variation across VISNs and facilities. For example, on March 27, 2011, 
VHA established the OMHO to enhance monitoring, collaboration, support 
for mental health field operations, and engagement with VISNs and 
facilities. Addressing variation in mental health services is a major 
OMHO focus. OMHO is part of VHA Operations and collaborates closely 
with policy leadership in the Office of Mental Health Services. OMHO 
staff has been trained to provide technical assistance to VISNs and 
facilities and engage in ongoing close support, assessment and 
evaluation of the effectiveness of their interventions.
    In addition, VHA has developed new tools for assessment of 
variation in mental health services. OMHO has developed a comprehensive 
new tool for assessment of VHA mental health services and variation 
across VISNs and facilities, the Mental Health Information System 
(MHIS). The MHIS includes over 200 indicators that are based on ongoing 
surveys and health system administrative measures. These provide an 
essential tool for evaluating variation in mental health services. 
Indicators of services availability and utilization are calculated for 
specific items and item domains, by facility, VISN, and nationally. The 
MHIS enables assessment of variation in key aspects of VHA mental 
health services. Facilities are flagged for focused review and 
implementation support if their scores on specific measures are not 
consistent with policy expectations. Where specific policy guidelines 
are not available, thresholds for indicators were based on 
distributional attributes, with low performing outliers flagged for 
immediate review and assistance. MHIS is being updated quarterly.
    VHA has also ensured the availability of these resources, including 
the MHIS, for leadership throughout VHA. In September and October, the 
MHIS was introduced in conference calls to VISN mental health 
leadership. In addition, VHA has initiated ongoing consultation and 
review meetings with VISN mental health leadership. For each VISN, OMHO 
consulted with VISN mental health leadership regarding the MHIS and 
VISN- and site-specific results. These consultations also served as an 
introduction to the mission of OMHO and the specific role of OMHO 
Technical Assistants.
    To further ensure that VA reduces variation across VISNs and 
facilities, VHA has initiated ongoing site visits, comprised of a lead 
consultant from the Office of Mental Health Operations and mental 
health subject matter experts from the Office of Mental Health 
Services, VISN Mental Health Directors, Office of Homeless Programs, 
Program Evaluation Centers, Mental Health Research Centers, Centers of 
Excellence, mental health leadership from the field, and/or experienced 
mental health front-line providers to assess mental health services. 
Based on the VISN-level consultations, specific sites were identified 
for immediate site visits.
    Twenty-one (21) site visits will have been conducted by the end of 
December 2011. Visits focus on those sites and those domains that have 
been flagged for close review. Visits include assessment of strengths 
and barriers of specific programs and development and review of VISN 
and site-specific plans to address concerns and reduce variation in 
mental health services. Technical Assistants are assigned to specific 
VISNs and provide ongoing support and engagement to address concerns. 
In addition, VHA has initiated development, review and ongoing 
assessment of VISN level mental health Strategic Action Plans. Each 
VISN has provided a Strategic Action Plan to address marked variation 
in mental health services. Noted above, these are an important element 
of the dialog between VHA OMHO and VISNs and facilities.

    Question 8. In response to the survey's findings, VA provided the 
Committee an action plan with concrete steps the Department is taking 
to resolve longstanding issues with mental health care. Specifically, 
VA tasked focus groups (potentially ten groups) with the mission of 
assessing in more detail the key themes from the initial query on 
scheduling, staffing, space, office hours, and C&P/IDES in mental 
health services.
    Please share with the Committee, the findings from each focus 
group.
    Response. The ten focus groups are being conducted by Altarum under 
a contract with VHA and are due to be completed with an aggregated 
report of the findings by January 31, 2012. The ten sites include 
Boise, Boston, Iowa City, Memphis, Minneapolis, Nashville, San Antonio, 
Waco, Walla Walla, and White River Junction. To ensure confidentiality, 
VA has not requested a facility-specific report of the findings. VA 
will provide the final report to the Committee when it is available.

    Question 9. The Department has transitioned to a composite mental 
health access metric that includes several different wait time 
standards. Are there other metrics that were not included, which would 
be beneficial to developing a comprehensive picture of access to care?
    Response. Although the Department has transitioned to a composite 
mental health access metric for use as a performance measure to 
prioritize and incentivize specific quality improvement efforts system-
wide across VA, these are by no means the only mental health access 
metrics that the Department tracks. In fact, OMHO has created the 
Mental Health Information System (MHIS) which includes well over 200 
measures that examine facility- or VISN-level access to specific 
treatments or elements of mental health programming that will provide a 
more comprehensive picture of access to care and other measures of 
quality of care delivery. This MHIS was designed to allow comprehensive 
monitoring of mental health care elements as described in the Uniform 
Mental Health Services Package and other VA policies and initiatives, 
and thus is highly beneficial for developing an overall picture of 
access to care. These measures typically look at the percentage of 
patients in a relevant diagnostic or demographic cohort who receive a 
specific treatment or service. For example, one measure looks at the 
percentage of patients with an opioid dependence diagnosis who receive 
opioid agonist treatment in VA or by contract. Another looks at the 
percentage of Veterans with a mental health service connection living 
within the VISN catchment area that receive VA specialty mental health 
services. While the absolute percentage of patients that should receive 
a specific treatment or service depends on clinical factors and patient 
preferences and is thus unknown, we believe based on past experience 
that these patient factors will be relatively uniform across 
facilities. This information system allows us to identify facilities 
where fewer patients are receiving a specific type of mental health 
service for targeted intervention and to improve local access to that 
service or treatment.
    In addition, the VISN Support Service Center produces several 
reports designed to assist facilities in adapting programming and 
services to improve access for patients. These reports quantify how 
many people waited, how long they waited, as well as how many are 
currently waiting for mental health care. The ``Access List'' report 
was designed to help reduce the number of future appointments with long 
waits. The report shows the number of patients and appointments in the 
queue waiting, but gives the most attention to those patients who have 
already waited more than 14 days for an upcoming visit. Another access 
metric is the ``Electronic Waitlist (EWL)'' report, which provides 
information on Veterans on the EWL, including those waiting for mental 
health care. The ``Pending Future Appointments'' report was designed to 
provide information on Veterans who have pending appointments, 
including mental health appointments, as of a given date. Demographic 
information about the Veterans with pending appointments allows for 
detailed monitoring. The overall goal in the use of these reports is to 
help reduce the number of appointments with long waits.

    a. Does the Department have standard requiring patients who are 
prescribed new antidepressants to be seen within one month of starting 
the prescription in order to be reevaluated?
    Response. Although VA does not have a policy requirement that 
patients who are prescribed new antidepressants be seen within one 
month of starting the prescription in order to be reevaluated, page 80 
of the VA/DOD Clinical Practice Guideline for the Management of Major 
Depressive Disorder (2009) does recommend that clinicians follow up and 
reassess patients at 2 weeks following initial treatment with a new 
antidepressant, and then, if the patient has not responded to initial 
treatment, again between 4-6 weeks to adjust treatment as needed. This 
guideline provides recommendations for clinicians making practice 
decisions regarding the treatment of patients for major depressive 
disorder based on existing evidence and expert consensus, but these 
recommendations are not meant to set policy or supplant clinical 
judgment regarding what is appropriate clinical care for an individual 
patient. This is explicitly stated at the start of the guideline in the 
following statement ``The Department of Veterans Affairs (VA) and The 
Department of Defense (DOD) guidelines are based on the best 
information available at the time of publication. They are designed to 
provide information and assist in decisionmaking. They are not intended 
to define a standard of care and should not be construed as one. Also, 
they should not be interpreted as prescribing an exclusive course of 
management.
    Variations in practice will inevitably and appropriately occur when 
providers take into account the needs of individual patients, available 
resources, and limitations unique to an institution or type of 
practice. Every healthcare professional making use of these guidelines 
is responsible for evaluating the appropriateness of applying them in 
any particular clinical situation.''
    Thus, while the Department recommends that patients prescribed new 
anti-depressants be seen within one month of starting the prescription, 
this is not a standard (see Guideline link: https://
www.qmo.amedd.army.mil/depress/depress.htm).

    b. If so, what is the compliance with this standard?
    Response. As stated in the above response, VA has no policy 
requirement or standard that patients who are prescribed new 
antidepressants be seen within one month of starting the prescription 
in order to be reevaluated. VA does, however, have a guideline for 
clinicians making practice decisions regarding the treatment of 
patients for major depressive disorder.

    c. If not, why is this not tracked?
    Response. Because this is not part of the current VA performance 
measurement set, follow-up after new anti-depressant prescription is 
not currently included in our main mental health measure tracking 
system. However, VA is able to track receipt of VA care following new 
prescriptions on demand. Nationally, 69.7 percent of the 187,781 VA 
patients with a new anti-depressant prescription in the 4 quarters 
ending in FY 2011 Quarter 2 had another VA encounter within 30 days. 
Across VA facilities, the rate of 30 day follow-up after a new anti-
depressant prescription ranged from 57.2 percent to 83.6 percent.

    Question 10. Please provide an update of the wait time data 
provided by the Department in response to the question for the record 
(Question one: c & e) requested by Senator Burr following the 
Committee's mental health care hearing in July.
    Response. Please see Attachment B, which provides the wait time 
data for completed mental health appointments by VISN for FY 2011 
through November, FY 2012. Within each VISN page, the listing is by 
facility and then by clinic.

    [Attachment B was received and is being held in Committee files.]

    Question 11. VISN 3 utilizes a PTSD software based program named 
``Family of Heroes'' that allows veterans and their families to readily 
access a web-based, interactive roll playing simulation. Please provide 
the Committee with more details regarding this effort, including 
utilization and an evaluation of its efficacy.
    Response. VISN 3 (the New York metro area) contracted with Kognito 
Interactive, a New York City-based developer of role-play training 
simulations, to design and make available to the families of Veterans--
particularly those who have returned from combat--an online training 
simulation called Family of Heroes. Family of Heroes is designed to 
teach family members critical skills to support their Veteran's 
transition to post-deployment life.
    This training simulation provides users with the opportunity to 
engage in simulated conversations with fully-animated Veteran avatars 
who exhibit signs of PTSD, Traumatic Brain Injury (TBI), and 
depression. Each ``virtual Veteran'' possesses his or her own 
personality, emotions, and memory, thus replicating real-life 
interactions with individuals experiencing post-deployment stress. This 
unique learning experience provides a hands-on experience wherein users 
learn and internalize best practices for approaching and talking with 
at-risk Veterans and, if necessary, motivating them to seek help at the 
VA. The training includes three simulated conversations:
    In the first conversation, users assume the role of the wife and 
learn to de-escalate an argument with her husband Dave who is 
experiencing PTSD and mild TBI. In the second, users assume the role of 
the husband and learn to re-negotiate family responsibilities with his 
wife Alicia who is experiencing post-deployment stress. Finally, in the 
third, users assume the role of the mother and learn to motivate and 
refer her son Chris, who is exhibiting signs of depression and thoughts 
of suicide, to support services.
    The program was presented at the poster session of the DOD/VA 
Suicide Prevention Conference in Boston in March 2011, where it won the 
first place award of excellence for Best in Quality and Originality. 
The program was also presented at the National VA Mental Health 
Conference in Baltimore in August 2011.
    The program was rolled out to VISN 3 VA medical centers and VA 
community partners in September, 2011, and formally launched the week 
before Veterans Day. To date, 52,792 users have accessed the Family of 
Heroes Web site. The Web site has a Contact Us (VA) option and this 
user information is provided to the VISN 3 VA medical center closest to 
the address provided. To date, no referrals have come to any VISN 3 VA 
medical centers from this Contact Us option on the Web site.
    In order to better understand the impact of the Family of Heroes 
program, VA researchers are conducting a study, using funding from the 
VISN 3 Mental Illness Research Education and Clinical Center. Recently 
returned Veterans from the conflicts in Iraq and Afghanistan who are 
living with PTSD will be invited to participate in this study. In 
total, 120 of these Veterans from the New Jersey area will be invited 
to have their spouse or a close family member participate with them in 
the study. Half of these Veterans will have their spouse/family take 
the web-based, Family of Heroes program, while the other half will not 
complete the Family of Heroes program. This will allow the researchers 
to compare these two groups. By understanding the differences between 
the groups, the researchers can pinpoint the ways in which 
participating in Family of Heroes helps family members and spouses 
support their Veterans. The research study will pay special attention 
to whether the program will help improve PTSD symptoms and relationship 
health. The researchers will also determine whether the program 
increases the use of mental health services in the VA or elsewhere.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
                  U.S. Department of Veterans Affairs
    Question 1. In VA's testimony and the action plan VA developed, VA 
states that mental health staffing has increased by 47.8 percent since 
2006. However, staffing shortages were identified by the mental health 
providers you surveyed and confirmed by testimony we heard at the 
hearing.

    a. Please provide the Committee with a breakdown of the providers 
that have been hired in mental health since 2006.
    Response:


------------------------------------------------------------------------
                                       Increase in Mental
    Discipline or Professional      Health Clinicians since   % increase
                                              2006
------------------------------------------------------------------------
Nurse.............................                  2115.53           34
Physician Assistant...............                   333.79           30
Physician.........................                   741.37           41
Psychologist......................                  1409.63           87
Social Work.......................                  2767.10          125
Therapist.........................                   456.90           34
                                   -------------------------------------
    Total*........................                  7824.33           55
------------------------------------------------------------------------
*Total includes staff hired for the Homeless program as well as mental
  health.

    b. How many of those additional staff are actually engaged full-
time in clinical care?
    Response. Nationally aggregated data shows eighty-seven (87) 
percent of mental health Full-Time Employee Equivalents (FTEE) are 
providing direct clinical care.

    c. How does VA decide what type of providers are needed at VA 
facilities?
    Response. Although some programs such as Residential Rehabilitation 
programs and Mental Health Intensive Case Management have specific 
standards for type and amount of staffing based on either number of 
beds or number of Veterans served, many other outpatient programs do 
not currently have national standards. For these programs, facilities 
develop staffing standards based on the range and type of services 
provided and the volume of care provided. Staffing decisions are also 
developed locally based on the types of providers that are available in 
the local area. VA mental health is currently working to develop 
national guidance on staffing to assist facilities in determining their 
staffing needs.

    d. How many positions for mental health providers does VA currently 
have open?
    Response. The number of open positions for mental health providers 
is approximately 1,500 positions as of December 2011. This is a 
constantly changing number as positions are filled and vacated through 
normal processes. However, based on the survey VA conducted in 
December, sites reported filling 870.82 FTEE that were vacant in May. 
This December survey was a follow-up to the May 2011 survey which asked 
all medical centers and VISNs to complete a full staffing report on all 
mental health vacancies.

    Question 2. VHA has placed considerable priority on having its 
mental health clinicians provide evidence-based psychotherapy to treat 
PTSD, but that therapy calls for intensive treatment involving 12-15 
sessions. Yet, as we heard from Dr. Washington, some VA facilities 
place emphasis on seeing new patients within 14 days, but cannot 
provide the timely follow-up care.

    a. For the most recent fiscal year for which you have data, what 
percentage of OEF/OIF patients with mental health diagnoses are 
actually receiving evidence-based therapy?
    Response. VHA cannot currently provide administrative data on the 
number of OEF/OIF/OND Veterans receiving these treatments. This is due 
to the limitations of Current Procedural Terminology codes used for 
tracking health care services, which do not allow distinction of 
different types of psychotherapy. OMHS has developed documentation 
templates for each of the EBPs it is nationally disseminating; these 
templates will be added nationally into VA's electronic medical record. 
These templates will allow for precise tracking of EBP delivery and 
treatment completion, as well as facilitate documentation of the types 
of Veterans who engage in these treatments. The templates have been 
piloted at several facilities and are scheduled for full system 
deployment later in FY 2012.
    While awaiting development of these new informatics processes, VA 
has conducted surveys of the field to obtain information on the extent 
to which OEF/OIF/OND Veterans with PTSD have been offered and provided 
EBPs for PTSD (specifically Cognitive Processing Therapy [CPT] or 
Prolonged Exposure Therapy [PE]), as well as the extent to which these 
Veterans have completed a full course of one of these treatments.
    A national survey of VA facilities evaluating the extent to which 
these therapies are provided by facilities indicated that all 
facilities are providing CPT or PE, and 98 percent of facilities were 
providing both of these therapies, which have been found to be equally 
effective. Survey results further indicate that the level of capacity 
to provide these therapies varies throughout the system. OMHO is 
assessing this variability through the site visits that are ongoing, 
and VA continues to increase its capacity through training. Training in 
CPT and PE this fiscal year has involved a targeted approach placing 
important focus on sites that have fewer trained staff. The 
availability of clinics with weekly 60-90 minute sessions, as these 
therapies require, is also an important standard VA is working to 
ensure is consistently in place throughout the system.
    Survey data have further indicated 30 percent of OEF/OIF/OND 
Veterans offered CPT or PE began treatment. Of those Veterans that 
initiated treatment, 51 percent completed a full course of therapy. It 
is important to note that these survey data are approximations reported 
by facilities based on locally available data collected by facility 
staff, since centralized administrative data for tracking specific 
types of psychotherapy are not available. These data are comparable to 
data in the literature that shows that the average completion rate for 
psychotherapy is 53 percent (average from a meta-analysis of 125 
studies).

Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy 
            dropout. Professional Psychology: Research and Practice, 
            24, 190-195.

    b. How does VA plan to address the lack of appointment availability 
for follow-up care?
    Response. OMHS, in coordination with OMHO, has developed national 
guidance on fully implementing EBPs at the local level. This guidance 
provides detailed requirements for providing EBP with the appropriate 
level of intensity and session frequency with which they were 
originally designed to be delivered and shown to be effective. In 
addition, VA's national, competency-based staff training programs in 
Cognitive Processing Therapy and Prolonged Exposure Therapy have 
implemented a targeted training approach this fiscal year, placing 
important focus on sites that have fewer trained staff.
    Furthermore, the OMHS and OMHO have developed and are now actively 
implementing in the field, a performance measure that requires that 
OEF/OEF/OND Veterans with PTSD receive a minimum of 8 sessions of 
psychotherapy within a 14-week period. OMHO has also developed a 
``dashboard'' of metrics to monitor and provide feedback to the field 
on the delivery of courses of psychotherapy and a broad array of other 
services.
    VA is also working to promote engagement in evidence-based 
psychotherapy for PTSD by promoting the implementation of these 
therapies through telemental health modalities. EBP for PTSD telemental 
health services offer an opportunity to overcome physical and other 
access barriers (e.g., physical distance, transportation costs and 
difficulties, job responsibilities) to initial and ongoing 
participation in evidence-based psychotherapy. As part of this effort, 
VA has developed a Task Force that has issued recommendations for a 
national strategy to promote the implementation of evidence-based 
psychotherapy for PTSD telemental health services, which are already 
provided at some facilities and have been shown to be effective with 
Veterans. Funding has been provided to the field to place approximately 
100 EBP for PTSD Telemental Health Providers at carefully selected 
sites throughout the system. Moreover, VA has developed an Evidence-
Based Psychotherapy for PTSD Toolkit to help program managers and 
front-line staff implement these services. An all-day workshop on the 
delivery of CPT and PE via telemental health was conducted at VA's 
national mental health conference in August 2011.

Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy 
            dropout. Professional Psychology: Research and Practice, 
            24, 190-195.

    Question 3. VA has the authority to use fee-basis care to meet 
veterans' needs if their needs cannot be met within VA. According to 
information VA provided my staff, on average about two percent of VA's 
mental health patients are referred to fee-basis care per year. When a 
VA provider decides fee-basis care is needed, it can take several 
months before the request is granted by the facility, leaving that 
veteran waiting for the needed care that is available in the private 
sector.

    a. If VA has big staff shortages and long wait times to access 
care, why have only two percent of veterans in need of mental health 
care been referred for fee-basis?
    Response. When VA facilities are unable to furnish cost-effective 
hospital care or medical services because of geographical 
inaccessibility or lack of required staff or equipment, VA may contract 
with non-VA facilities to furnish such care or services to certain 
eligible Veterans. A referral for non-VA care is a clinical decision, 
which may include consideration of VHA's ability to provide the 
required care in a timely manner, or to address eligible Veterans' 
clinical needs if a Veteran is not geographically accessible to a VHA 
facility. Referral to fee basis care does not always guarantee more 
timely care however, especially in accessing evidence-based 
psychotherapies. For example in facilities that have experienced 
problems with staff shortages or wait times, especially in rural areas, 
there is a limited provider pool for both VA and non-VA needs. Because 
of this, VA is expanding its telemental health services to provide 
coverage for areas that have difficulty locating either VA or fee basis 
providers.

    b. Please describe the process for getting a request for fee-basis 
care approved.
    Response. The referral process for non-VA care from a VA facility 
begins with a provider making the determination that the VA site is 
unable to provide the necessary clinical care for the Veteran at that 
facility, either because the facility lacks the clinical resources to 
provide that care timely, the VA facility is not available, or the 
Veteran is unable to travel to a VA facility to receive care. Once the 
determination is made, the facility staff determines the most 
appropriate location of care, and if all administrative eligibility 
requirements are met, a referral will be processed to provide these 
services in the community. If a contract is in place for the required 
service and that is the most appropriate clinical setting, Veterans 
will be referred to those contracted providers. VA is implementing 
standardized business practices in FY 2012 to ensure equity of access 
for services and appropriate care coordination, management, and 
oversight of these non-VA services. These new processes include 
standardized business practices such as deploying standardized non-VA 
consult/referral templates across all VHA medical centers, and 
Implementing new tools and Standard Operating Procedures (SOP) to 
improve the way we coordinate non-VA healthcare services for our 
Veterans.
    The scope of this initiative encompasses the processes between the 
time when a VA provider generates a consult/referral for a Veteran 
until the time the Veteran receives the authorized services and fee 
program staff receives all required clinical documentation.

    Question 4. At the hearing, VA testified that their facilities have 
off-hours appointments for mental health.

    a. Please specify by facility type, how many facilities have off-
hours appointments?
    Response. Based on data through December 12, 2011, mental health 
(MH) off-hours appointments are provided at 152 VA medical centers and 
376 CBOCs.

    b. Please specify whether these hours are early morning, evening or 
weekend appointments, and the types of services available.
    Response. Data from October 1, 2010 through December 12, 2011, 
indicate that during early morning hours 179, 880 MH appointments were 
provided at 152 VA medical centers, and 32,020 at CBOCs; during evening 
hours 393, 825 MH appointments were provided at VA medical centers and 
68,876 at CBOCs; and during weekend hours, 118,563 MH appointments were 
provided at medical centers and 9,692 at CBOCs. Each facility provides 
different MH services during off-hours. Attachment C contains a list of 
stop codes indicating the types of MH services provided nationally 
during off-hours.
                              Attachment C

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    c. What metrics are used by the facilities to decide what 
appointments to offer (early morning, evening or weekend) and what 
types of services will be available during those off-hours 
appointments?
    Response. Facilities use various metrics for determining what 
services to offer and what times of the day to offer appointments, 
including wait time studies, patient focus groups and surveys, and 
staff focus groups and surveys. In addition, some types of services and 
appointment times are offered in response to VHA Handbook 1160.01: 
Uniform Mental Health Services in VA medical centers and Clinics.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
               IV to U.S. Department of Veterans Affairs
    Question 1. I mentioned a question from a recent call with West 
Virginia veterans, and a female veteran talking about access and making 
women veterans comfortable in VA facilities. I know that each facility 
should have a designated coordinator for women veterans, and that is 
important I understand why it is hard for female veterans who have 
survived Military Sexual Trauma (MST) to wait in a large area 
surrounded by men. But what has VA done to survey the VA facilities 
about space and privacy?

    a. Has VA done a systemic review of VA facilities--both Medical 
Centers and Vet Centers--to access the needs of women veterans and 
privacy?
    Response. Women Veterans Program Managers review structural, 
environmental, and psychosocial patient safety and privacy issues in 
all VHA outpatient care settings and conduct monthly environment of 
care rounds. Each facility must engage in an ongoing, continual process 
to assess and correct physical deficiencies and environmental barriers 
to care for all Veterans, particularly women Veterans. Currently, every 
VHA health care system has in place a full-time Women Veterans Program 
Manager to improve women Veterans' access to care.
    In addition, Women Veterans Program Managers and Deputy Field 
Directors conduct on-site visits to monitor compliance with correction 
of privacy deficiencies and communicate findings to local leadership. 
Other strategies include site visits by VISN Environment of Care Teams, 
random site visits, reviews by VHA's Office of Environmental Programs 
Service, as well as System-wide Ongoing Assessment and Review Strategy 
(SOARS) site visits. VHA Environmental Programs Service assists and 
ensures compliance with planning needs.

    b. What has VA done to provide specialized programs for women 
instead of group counseling? How readily available is such personalized 
care?
    Response. The Veterans Health Administration offers a full 
continuum of mental health services for women Veterans. Every VHA 
facility has mental health outpatient services for women. A wide range 
of services are available including formal psychological assessment and 
evaluation, psychiatry, and individual and group psychotherapy. 
Specialty services are available to target problems such as PTSD, 
substance abuse, depression, and homelessness. Many facilities have 
specialized, women's only outpatient services. These services enable 
women Veterans to stay at home, surrounded by family, friends, and 
other supports. Moreover, women Veterans can maintain employment and 
stay integrated into their community, which helps facilitate their 
recovery.
    Women Veterans can also receive services through most of VA's 
residential/inpatient treatment programs. Specialized residential 
programming for women is a resource that is rare to non-existent in the 
private sector. There are 19 programs that are able to provide 
specialized care in a VA residential or inpatient setting for mental 
health conditions related to MST. When clinically indicated, Veterans 
may benefit from receiving residential treatment in women's only 
environments. VA has 11 residential or inpatient programs that provide 
treatment to women only or that have separate tracks for men and women. 
One (1) additional VA program provides women-only treatment in a non-VA 
residential setting in conjunction with a local non-profit program for 
homeless and at-risk Veterans. These programs are considered regional 
and/or national resources, not just a resource for the local facility. 
Some of these women-only programs focus on MST specifically, while 
others focus on specialized women's care in general (including MST).
    VA recognizes that some Veterans will benefit from treatment in an 
environment where all of the Veterans are of one gender as this may 
help address a Veteran's concerns about safety and improve a Veteran's 
ability to disclose trauma details, address gender-specific concerns, 
and engage fully in treatment. However, VA also recognizes that mixed-
gender programs have advantages, as they may help Veterans challenge 
assumptions and confront fears about the opposite sex and provide an 
emotionally corrective experience. Given these considerations, VA does 
not promote one model as universally appropriate for all Veterans. The 
needs of a specific Veteran dictate which model is clinically most 
appropriate.
    VA policy requires that mental health services be provided in a 
manner that recognizes that gender-specific issues can be important 
components of care. All VA facilities must ensure that outpatient and 
residential programs have environments that can accommodate and support 
women with safety, privacy, dignity, and respect. All inpatient and 
residential care facilities must provide separate and secured sleeping 
and bathroom arrangements including, but not limited to, door locks and 
proximity to staff for women Veterans.
    VHA facilities are strongly encouraged to give Veterans the option 
of a consultation from a same-sex provider regarding gender-specific 
issues when they are in a mixed gender program or group. Veterans being 
treated for conditions related to MST have the option of being assigned 
a same-sex mental health provider or an opposite-sex provider if the 
MST involved is a same-sex perpetrator.

    Question 2. Another recent question by a West Virginia veteran was 
about the waiting period for ``de-tox'' in our state. When asked, VA 
facilities say they can provide care, but veterans in our state tell 
another story. How do we provide clear incentives for VA facilities to 
report and deal with shortfall in staff or care, rather than using 
creative ways to ``count'' care and visit to meet guidelines?
    Response. As part of the action plan recently submitted to the 
SVAC, VA outlined a plan to develop a nationwide staffing model for 
mental health. The national staffing plan will ensure that VHA 
facilities to include the four Medical Centers in West Virginia are 
evaluating staffing in a consistent way across sites and will allow VA 
to monitor variations in practice. At the current time, staffing is 
determined locally. The ongoing site visits as noted in an earlier 
response will be assessing mental health staffing levels.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
                  U.S. Department of Veterans Affairs
    Question 1. When DOD separates an active-duty servicemember, who 
has been identified as having behavior health needs, does DOD share 
that information with VHA behavioral health services in order to assure 
continuity of care and assist VHA in its outreach efforts?
    Response. Over the last 10 years DOD and VA have expanded sharing 
of protected health information (PHI), including interfaces between 
their respective health information systems. The VA/DOD Bi-directional 
Health Information Exchange was initiated in 2008 and is designed to 
ensure that providers from both systems have access to information 
related to current treatments, which aims to improve continuity of care 
for the Servicemember or Veteran. The two Departments are currently 
developing next generation solutions, including a fully integrated 
electronic health record with a shared user interface. A joint VA/DOD 
task group is also currently examining policies for health information 
sharing between VA and DOD, including an analysis of legal, ethical, 
moral, and privacy issues related to VA/DOD health information sharing. 
The ultimate goal is to provide continuity and coordination of care 
while allowing Veterans and Servicemembers some measure of control over 
whether, how, and with whom their information is shared.
    Currently, when a Servicemember is separated from DOD and 
transferred directly to a VA facility, for example, to an inpatient 
treatment program, that Servicemember's medical records are transferred 
to VA. When a separating Servicemember is referred to VA for care, such 
as following a Post-Deployment Health Reassessment (PDHRA), limited 
information may accompany the referral (e.g. name, diagnosis, reason 
for referral), and if the Veteran chooses to seek care at a VA 
facility, an authorization for release of information signed by the 
Veteran will allow for his or her records to be forwarded to VA.
    Continuity of care is also facilitated through the DOD inTransition 
program, which provides counselors who are trained to assist and 
support Servicemembers making transitions from one location to another 
within DOD, as well as those who are transitioning from the DOD health 
care system to VA. Through telephone assistance, the Servicemember and 
family members work with a personal coach who provides advice, 
information about mental health care, location of resources, and 
assistance in connecting with new providers. The inTransition program 
operates 24 hours a day, 7 days a week, 365 days a year. VA is a 
partner with DOD on the program, which is one of the Strategic Actions 
included in the VA/DOD Integrated Mental Health Strategy.
    With regard to sharing information to assist with outreach efforts, 
VA is working with DOD Reserve Affairs to explore the possibility of 
receiving both general and specific information that would assist VHA 
in reaching out to National Guard and Reserve members as they are 
preparing to separate and to families who are currently receiving 
behavioral health care through TRICARE.

    Question 2. Will VA consider collaborating with Dr. Van Dahlen's 
Give an Hour program and its volunteer mental health providers?
    Response. VA is already exploring opportunities to collaborate with 
Give an Hour. Most recently, our Veterans Crisis Line leadership has 
initiated conversations with Give an Hour about the development of a 
potential memorandum of agreement with Give an Hour concerning the 
ability of the Crisis Line to assist them with any Veteran their 
practitioners identify as being in crisis or needing immediate medical 
attention. Also, the memorandum of agreement would facilitate our 
ability to provide a referral to Give an Hour as a resource to those 
Veterans who contact the Crisis Line and are not willing or able to 
access VA services for any of a number of reasons (e.g., stigma, 
dishonorable discharge, physical distance from VA facilities). In 
addition, VA sees Give an Hour as a resource for family members of 
Veterans who could benefit from their own mental health treatment in 
ways that are not related to the treatment needs of the Veteran.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
                  U.S. Department of Veterans Affairs
    Question 1. Alaska has a difficult time in recruiting and retaining 
mental health providers. Can you provide details on the VA Rural Health 
Coordinator's efforts to expand telemental healthcare, outreach, and 
training? Are there new initiatives to expand telemental health access, 
and can you expand on them?
    Response. The Office of Rural Health (ORH) and the Office of Mental 
Health Services (OMHS) places a great emphasis on making telemental 
health services more accessible to rural Veterans. A new initiative 
that ORH is funding in FY 2012 for approximately $1.1 million, the 
``Oregon Rural Mental Health Initiative,'' involves expanding home-
based telemental health (HBTMH) services to rural areas in Veterans 
Integrated Service Network (VISN) 20. The goal is to train and to 
provide equipment to 70-100 providers in 30 facilities and community-
based outpatient clinic (CBOC) sites throughout Oregon, Washington, 
Idaho, and Alaska. Rural Veterans will be able to receive mental health 
services (e.g., psychotherapy, medication management, psychiatric 
evaluations) from their homes by using inexpensive webcams attached to 
their computers to communicate with their providers. There is a special 
emphasis on expanding telemental health services in Alaska. Two mental 
health providers have been trained to initiate HBTMH with Veterans in 
rural Alaska. For parts of Alaska that lack high speed internet, the 
use of secure cellular notebook connectivity modalities will be 
explored. It is anticipated that by the end of FY 2012, 1,200 unique 
rural Veterans will have been impacted by this initiative.
    In addition, VHA is initiating several Alaska-focused initiatives. 
Contact has been made with tribal officials who have a community health 
clinic in Talkeetna, a remote town about 2.5 hours driving time from 
Anchorage. They have agreed to allow VA to provide a pilot telemental 
health care program for Veterans into their clinic, and we are working 
to equip their clinic with secure telemental health equipment to 
initiate this care. They have offered to help VA establish a similar 
site in Willow, Alaska, where they are building a new community health 
clinic. Assuming these small pilots are successful, VA hopes to expand 
the ability to deliver such care to other rural and highly rural sites 
in the state. We have also been working to equip the main facility in 
Anchorage with the ability to deliver telemental health services from 
Anchorage to CBOC sites in Fairbanks, Juneau, Kenai, and Mat-Su, and to 
prepare them to expand their Home-Based Telemental Health capacity.
    Following from the recommendations of a national VA Evidence-Based 
Psychotherapy for PTSD Telemental Health Task Force, VHA has developed 
a strategic plan that includes two core components to promote the 
delivery of EBP for PTSD telemental health services nationally: (1) 
Expansion of Cognitive Processing Therapy (CPT) and Prolonged Exposure 
(PE) Therapy clinical video teleconferencing services provided from 
medical centers to community-based outpatient clinics; (2) Piloting of 
regional CPT and PE clinical video teleconferencing clinics that will 
supplement the delivery of CPT and PE telemental health services 
provided by local medical centers and clinics and serve as regional 
sites of excellence and technical support. Alaska will be included in 
this effort.

    Question 2. Do you have numbers on how many veterans are receiving 
psychotherapy and medication management using secure videoconferencing? 
Are there other similar arrangements? (Linda Godleski)
    Response. In FY 2011, 55,305 Veteran patients received mental 
health services using secure videoconferencing; approximately 43 
percent received a combination of Medication Management and 
Psychotherapy; 30 percent received Medication Management alone; 20 
percent received psychotherapy alone; 7 percent were Other (e.g., 
Initial Diagnostic Evaluation).

    Question 3. Can you describe the staffing process for a typical 
mental healthcare facility? Does each facility have a base staffing 
document detailing authorized positions, and is there a minimum 
required fill level for positions at the facility? Can a facility 
director make a decision to leave positions unfilled if they are 
authorized and there are qualified applicants?
    Response. Every facility has a posted, approved organizational 
chart that includes authorized positions (ceiling). Facilities update 
their approved staffing routinely as new services are added to amend or 
to reflect other changes in service provision as well as to ensure that 
the numbers were supportable by their budgets. There are no minimum 
fill levels for positions established.
    For specifically-funded positions, facility directors are required 
by the VISN Director to begin recruiting and hiring positions 
immediately. Requests for non-funded new positions or for filling 
vacant positions go to the facility Resource Management Board.
    Resource Management Boards make decisions based on justification 
submitted for the request and balance it with all services in the 
medical center, taking into account the approved ceiling, clinical 
needs, current budget, and total FTEE.
    In addition, the ongoing site visits, as noted in an earlier 
response, will be assessing mental health staffing levels across 
facilities and developing national standards to guide facility 
decisionmaking. These site visits serve as an additional check on how 
facilities are serving their Veteran population with current staffing 
on-board.

    Question 4. What is the (plan/formula) about what the patient: 
psychiatrist ratio should be? (Follow-up corollaries: patient: 
psychotherapist (and what training level, what types of 
psychotherapies) ratio? patient: psychiatric nurse? If so, what are 
these ratios, and on what evidence-based literature is this based? 
national, international?
    Response. There currently is no well-developed literature on what 
mental health staffing levels should be as this will vary depending on 
the type and range of services provided. VA, as the largest integrated 
health care system, provides many services that are not offered in 
other types of health care systems and is therefore not comparable to 
other settings even if such guidance existed. Also, VA is not 
comparable to other settings in the level of qualifications required. 
Unlike many community-based clinics, VA hires primarily masters or 
doctoral level clinicians to ensure the workforce is adequately 
credentialed to meet the mental health needs of Veterans.
    VA has examined the productivity of the mental health workforce 
based on existing community standards. VA providers tend to be more 
productive than their academic counterparts but less than private 
practice providers. Currently, VA is developing a staffing model. The 
timeline and process for development of the staffing model was 
submitted to SVAC as part of the mental health action plan, sent in 
November 2011.

    Question 5. How do these ratios compare to the standard of care in 
the community (the standard of care vis-a-vis community mental health 
centers, as would be the most reasonable comparison)?
    Response. Please see response to question 4 above.

    Question 6. Is there a requirement/policy that VA SBH (social 
behavioral health) outpatient clinics (such as what exists in 
Anchorage) provide a program for the OEF/OIF (operation enduring 
freedom/operation Iraqi freedom) veterans? If so, what is the program 
intended to provide?
    Response. VHA Handbook 1010.01, Care Management of Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, 
states that all ``VA health care facilities must provide appropriate 
health and mental health services to Veterans who served in OEF and 
OIF. Coordination of those services is to be ensured by the OEF-OIF 
Care Management Team at each facility led by the OEF-OIF Program 
Manager.'' Each VA medical center or outpatient clinic (such as exists 
in Anchorage) must appoint a masters level social worker or registered 
nurse as the OEF-OIF Program Manager to ensure that these Veterans 
receive patient-centered and integrated care. Program requirements 
include:

     Ensuring that OEF-OIF Veterans are screened to determine 
the need for mental health care or case management services.
     Facilitating seamless transition from DOD military 
treatment facilities and transition units.
     Assignment of a case manager (RN or social worker) for all 
seriously ill or seriously injured OEF-OIF Veterans as well as others 
requiring case management services.
     A Transition Patient Advocate to provide outreach to 
Veterans and Servicemembers transitioning from DOD to VA care to smooth 
their entrance into the VA patient-aligned care teams and to assist 
with eligibility for VA benefits including those specifically targeting 
OEF-OIF Veterans.
     Close collaboration with specialty programs to address 
issues such as polytrauma, Traumatic Brain Injury, blindness, and PTSD 
to ensure care coordination.
     Assisting with accessing special benefits such as home 
modification, in-home services, and coordination with community 
resources.
     Providing a regularly scheduled interdisciplinary team 
review of the special needs of OEF-OIF Veterans (Integrated Post Combat 
Care Team).
     Keeping VA leadership abreast of new programs, Veteran 
needs, challenges, and resource requirements.
     Tracking and monitoring the OEF-OIF Veterans and the 
quality care measures that apply specifically to this group.
     Meeting new OEF-OIF Veterans in the VA Introductory Clinic 
to advise them of their specific benefits and to facilitate case 
management from the first encounter with the VA.
     Assessing the need for Post-9/11 Caregiver Support Program 
referral and ensuring this process is implemented.

    Question 7. If this is a requirement/policy of VA, why does that 
not exist in Alaska clinic, let alone outlying CBOCs?
    Response. The OEF-OIF Program has been in existence in Alaska as a 
formalized program since 2007, when a Transition Patient Advocate and a 
Program Manager were hired. Prior to that time, a case manager provided 
outreach and care coordination for these Veterans. The program expanded 
in 2009 with the addition of staff. In addition:

     OEF-OIF Program staff as well as other mental health 
providers from the Alaska VA have provided on-site training for 
community providers throughout the state on issues specific to OEF-OIF 
Veterans.
     OEF-OIF staff have traveled throughout the state with the 
National Guard for Yellow Ribbon events and continue to do so.
     OEF-OIF staff continue to provide community briefings, to 
brief transitioning servicemembers from Anchorage and Fairbanks 
military installations, and to coordinate care for Servicemembers and 
Veterans coming to Alaska from other states.
     They have cross-trained CBOC social workers to provide 
screening and case management for the OEF-OIF Veterans in their 
communities, and they consult with them on local Veteran issues, 
benefits, and concerns. They travel to the CBOCs to consult and assist 
as needed.
     In July 2011, the OEF-OIF Program Manger resigned from the 
Alaska VA. The service chief in Social and Behavioral Health, a 
seasoned psychologist with experience in the VA and in treating PTSD, 
has been serving as the acting Program Manager.
     The position was announced three times since July 2011. 
The first two announcements did not provide candidates with sufficient 
knowledge or experience for this position. The third announcement has 
closed and interviews are being planned.
     A Caregiver Support Coordinator, a retired Army RN, was 
appointed in the spring of 2011. He has fully implemented that program 
and continues to offer nursing expertise in collaboration with the 
social workers providing care for OEF-OIF Veterans.
     Integrated care delivery is ensured by the social workers 
in the Patient Aligned Care Teams who serve as case managers for the 
OEF-OIF Veterans on their teams.
     Anchorage and CBOC mental health providers have received 
training and are providing evidenced-based psychotherapies for the 
treatment of PTSD.

    Question 8. What is the plan to expand Vet Centers in Alaska?
    Response. VA's decision to establish new Vet Centers in 28 counties 
throughout the country in 2010 was based on consideration of county 
Veteran population and distance from the nearest Vet Center. The county 
Veteran population is identified in VetPop, which is VA's latest 
official estimate and projection of the Veteran population and their 
characteristics. VA's intent with this expansion was to extend access 
to Vet Center services to underserved Veterans in more rural areas. The 
criteria for establishing a new Vet Center is outlined below. These 
criteria were applied to a Nation-wide analysis of Veteran population 
by county:

     County with more than 40,000 Veterans and more than 30 
miles to nearest Vet Center
     County with more than 20,000 Veterans and more than 60 
miles to nearest Vet Center
     County with more than 10,000 Veterans and more than 100 
miles to nearest Vet Center
     Two adjacent counties with more than 10,000 Veterans and 
more than 100 miles to the nearest Vet Center

    Based upon these criteria, VA concluded that the size of the county 
Veteran population and distance to the closest Vet Center do not 
support the establishment of a new Vet Center in Alaska. The three 
counties with comparable Veteran population, Anchorage at 31,000, 
Fairbanks North Star at 11,700, and Matanuska-Susitna at 10,500, are 
covered by the Vet Centers in Anchorage and Fairbanks, and the Vet 
Center outstation in Wasilla. However, VA is augmenting the staff at 
the Vet Centers in Anchorage and Fairbanks by adding a qualified family 
counselor at each Vet Center.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Roger F. Wicker to 
                  U.S. Department of Veterans Affairs
    Question 1. It has been nearly 5 months since the Assistant 
Inspector General testified before this Committee about the wait times 
between acceptance into a mental health residential program and the 
start of that program. Have things improved? What is the wait time now?
    Response. During the July 14, 2011, hearing, ``VA Mental Health: 
Closing the Gaps,'' the Assistant Inspector General for Healthcare 
Inspections testified about recommendations from the Office of the 
Inspector General's (OIG) recent follow-up review of the Mental Health 
Residential Rehabilitation Treatment Programs (MH RRTP) (A Follow-Up 
Review of VHA Mental Health Residential Rehabilitation Treatment 
Programs, June 22, 2011). The follow-up review recommended that VHA 
ensure contact between MH RRTP staff and/or engagement in MH treatment 
for patients in the interim between their acceptance into and actual 
participation in a MH RRTP. In response to the recommendation, the 
Office of Mental Health (OMHS)--MH RRTP Section, along with the Office 
of Mental Health Operations (OMHO) reviewed policy and clarified 
guidelines and procedures. Guidance was provided during a series of 
national conference calls with VISN and medical center leadership, and 
Program Managers in August 2011. Additionally, the Office of the Deputy 
Under Secretary for Health for Operations and Management sent written 
guidance to the VISN and Medical Center Directors on August 8, 2011.
    These efforts were designed to directly address the concern noted 
by the OIG. While the OIG report did not specifically identify concerns 
with average wait time for admission to residential mental health 
treatment, all MH RRTP programs are required to monitor wait times and 
ensure that admissions occur as quickly as possible. In FY 2010, MH 
RRTP program managers reported that the average number of days between 
screening and admission was 17.6, with 25 percent of programs admitting 
Veterans within less than 3 days between screening and admission. 
Preliminary review of administrative data for a subset of programs for 
FY 2011 indicates that the average number of days between screening and 
admission was 17.5. Complete information on the FY 2011 average wait 
time between screening and admission is not yet available, however it 
is being evaluated during our site visits.

    Question 2. In July, only 4% of patients were referred to 
vocational rehabilitation services. What percentage of veterans is 
being referred now?
    Response. We believe that this statistic is from Assistant 
Inspector General for Healthcare Inspections' written statement for a 
hearing before the Committee on July 14, 2011, and is a typographical 
error. The OIG report (10-04085-203) outlines that 92 percent of all 
Veterans admitted to a Mental Health Residential Rehabilitation and 
Treatment Program (MH RRTP) are assessed for Occupational Dysfunction, 
and that 60 percent are referred for vocational rehabilitation 
services.

    Question 3. In July, the Assistant Inspector General testified 
about the shortcomings of readjustment counseling and Post Traumatic 
Stress Disorder. Have those shortcomings been resolved?
    Response. OIG made two recommendations which have been resolved.
    OIG Recommendation 1: Ensure that Vet Center Team Leaders perform 
monthly provider's record reviews and provide supervision and 
consultation to providers in compliance with Readjustment Counseling 
Service (RCS) policy.
    All Vet Center Team Leaders are required to comply with the 
supervision and consultation requirements and all Vet Centers are being 
monitored for compliance through annual site visits. A performance goal 
for the Team Leaders specifically related to supervision and 
consultation and is within the FY 2012 performance appraisal. In FY 
2011, a performance goal regarding the remediation of all site visit 
deficiencies was included. RCS has increased the level of specificity 
for FY 2012.
    OIG Recommendation 2: Ensure that corrective action is taken when 
supervision and consultation issues are identified through the annual 
clinical quality reviews.
    RCS has developed an electronic template to monitor clinical site 
visit reports and deficiency remediation. Once the Regional Manager 
approves a clinical site visit, an electronic template identifying any 
deficiencies is completed in the Vet Center electronic recordkeeping 
system. Until all deficiencies are resolved, the clinical site visit 
report will remain in an incomplete status and highlighted on the 
responsible officials' menu every time they enter the Vet Center 
electronic recordkeeping system. This process was implemented on 
October 1, 2011.

    Question 4. What is the suicide rate among our veterans who have 
been treated for mental health problems?
    Response. In FY 2009 (the most recent year for which VA has data), 
the suicide rate among Veteran patients with mental health or substance 
use disorder diagnoses was 56.4 per 100,000, as compared to 23.5 per 
100,000 among patients without these diagnoses. The resulting rate 
ratio was 2.4. This continues a steady trend of lowering rate ratios 
observed since FY 2001, when the rate among patients with mental health 
or substance use disorder diagnoses was 78.0 per 100,000, as compared 
to 24.7 per 100,000 among patients without these diagnoses (rate ratio 
of 3.2).

    Question 5. What is the percentage of veterans who are receiving 
follow-up contact within 7 days of being discharged from a mental 
health ward as required?
    Response. Data through November 2011 indicate that approximately 
65.8 percent of VHA patients discharged from acute inpatient mental 
health hospitalization are contacted within 7 days of inpatient 
discharge. VA has targeted this measure for improvement in FY 2012, 
recognizing that Veteran preference and enrollment in follow-up care 
outside of VA are factors in increasing the rates. The RAND/Altarum 
report indicated that private sector benchmarks for this measure were 
under 50 percent for follow-up.

    Question 6. Is that follow-up contacting helping to identify at-
risk veterans and reduce suicide rates?
    Response. Yes, along with the follow-up requirements, there are 
more stringent requirements for those patients who have been identified 
as being at high risk. All of these efforts combined are making a 
difference. All patients who have a high risk designation should be 
seen a minimum of 2 times during the first 14 days after designation 
and 2 more times during weeks 3 and 4 after designation. Specific 
interventions, such as safety planning and attention to means control, 
are required. We believe that these interventions and follow-up 
strategies are effective and that the decreasing suicide rates among 
the Veterans with mental health diagnoses is an indication of this. The 
follow-up strategies and enhanced care package were started in 2008, 
and at this point we only have 2009 data to compare to. We will know 
more about effectiveness next year when the 2010 data is available from 
the Centers for Disease Control and Prevention.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Scott P. Brown to 
                  U.S. Department of Veterans Affairs
    Question 1. Should a Vietnam veteran suffering from PTSD be placed 
in the same peer counseling group with 21-year old Iraq and Afghanistan 
veterans? In other words, should the VA rely solely on evidence-based 
treatments without an appreciation for cultural, age and environmental 
concerns?
    Response. OMHS is committed to transforming mental health services 
in VHA to the recovery model. One key part of that transformation 
includes individualized treatment plans that are designed to meet the 
Veteran's self-determined goals. The treatments that are recommended 
and provided to the Veteran take into account the Veteran's goals and 
individual characteristics and needs. Depending on the specific goals 
that are to be achieved, group therapy with Veterans from different 
service eras can be very beneficial, as can group therapy with Veterans 
from a single service era. The most important consideration, though, is 
what the individual Veteran needs in order to reach his or her recovery 
goals.
    Given VA's Veteran-centric orientation, a decision about the type 
of group in which a Veteran should be involved for counseling should be 
based on a discussion of treatment options between the Veteran and his 
or her clinician. Although VA does rely heavily on evidence-based 
treatment, VA also has an appreciation for cultural, age, and 
environmental concerns. While VA policy indicates that all Veterans 
with PTSD must be offered and informed about evidence-based 
psychotherapies for PTSD, decisions about which psychotherapy a Veteran 
receives must be discussed with the Veteran and the Veteran's 
preferences must be considered. VA is extremely supportive of peer 
counseling programs (both formal and informal) and supports the fact 
that many Veterans choose to participate in peer counseling groups 
instead of, or in conjunction with, evidence-based psychotherapy. 
Although there are some Veterans who may not feel comfortable 
participating in peer support groups with Veterans from a different 
Service Era, there are other Veterans who may benefit from being in a 
peer counseling group with someone from a different generation who has 
had many similar experiences, despite the differences in service or 
generation. Treatment considerations should always be made on an 
individualized basis, as each Veteran has unique concerns and issues.

    Question 2. The Committee has received anecdotal evidence from 
psychiatrists being ordered to reduce treatment sessions from one hour 
to 30 minutes in order to get more patients in each day, despite the 
doctor's belief that the patients need an hour of therapy. In an effort 
to get more veterans seen by mental health care providers, is the VA 
compromising on the quality of care it is providing?
    Response. VA policy on delivery of psychotherapy services is 
designed to effect quality of care. Psychiatrists in the VA system as 
well as those in community private, Medicare/Medicaid, and self-pay 
settings typically provide medication management. VA patients are 
typically assigned to a psychiatrist for medication management and to a 
psychologist, social worker, or other licensed mental health provider 
for psychotherapy. However, psychiatrists can also provide 
psychotherapy if it is determined that it is clinically indicated. 
There are no national VA policies in place that restrict psychiatrists 
from providing any service that they determine is clinically indicated, 
as long as it is within their scope of practice. The appointment 
lengths for psychotherapy are determined by the standard of practice, 
typically either 20-30 minutes or 45-50 minutes, depending on what is 
determined to be clinically indicated. For prolonged exposure, the 
appointment length is 90 minutes; this, however, is atypical of most 
psychotherapies. Local mental health leadership may direct its local 
resources of psychiatrists, psychologists, and other mental health 
providers to make services available to Veterans to meet their mental 
health care needs. In addition to local quality monitors, VA's Office 
of Mental Health Operations, assisted by the Office of Mental Health 
Services, is carrying out a series of sites visits designed to assess 
compliance with policy concerning access to care and provision of 
treatment services. The first wave of these visits was completed on 
December 30, 2011.

    Question 3. Many of the panelists this morning are VA mental health 
care providers who are concerned with the timeliness and quality of 
care being provided to our veterans. They are frustrated by some of the 
administrative provisions that, from their prospective, are inhibiting 
their ability to provide meaningful, quality care. How is the VA using 
the knowledge and experience of its own practitioners to improve the 
currently challenged VA mental health care system?
    Response. VA has a number of efforts underway to collect 
information from providers and to use this information to drive 
improvements in care. VA is currently sending site visitors to all VA 
health care systems in FY 2012. Part of the protocol is to interview 
frontline mental health staff about their experiences in care delivery 
and to ask them both for best practices that should be disseminated and 
for recommendations to improve care delivery at their site. Findings 
from the site visits will be used to develop improvement plans for 
facilities and, if widespread, to develop system-wide interventions.
    VA has also contracted with Altarum to conduct 10 focus groups at 
facilities with front-line staff. The purpose of the focus groups is to 
understand concerns about barriers to delivery of care and to guide 
improvement. The report generated from the focus groups will be used to 
develop a survey that can be administered at every facility nationwide, 
and leadership will be charged with using the information to improve 
practice.
    In addition, providers are often members of telephone communities 
of practice that VA has set up to allow providers with special skills 
to share information about best practices and opportunities for 
improvement. These national groups are often mirrored within VISNs to 
allow subject matter experts to meet regularly and improve care.
                                 ______
                                 
 Response to Follow-up Posthearing Questions Submitted by Hon. Richard 
              Burr to U.S. Department of Veterans Affairs

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 Attachment: Duties, Responsibilities, and Qualifications of Evidence-
  Based Psychotherapy (EBP) for PTSD Telemental Health (TMH) Provider
    Background: As part of its efforts to innovate and transform health 
care, the Veterans Health Administration (VHA) has nationally 
implemented telehealth services, including, specifically, telemental 
health services. Building on these efforts, VHA is in the process of a 
major expansion of telehealth care. One major component of VHA's 
expansion of telehealth services and area of significant opportunity is 
the delivery of evidence-based psychotherapy for PTSD through 
telehealth modalities, including clinical video teleconferencing (CVT).
    Over the past several years, VHA has nationally disseminated and 
implemented Cognitive Processing Therapy (CPT) and Prolonged Exposure 
Therapy (PE), two evidence-based psychological treatments for PTSD that 
are among the most effective treatments available for PTSD (Institute 
of Medicine, 2007; VA/Department of Defense, 2010). Pursuant to VHA 
Handbook 1160.01, Uniform Mental Health Services in VA medical centers 
and Clinics, all Veterans with PTSD must have access to CPT and PE as 
designed and shown to be effective. Indeed, telemental mental health 
modalities, such as CVT, offer increased ability to provide these 
specialized interventions to Veterans in remote and rural areas who may 
otherwise have limited access to these treatments. Moreover, recent 
research, including research conducted within VA, has shown these 
therapies to be effective and well-accepted by patients when delivered 
utilizing telehealth technologies, with results on par with face-to-
face delivery of these treatments.
    The Office of Mental Health Services, in collaboration with the 
Office of Mental Health Operations in the Office of the Deputy Under 
Secretary for Health for Operations and Management (10N), is 
implementing a national initiative to implement CPT and PE telemental 
health services, pursuant to the recommendations of a national VA 
Evidence-Based Psychotherapy for PTSD Telemental Health Task Force. One 
primary component of this initiative is the expansion of CPT and PE 
delivery through ``hub and spoke'' VAMC-to-CBOC clinical video 
teleconferencing. As part of this expansion, full-time EBP for PTSD 
Telemental Health Providers will be placed at various medical centers 
and clinics throughout the system. Specific plans are being developed 
with each VISN regarding the placement of EBP for PTSD Telemental 
Health Providers at specific facilities.
    Summary: The EBP for PTSD Telemental Health Provider is a licensed 
independent mental health professional, including psychologists, social 
workers, advance practice nurses, marriage and family therapists and 
licensed mental health professional counselors (hired under Hybrid 
Title 38) that can provide CPT and/or PE to treat Veterans with PTSD 
telemental health services. Funding is available through VACO to hire 
new staff in this role; appropriate existing staff may also be 
reassigned to serve in this role. Process and outcome procedures will 
be implemented nationally to evaluate the impact of the specialty 
mental health services provided by the EBP for PTSD Telemental Health 
Providers.
Duties:
    The EBP for PTSD TMH Provider will focus on the delivery of CPT 
and/or PE to Veterans through telemental health modalities. This is a 
full-time position. Specific duties include:

    1. Providing screening, assessment, diagnosis, and treatment of 
Post Traumatic Stress Disorder, and concomitant conditions, with a 
primary focus on the delivery of Cognitive Processing Therapy (CPT; 
either using group or individual modalities) and/or Prolonged Exposure 
(PE), both time-limited, evidence-based approaches to the treatment of 
PTSD;
    2. Providing CPT and/or PE through the use of telemental health 
modalities; evidence-based psychotherapies for other mental health 
conditions may be provided on a limited basis as a secondary role;
    3. Applying advanced theories and techniques to a wide range of 
patients with PTSD;
    4. Providing professional consultation in areas related to 
evidence-based treatments for PTSD;
    5. Coordinating treatment planning and delivery of services that 
best meet the needs of patients diagnosed with PTSD and are based on 
scientific research on optimal treatment;
    6. Promoting communication/interactions between team members, 
patients, and their families to facilitate the treatment process;
    7. Training and supervision of clinical staff/trainees, as 
appropriate;
    8. Participation in program evaluation efforts in conjunction with 
Office of Mental Health Services, the medical center, and Office of 
Telehealth Services as appropriate;
    9. Other duties as assigned.
Qualifications:
     Knowledge of clinical research literature regarding 
treatment of PTSD.
     Previous experience providing direct clinical care to 
adults with PTSD is preferred.
     Previous experience providing evidence-based interventions 
for mental health problems is preferred.
     Trained to competency in CPT or PE, or is willing to 
complete competency-based training in one or both of these therapies.
     Ability to deliver CPT or PE through telemental health 
modalities is preferred.
     Independently licensed to provide the required clinical 
services or will become independently licensed within two years of 
hiring and will be supervised by licensed VA staff in the interim.
     Demonstrated ability to function successfully as a member 
of an interprofessional team and to independently carry out clinical 
responsibilities is preferred; willingness to be mentored in acquiring 
this capacity is acceptable.

    Knowledge of common medical and mental health conditions associated 
with PTSD is preferred.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman Murray. Thank you very much.
    Dr. Schohn, I am glad that the department has recognized 
the inadequacy of the waiting times and how they are measured 
and has pledged to hold our network directors accountable for 
their performance on these metrics. But I wanted to ask you if 
you believe that facilities are gaming the system and not fully 
reporting wait times and wondered what you thought.
    Ms. Schohn. VHA does not condone gaming of any sort. I am 
not aware of particular facilities that are doing anything of 
the kind; and if I were, I would act immediately on finding 
that out.
    We are engaged in auditing to ensure, in fact, that that is 
not happening. It is a requirement of the directive published 
by VHA in terms of auditing this on a regular basis. But we are 
conducting a special audit of mental health practices to 
reinforce that it should not be happening.
    Chairman Murray. Why do you think there is a disconnect 
between what the VA providers are telling us and what VA is 
telling Congress?
    Ms. Schohn. I believe the disconnect is in some of what was 
mentioned by Dr. Washington is that patients are not having 
access to the evidence-based therapies in the way that we 
expect they should be.
    What we understood from the provider survey was that 
providers were saying that there is access to the system but 
not necessarily access to those specific therapies in the times 
that they should occur, and we are working on ensuring that 
that happens.
    We have recently put through a new information to the field 
and are working also through site visits and actually reaching 
out when we get evidence that that is happening to find ways to 
solve the issues that Dr. Washington presented here today.
    Chairman Murray. Dr. Zeitz, I wanted to ask you when you 
testified at a hearing before this Committee May 25, I asked 
you whether the VA had enough resources to meet OEF/OIF 
veterans needs for mental health care and you said the 
researchers were not the problem.
    In light of what you have learned since last May, 
especially from your own providers, do you stand by that 
statement from May?
    Ms. Zeiss. I believe that we have unprecedented resources 
and that we have gotten them out to the field, and we have 
hired an enormous number of staff; and at the time, I believe 
that they were adequate if used in the most effective ways 
possible.
    We continue to have an increasing number of mental health 
patients. We have looked at the fiscal year 2011 data and the 
numbers have again jumped from fiscal year 2010 and we are 
proactively predicting what kinds of increases there will be in 
fiscal year 2012, and we are working with the Office of Policy 
and Planning to ensure that those predictions are embedded into 
the actuary model that drives the budget predictions.
    So, I can say that we will be aggressively following all 
the data that we have available to ensure that we can make 
effective predictions at the policy level about what the level 
of funding and level of staffing is that would be essential, 
and we will be partnering very closely with Dr. Schohn's office 
who are responsible for ensuring that those resources are used 
most effectively in the field, are used specifically to deliver 
the kinds of care that we have developed.
    Chairman Murray. So, you still today do not believe it is 
resources that are the issue?
    Ms. Zeiss. I believe that we are at a juncture where we 
need absolutely to be looking at resources because of the 
greatly increased number of mental health patients that we are 
serving.
    And some of that is because of the very aggressive efforts 
we have made to outreach and to ensure that people are aware of 
the care that VA can provide.
    The more we succeed in getting that word across and serving 
an increasing number of veterans the more you are absolutely 
right that we have to look at what is the level of resources to 
keep, to be able to sustain the level of care that we believe 
is essential.
    Chairman Murray. You are looking at it. You are asking. We 
need to have this information up front now if we need more 
resources. I mean, you just look the story up there of the 
thousands of people coming home. The people are not getting 
served, the people who we are reaching out to.
    It just feels to me like this is something we should know 
now. We have been 10 years into this.
    Ms. Zeiss. We believe that people are receiving an enormous 
amount of service from VA, and we agree as Dr. Schohn has said 
that we need to focus in on some specific aspects of care 
particularly the evidence-based therapies, and we are working 
with Dr. Schohn, who will be developing a very specific 
staffing model so that we can identify what are the levels of 
staffing that are available at specific sites that and how does 
map on to care.
    Chairman Murray. Well, let me ask a specific question: Dr. 
Schohn, according to the mental health weight data provided to 
the Committee by the VA, veterans at Spokane VA in my home 
State wait an average of 21 days for an appointment with a 
psychiatrist with a maximum wait time for a psychiatrist being 
87 days.
    Now, I have been told that all of these psychiatrists at 
the VA in Spokane are booked solid for several months, and 
there are other places in the country that are far worse than 
that.
    You mentioned that the VA is working to fill those 
vacancies, but the hiring process is very slow. What can the 
department do now to make sure that we are shortening these 
wait times?
    Ms. Schohn. In fact, there are efforts already underway in 
Spokane to improve the hiring. There, in fact, the waiting time 
has decreased. There is a shortage and there is variability in 
our system in terms of ability, for example, to hire 
psychiatrists in Spokane.
    One of the efforts that is being made is to use 
telepsychiatry, essentially to provide service from a site 
where there is a greater ability to recruit psychiatrists and 
to use their services at the site where they are at and to then 
be able to provide services to Spokane, for example.
    The Chief Medical Officer in Spokane has worked to ensure 
that coverage can come from other facilities within VISN 20 to 
ensure that the needs of the veterans in Spokane are met.
    Those are the kinds of things that we are working on as we 
come across evidence that, in fact, there are shortages in some 
areas. We know that in some other areas there are not shortages 
and that there may be some surplus that can be used at those 
sites.
    Chairman Murray. OK. Well, let me ask you another question. 
There was a provision about using community providers for 
mental health services in the caregivers omnibus bill that was 
passed by Congress earlier this year.
    It included peer-to-peer services, and we heard from our 
first panel about how important access to care and peer- to-
peer services are. I am told that the department is making very 
little progress on implementing that.
    Can you tell me what is holding up that?
    Ms. Schohn. We have made some progress. I am going to ask 
Dr. Kemp to talk specifically to that.
    Ms. Kemp. As you are aware, most of our peer-to-peer 
services or a lot of our peer-to-peer services I should say are 
provided by Vet Centers, which is an exceptional program that 
you are all very familiar with and we endorse and support.
    We have grown the number of Vet Centers. By the end of this 
year we will have 300 Vet Centers across the country open and 
working in addition to the 70 mobile Vet Centers that will be 
up and traveling across the country.
    So, I think we have made huge strides in providing those 
services to combat veterans and their families across the 
country.
    We also have a contract which has been let out and is in 
the process of being filled to provide training to train more 
peer-type support counselors. We are looking forward to that 
being completed, and we will get those people up and going as 
soon as we are able to get them on board.
    We agree with the intent of that legislation for lots of 
good reasons. We will continue to implement those services.
    Chairman Murray. OK. Well, this Committee will be following 
that very closely. And before I turn it over to Senator Burr, I 
just want to say I am really disturbed by the disconnect 
between the provider data and your testimony on the wait-time 
issue, and I am going to be asking the Inspector General for a 
review of that issue.
    I assume, Senator Burr, you will join me in that, and I 
would like all of your commitment to work with them to make 
sure we get the data.
    Ms. Kemp. Absolutely.
    Chairman Murray. Senator Burr.
    Senator Burr. Thank you, Madam Chairman.
    Dr. Schohn, how is it that that Give an Hour can identify 
the need for flexibility in the delivery of mental health 
services but the VA cannot?
    Ms. Schohn. I think we agree with Give an Hour that we do 
need to have flexible mental health services. VHA in its 
uniform services package has had the policy that off-hours is 
required at all medical centers and very large CBOCs since 
2008.
    What we understand from the survey is that off-hours have 
not always been available at the smaller Community-Based 
Outpatient Clinics. The policy group that Dr. Petzel has just 
put together is addressing those issues, and I would ask Dr. 
Zeiss to speak specifically to that.
    Ms. Zeiss. Well, and let me just check on the question 
because you talked about flexibility, and there are many 
aspects of flexibility.
    Senator Burr. I will give you credit for having one. How 
about that? But I have yet to see one yet.
    Ms. Zeiss. I believe, as Dr. Schohn has been saying, we do 
have flexibility in hours of service. What we have discovered 
is, in looking at the data, is that the initial requirement was 
for evening clinic, one evening clinic at least a week and 
others as needed.
    What we are finding is that the data suggests that what 
works much better for veterans is early morning hours and 
weekend hours. So, the policy group is looking very carefully 
at that in terms of changing and creating even more flexibility 
than the original after-hours policy.
    The uniform mental health services handbook that Dr. Schohn 
referenced also has an incredible array of flexible programs 
and defines a very broad range and flexible range of mental 
health services that can be provided.
    Senator Burr. Let me stop you there, if I can. Let me just 
say I have a tremendous amount of respect for all of you. I 
mirror what you have heard from other colleagues. I thank all 
the VA employees for what they do.
    But the fact that you have got something written in a book 
or you have put out a guideline and believe that you can still 
come in front of this Committee and say, we have got it, it is 
written, it is right there.
    What we hear time and time again, and I heard from Mr. 
Roberts in his testimony, there is no evening option in areas. 
It does not exist.
    Whether your data shows that is preferred to be in the 
morning or the afternoon, in his particular case your guideline 
says the evening, and he testified it does not exist.
    So, I hope you understand our frustration and, Dr. Schohn, 
I am going to ask you to provide for the Committee a detailed 
audit of how the $5.7 billion has been spent; and I am not 
talking about breaking it down into 403 million categories. I 
am talking about for the Committee a detailed description of 
how we spent that $5.7 billion in additional mental health 
money.
Response to Request Arising During the Hearing by Hon. Richard Burr to 
 Mary Schohn, Ph.D., Director, Mental Health Operations, U.S. Veterans 
                         Health Administration

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Now, let me just ask you. Is Dr. Washington is correct when 
she said a majority of the patients seen in the 14-day window 
are there for the purposes of information gathering, not 
necessarily treatment, and many are not seen by the health care 
professional, they are seen by staffer there to collect data.
    Ms. Schohn. That is not how the policy is written, and if 
that is happening----
    Senator Burr. Then let me ask it again. Is she right or is 
she wrong?
    Ms. Schohn. I do not know about Wilmington I will admit. 
That is something I would certainly want to follow up on 
because that is not the expectation of how services are to be 
delivered.
    Senator Burr. Let me read you some comments that have been 
made today, Dr. Schohn, and you just tell me whether these are 
acceptable.
    Veterans have little access to follow-up care.
    Ms. Schohn. That is not acceptable.
    Senator Burr. VA focuses on medication management.
    Ms. Schohn. That is not acceptable, and we have a huge 
policy and training program to ensure, in fact, that veterans 
have access to evidence-based psychotherapy.
    Senator Burr. Cannot fill appointments for the prescribed 
amount of time.
    Ms. Schohn. That I am not totally clear what that means.
    Senator Burr. I would take for granted that an attending 
had said that somebody with PTSD needs to have a frequency of 
consults, a frequency of treatment and it should extend for 
``X'' amount of time.
    Would you find it unacceptable if, in fact, the system was 
not providing what the health care professional prescribed to 
have?
    Ms. Schohn. Absolutely. We do have a system set up in place 
to actually monitor if, in fact, this is not happening. We are 
concerned by reports that it is not happening in places. We 
have many evidences of places where it is happening. But as we 
hear these reports, we are as concerned as you are and have 
developed a plan to go out and visit sites to ensure that these 
things are happening and to make corrections when they are not.
    Senator Burr. Inability to get appointments.
    Ms. Schohn. Same thing. The VA is available to veterans. We 
want to assure that any veteran needing mental health care has 
access in the timeliness standards that we think are important.
    Senator Burr. Mental health treatment is trumped by new 
entries into the VA system.
    Ms. Schohn. Again, not acceptable.
    Senator Burr. These are all issues that exist with the 
current mental health plan at VA, and I would only say to you 
that the one difference between what I heard from Give an Hour 
or any group that has been in that has focused on mental health 
treatment for our veterans and where the VA is, and I hope you 
will not take this the wrong way, is they are focused on 
outcome and you are focused on process.
    As a policymaker, our commitment to our country's veterans 
are we are going to get you better, and we are sticking them in 
a system that they are the first one that loses confidence in 
it. We are sort of the last ones. We are still debating.
    I would tell you that maybe we need to look at how 
everybody else is looking at the mental health within the VA 
and ask ourselves, if so many people find in substandard, if so 
many people have difficulty navigating it, would it suggest to 
us that the plan that we have got is either not working or it 
is the wrong one?
    It is troubling to me that you can have a not-for-profit 
organization like Give an Hour or any other one that is out 
there that the VA is not aggressively reaching out to try to 
utilize in some fashion to leverage our ability to deliver 
care.
    Any comment on that?
    Ms. Schohn. I would just like to clarify. VA is recognized 
as the largest integrated mental health provider in the country 
and quite possibly the world.
    The GAO and the RAND study have recently shown that it is 
leading the private sector and other providers of health 
services in terms of mental health. We are concerned about the 
variability, and we are concerned about the stories that we 
hear where we are not living up to our aspirations.
    Senator Burr. So, are we just sort of plucking out of the 
United States just the people that fall through the cracks, and 
everybody else makes it?
    Ms. Schohn. I cannot address that. I can say that we do 
have evidence of patients being seen in a timely fashion, of 
getting access to the care they require, and again, I am 
personally concerned when I hear these stories about that not 
happening.
    Senator Burr. I remember last time, and I cannot remember 
whether it happened, Chairman, in the last hearing but we had 
one that dealt with suicides, and the VA highlighted the fact 
that their 24-hour hotline calls had increased and how 
successful that was.
    And my comment was that that is a demonstration that our 
mental health treatment does not work in the fact that more 
people are considering suicide and calling the 24-hour hotline.
    We look at things somewhat differently. And maybe as you 
provide for us that detailed breakdown of how we have spent 
this money, maybe the Committee can glean some information; and 
through our collective efforts, we can find how to tweak the 
plan or put the parameters in place that assure us that we are 
making progress.
    But I think what, and I do not want to speak for the 
Chairman, but I think what she and I are saying is these 
hearings are not going to be 6 months apart from now on.
    They are going to be much closer together. We are going to 
get to the granular level of understanding of exactly the 
execution, and I am willing to do it facility by facility by 
facility.
    So, the Chairman may not ask you about Washington next 
time, and I am not going to ask you about North Carolina. It 
will not be Spokane, and it will not be Fayetteville. But maybe 
Mars Hill and I do not expect you to know where Mars Hill, is 
but I would expect that our confidence that we deliver care in 
a town of 3,000 is as confident as we deliver care in a town of 
3 million.
    And if we are not there yet, which I do not think we are, 
then we have a long way to go. I thank you.
    Chairman Murray. Thank you very much, Senator Burr.
    I am now going to turn it over to Senator Rockefeller. He 
has chaired the Committee before, so I am going to turn the 
gavel over to him as well.
    I want the VA to know that I will be submitting questions 
for the record; and, as Senator Burr said, this is not a one-
time shot hearing. This is something we both care deeply about. 
We are going to continue to pursue it. Again, we have many, 
many soldiers coming home, many who need to be accessing the 
system. This is a number 1 priority for all of us.
    Senator Rockefeller.
    Senator Rockefeller. I want the gavel.
    [Laughter.]
    Chairman Murray. I knew you would.
    [Laughter.]
    Senator Rockefeller [presiding]. Thank you, Chairman 
Murray.

           STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 
                U.S. SENATOR FROM WEST VIRGINIA

    It should be easy to tell the truth. It should be easy to 
say that you are not satisfying the needs of veterans, that the 
policy says that you should be or that you are but, in fact, 
that you are not and you know it.
    The way this should work is that you should be able to tell 
us that it is not working, that the policy says that, but, in 
fact, it is not working.
    Why do I say that? For two reasons. One, as your testimony, 
the three of you have been vetted by OMB.
    Ms. Zeiss. Yes.
    Senator Rockefeller. Yes. I am pretty sure the answer is 
yes.
    But you understand what that means to us. Why should we 
have a gulf between us? We do not for 1 minute doubt, in fact, 
we rejoice in the improvements that the VA system is making, 
the points about it being better than the public system and the 
private system and all of that I think it is true.
    But it does not get all the veterans taken care of which is 
the only thing that matters. That you are better by a factor of 
seven than Johns Hopkins, it still does not matter if you are 
not taking care of the needs.
    Now, there are things to be said in your defense. I mean, 
the requests for mental health from 2007 to last year have gone 
up by a factor of, I do not know, it is 35 requests in 2006 to 
139,000 among just recent veterans, and that is just the 
veterans of the two wars.
    So, then somebody asked you are people dropping between the 
cracks and then you cannot because at OMB, because you 
represent the Obama Administration. I happen to think that 
Shinseki is the best VA Secretary we have ever had, and I have 
been on this Committee for 26 years, 27 years.
    But things go wrong, things still go wrong. You cannot grow 
fast enough. You have got budget problems. You are out hiring 
mental health counselors like crazy, thousands of them, got 150 
VA centers across the country, maybe more, all kinds of Vet 
Centers, CBOCs and all the rest of it.
    And you do not make me unhappy if you say, we are not doing 
what we should be doing, we are failing some people. The policy 
says we are not. OMB says we cannot say anything to you.
    And at some point, see, that makes all of the system kind 
of a farce. I believe in you. I trust you. What I want to do is 
to be able to trust your words, what you want to be able to do 
is believe in your words when you answer our questions.
    I do not think you can at this point because VA is huge. 
Twelve million people were for it or whatever it is and so 
there is a chain of command; and if somebody gets out of the 
chain of command, there is all heck to pay.
    Number 1, that is not the way General Shinseki looks at it. 
It may be the way your supervisors look at it or the way your 
departmental bosses look at it.
    But we cannot have hearings, we cannot make progress at the 
rate that we should, we cannot praise you to the extent that we 
should, we cannot criticize you accurately to the extent that 
we ought to and which you want us to do because you have a 
proscribed statement that you give and a proscribed policy that 
you have to stick with.
    And that is just not conversation. That is not progress. 
See, I trust you more when you tell me that we are not serving 
a whole block of, forget about detox for the moment, I am just 
talking about, you know, women who are uncomfortable sitting in 
waiting rooms with men because they are doing PTSD or whatever 
it is or sexual trauma problems, and they are uncomfortable 
sitting in a room with men.
    A very logical answer that you could give me, say, you know 
that is true and the reason for that is that we do not have 
enough rooms in which to be able to split them up so that they 
can have their privacy.
    You would say that hopefully only if it were true but my 
guess is it probably is true because the rush to attention 
under Chairman Murray and Ranking Member Burr about the general 
problems of veterans has exploded in this Committee in the last 
five, six, seven, eight, 9 years. It has exploded. We want to 
help.
    You know, one of the reasons that I am sort of glad that 
the Super Committee did not succeed is because you all are 
protected in the sequester process, and you were not in their 
process.
    Now, I am not saying they would have done anything to you. 
I just do not know. But I just want to hear the truth. 
Otherwise, we are not having a hearing. We are having a you-
are-holding-up-your-end-of-the-bargain. We are trying to be 
tough questioners. You are trying to be tough answers. And 
nothing is substantially accomplished from it.
    That is a deep, deep frustration. It is not just with you. 
In the Commerce Committee, in the Finance Committee and the 
Intelligence Committee, Senator Burr and I are on that, it is 
the same thing. It is the same thing.
    It tends to be less on Intelligence because that is in a 
room where nobody can listen, including any of the bosses.
    And so, people tend to tell more truth there but we need to 
have that, we need to have that. I want to trust you. I do 
trust you. But it pains me when I feel you cannot answer the 
way you really want to answer because you are not in the VA 
because of the money. You are not in the VA because it is a 
hobby. You are in it because you want to do good, and 
therefore, anything that stands in your way about doing good, 
you should rebel against.
    Now, that is a naive statement. Everybody in the VA turns 
into a whistle blower. But darn it, I mean, if you look at the 
coal mines in West Virginia, you cannot whistle blow. So, 
people died.
    If you whistle blow, you get fired, not by all companies 
but by a lot of them. You get fired. You get paid about $61,000 
a year to be a coal miner. Well, that is about five times more 
than you can make it anything else within 100-mile radius of 
where you probably live.
    So, you do not take on the system; and if nobody takes on 
the system, then, you know, you do not see progress.
    I got around that and, Senator Burr, you might be 
interested in this, and I will stop talking eventually. 
[Laughter.]
    But look at what I had to do to get around it. I knew I was 
not going to get any legislation on mine safety. Let us just 
make that into women's PTSD or mental health. I knew I was not 
going to be able to get legislation.
    So, I went to the Chairman of the Securities and Exchange 
Commission, Mary Schapiro, and I said what would happen if you 
put up on your Web site quarterly reports on the investment 
enticements, your profits and losses and earnings ratio and all 
the kind of financial information because you use that because 
you are trying to get people to invest in you.
    And in a very easy maneuver, she said, well, from now on, 
as I asked her to and she said she would do it, you also have 
to publish all of your violations of mine safety. That is what 
is happening.
    Coal mines do not like it. MSHA does not like it because 
sometimes MSHA is not doing the job themselves. So, the coal 
companies can say well, it is MSHA's fault, and maybe it is 
MSHA's fault. I do not care so long as the truth comes out; and 
in this case, so long as investors can make a wise decision 
about whether to invest in that company or not.
    We are going to do the same thing on another major problem 
having to do with cyber security-going around the legislative 
process because we cannot get it done.
    So, we are having a horrible time trying to be helpful to 
you. Do not make it harder for us to be helpful to you by not 
telling us how we can be. I am much more interested in what is 
not working than I am in what is working because I assume that 
you are all doing a much better job than was true before just 
because the whole quality of the VA has risen, you know, 
exponentially, impressively, amazingly, and on all fronts and 
with all kinds of new pressures on them because of people 
coming back from Iraq and Afghanistan and the rest of it and 
all the women's problems, mental health problems, suicide 
problems, everything all at once, and then there is no money.
    Nothing wrong with your telling me that. We are not doing 
what we could because that I will believe, and then that makes 
me, in turn, want to help you.
    But if you say our policy will not allow that, which is the 
same thing as saying it will not allow it but it is happening, 
if you tell me that the policy will not allow that but it is 
happening, then I want to help you even more because you are 
being fair and square with me.
    That is all I want to say.
          Prepared Statement of Hon. John D. Rockefeller IV, 
                    U.S. Senator from West Virginia
    I believe we must be diligent and honest about the challenges 
facing VA in caring for the invisible wounds of war for our veterans, 
particularly our veterans returning from Iraq and Afghanistan. I 
believe the VA survey and this hearing are a tremendous example of the 
strong leadership of Chairman Murray and a commitment to find real 
solutions.
    I also believe that VA is working hard. Thousands of new mental 
health professionals have been hired in recent years. New, innovative 
programs have been launched, and that is promising. Dedicated VA staff 
at Medical Centers and Vet Centers in West Virginia and across our 
country wants to do their best to help our veterans.
    Today's hearing is an important step. It is an effort to get to the 
real facts of how our veterans are served and I strongly support it. 
This Committee must have the real facts in order to make the necessary 
decisions to enhance the care promised to our veterans, and the quality 
of care they deserve.

    Senator Burr. Is the Chairman recognizing me?
    Senator Rockefeller. Of course, I do.
    Senator Burr. I thank my good friend. Just a couple of 
quick follow-ups if I can.
    Dr. Schohn, in oral testimony from the July 14, 2011, 
hearing, Deputy Undersecretary Schoenhard said he wanted to, 
``* * * personally follow up with Andrea Sawyer and Daniel 
Williams to learn more of their story and what we can learn.''
    Do you know if he followed up with them personally?
    Ms. Schohn. I do not. I did follow up with them personally.
    Senator Burr. Did he ask you to follow up with them?
    Ms. Schohn. He asked me to follow up with them personally.
    Senator Burr. What policy changes resulted from those 
conversations?
    Ms. Schohn. I do not believe policy changes have resulted 
from them. Again, I think the issue, from my perspective, is 
not about the policy. I think the policies are fine but I think 
to the point I am hearing is the implementation of the 
policies.
    So, how we are following up is to ensure that the policies 
are implemented as they are intended to be. And we are, in 
fact, working that.
    Senator Burr. Are you convinced today that we still have an 
implementation problem?
    Ms. Schohn. I am.
    Senator Burr. OK. At that same hearing, during an exchange 
with the Chairman on the reorganization of VHA's mental health 
office, Dr. Arana said the plan was to get out into the 
facility, ``* * * much the way the OIG does with on-the-ground 
visits.''
    Dr. Arana indicated he wanted to, ``* * * deploy this 
effort very strongly over the next 6 to 8 months'' and wanted 
to come back and highlight the progress.
    How many sites have been visited?
    Ms. Schohn. We have visited one formal site in terms of 
piloting the site-visit program. We have scheduled the 
additional site visits that we had intended for this year. 
After discussion with Dr. Petzel, we are speeding up our 
timeline in terms of doing the site visits to more facilities.
    Senator Burr. Am I reading something into what Dr. Arana 
said to us that I should not have, ``* * * deploy this effort 
very strongly over the next 6 to 8 months.''
    Is one site deploying strongly?
    Ms. Schohn. My understanding about Dr. Arana's comments was 
not specifically around the site visits. My office was started 
at the end of March and the plan----
    Senator Burr. Let me read you the quote again. And I quote, 
Dr. Arana said the plan was to get out in the facility, ``* * * 
much the way the OIG does with on-the-ground visits.''
    Ms. Schohn. And I think that is certainly intended. The 
timeline for making that happen, I do not believe he intended 
to say 6 to 8 months----
    Senator Burr. He said very, very strongly over the next 6 
to 8 months.
    Ms. Schohn. The 6 to 8 months I believe referred to the set 
of follow-up actions that we had intended to pursue of which 
the site visits was something that was----
    Senator Burr. Is it not important enough to do the site 
visits?
    Ms. Schohn. It is totally important to do the site visits.
    Senator Burr. Why would we have only done one?
    Ms. Schohn. It is important to do them correctly. As I 
mentioned, my office was started at the end the March, the 
beginning of April, with the intent to set up a system to 
ensure implementation of the uniformed services package. We 
have been developing the process----
    Senator Burr. So, it took us 9 months to set up the plan to 
determine how to gauge whether we were following the guidelines 
or not? I mean, you have got to put things in layman's terms. I 
think Senator Rockefeller just, I think, covered very 
eloquently that. Shoot us straight.
    Ms. Schohn. We have to set up the right process for doing 
it. We want to make sure that we are looking at the right 
things. We have set up a mental health information system so 
that we have data going out there that we can validate and 
ensure what is going on.
    We have been working with other parts of VA to ensure that 
we are doing site visits in a way that is reliable and 
believable. Of concern to us is that, in fact, and to address 
your concerns, is that we are able to give you information that 
we believe is valid. We think that is an issue, and we want to 
make sure that we are doing it the right way.
    Senator Burr. Senator Rockefeller has been on the Committee 
a lot longer than I. He has been around a lot longer than I 
have, come to think of it.
    Senator Rockefeller. Thank you.
    [Laughter.]
    Senator Burr. But since day one, the first hearing, the 
issue was raised--different administrations so this crosses all 
lines--the issue that was raised was they cannot get 
appointments.
    I mean, we can study the hell out of this but until we put 
a person on the phone that the job is whatever you do get this 
person an appointment. It might be, be courteous first, make 
sure they get an appointment, accommodate their schedule, ask 
them how many doctors they see at the VA facility, try to 
schedule all appointments on the same day, do not make 
transportation a reason that they could not come back and get 
follow-up.
    We still do not do that. It still does not happen. And the 
only thing I am pleading with you today is do not overanalyze 
this. This is not rocket science.
    The private-sector figures out how to schedule 
appointments, deliver care, help people get better every day, 
and in areas of the VA we do it extremely well.
    But it is typically one where they are inside the facility. 
We are not relying on than contacting us. They are in a room. 
They are not having to call for appointments. There is a floor 
nurse and physician that is in charge of them, and we do a 
pretty good job. We are rated the number 1 hospital in the 
world.
    But I would be willing to bet if we got rated on everything 
else we might be the largest but we are certainly not the best; 
and if you did one on customer satisfaction, I would be willing 
to bet we came in last.
    One last question. The July 14th hearing, you testified 
that VA was in the process of, I quote, developing a 
comprehensive monitoring system that looks at all the issues, 
implementing rates, combining the data into one place for all 
so that VA can write flag carriers or gaps that exist quickly 
based upon VA's available data. This package will be finished 
by year's end.
    We are a month away. Is it going to be finished?
    Ms. Schohn. Absolutely. In fact, we have already started 
deploying it, and we have been working with all of our VISNs in 
terms of looking at the data and developing plans where there 
are problems and issues. That is part of the whole site visit 
process and we are fully on board, ahead of schedule.
    Senator Burr. I hope you will put into your equation your 
answer to a lot of issues today. We have an implementation 
problem. I would hate 6 months from now to come back and to 
have your package out there identifying deficiencies, barriers, 
and the answer to be we have got an implementation problem.
    We are able to detect it but we have got an implementation. 
It is the right plan. It is just we have people who are 
implementing it wrong. That excuse is not going to work 
anymore.
    So, again I thank all three of you for your service to our 
country's veterans. I think every day the VA tries to fulfill 
what their core mission is.
    I do question, I will be very candid, I do question 
whether, when we think about the 24 hours ahead of us whether 
we see the human face of that veteran first. If we do not, then 
we are misguided, whether it is you or whether it is me from a 
policy standpoint.
    But I thank you for being here. I thank the Senator from 
West Virginia.
    Senator Rockefeller. And the thanks is very mutual.
    I think we have covered things here. I guess I will end 
with one of my least favorite words in the English language: 
something called metrics. A lot of people at the VA live by 
metrics, and you have got to. In other words, just as the 
question by Senator Burr, it is meant to be done in a month. 
When you said it is going to be done, I take you at your word.
    But metrics can also really mess things up because they can 
cause people to rush. They can cause people to overlook things 
or not think things through carefully enough. There is no way 
that I am going to win on the metrics issue. The VA is going to 
be ruled by metrics.
    Obviously, you cannot have a large organization without a 
real sense of control and you cannot have people going around 
saying all kinds of different things. Or can you? If it is in 
front of Congress, I think you can and I think you should.
    I use this OMB thing a lot. I am not picking on you. I use 
it a lot because I know darn well, and because I also know the 
people who are giving the testimony and I know they do not 
believe a word they are saying. But that is what they have to 
say because OMB changed their thing to make it, you know, 
comport.
    So, just take away the message that we enormously care 
about you. We enormously believe in you, that you are doing 
extraordinary work. You are accelerating faster than anybody 
except the new .com world, I guess, and they make a lot of 
money doing that and you do not.
    The truth will set us all free because it allows us to 
fight for you because we believe in everything that you are 
telling us and the fact that you cannot get people within the 
next 24 hours that the Senator was referring to.
    You have 55 people and in small place that needed attention 
in the next 24 hours and your doctor gets sick or you brought 
thousands of mental health professionals in.
    It is amazing to me. I do not know where you get them 
because I thought they were scarce everywhere, but I will 
believe you because I want to believe you.
    But allow us to asking the questions because that is the 
way we work together well. It is not your job to like us. 
Nobody else does so why should you. But it is our job to 
support you in your mission. That is our job, our only job.
    So, make it as easy as possible by always telling us the 
truth.
    Thank you. This hearing is adjourned.
    [Whereupon, at 12:20 p.m., the Committee was adjourned.]
                            A P P E N D I X

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       Prepared Statement of The American Psychiatric Association
    On behalf of the American Psychiatric Association (APA), a medical 
specialty organization which represents 36,000 psychiatric physicians 
nationwide, thank you for the opportunity to submit a statement to the 
Senate Veterans' Affairs Committee regarding veterans' access to 
timely, evidence-based mental health and substance use care. APA 
promotes the highest standards of care for our patients and their 
families, and to that end we strive for standards of excellence in the 
education and training of our psychiatrist workforce and excellence in 
psychiatric research.
    The APA vigorously advocates for immediate and seamless access to 
care for psychiatric and substance use disorders for America's 
veterans. We remain concerned that despite the concerted efforts of the 
Veterans' Administration (VA) and Department of Defense (DOD), stigma 
still shadows those who seek psychiatric care and discourages those who 
need care from seeking it. The unprecedented length and number of 
deployments of U.S. military personnel, as well as the nature of our 
current military engagements, have placed an enormous strain on those 
serving in all facets of the military as well as their families.
    We are encouraged by the significant progress which has been 
achieved by the VA in hiring mental health personnel, promulgating best 
practices and procedures to benchmark the timeliness and 
appropriateness of care and coordination of services. However, like 
many veterans advocacy organizations, the APA remains concerned about 
persistent reports of lengthy wait times for treatment appointments in 
some geographic areas, availability of psychiatric physicians and 
inconsistent implementation of evidence-based care. We applaud the 
Committee's oversight and accountability efforts which can assist the 
VA with policy implementation at the local level.
    The VA has undertaken extraordinary measures to overhaul its mental 
health system over the past ten years. The daunting task of hiring a 
sufficient number of mental health professionals including case 
managers, social workers, psychologists, and psychiatric physicians has 
been paramount. This task is further complicated by geographic scarcity 
of all physicians, including psychiatrists. Simply put, it takes time 
to train physicians and with a projected influx of 33,000 
servicemembers returning to the United States, time is of the essence.
    The APA encourages the VA to vigorously pursue training 
partnerships, loan forgiveness and telehealth services as opportunities 
which must be leveraged immediately. The VA and DOD could expand their 
current physician training programs to smaller, more rural hospitals 
with the assistance of the Center for Medicare and Medicaid Services' 
Graduate Medical Education (GME) program. Medical school loan 
forgiveness programs for psychiatrists who are in the early stages of 
their careers could draw more physicians into the rural areas served by 
the VA. A similar program has worked well under the auspices of the 
Indian Health Service. Telehealth consultations between a patient and 
his or her physician on psychiatric or substance use treatment issues 
are typically utilized when a patient is stable and recovering. 
Telehealth consultations could be encouraged between a provider in a 
rural area who would like to consult with a colleague or coordinate 
care with a case manager. These consults can improve patient care and 
outcomes.
    The American Psychiatric Association has offered extensive 
continuing medical education for the past nine years on PTSD, TBI and 
MST. A recent example, in May 2011, the APA partnered with VA staff and 
staff at the Tripler DOD facility to offer an entire ``track'' of 
educational courses in diagnosing PTSD, best treatment practices as 
well as training regarding the specific military cultures. This 
``track'' was offered to community-based psychiatrists who are not 
employed by the VA or DOD but instead might encounter military or 
former military members who seek are ``outside the system.'' The APA 
also offers web-based tools to its members to keep them informed of 
advances in treatment and research which benefit their patients.
    In addition, the APA is a partner of ``Give an Hour.'' This 
volunteer organization provides professional mental health and 
substance use disorder services through a network of professionals who 
volunteer their services for an hour a week to active and returning 
military, National Guard, veterans and their families. ``Give an Hour'' 
has been utilized as a portal for care for those who fear the stigma of 
seeking services within the VA or DOD structure. We encourage the VA's 
national leadership to pursue partnerships with ``Give an Hour'' 
especially in rural and underserved areas where lengthy waits between 
mental health treatment visits unfortunately remain.
    The APA would like to emphasize the importance of advocacy for 
returning military with psychiatric and substance use disorders. 
Families, in particular, need to be advocates for their loved ones. 
They need to make sure their family members has a comprehensive 
evaluation by a trained and qualified mental health professional and 
that they have access to necessary and appropriate ongoing treatment 
services. They should also ask lots of questions about any proposed 
diagnosis or treatment plan. To this end, the APA has jointly developed 
a Web site, www.Healthyminds.org to provide patients, families and 
physicians with as much information as possible about the evaluation 
and treatment of depression, PTSD and substance use disorders. Over a 
dozen major medical, family and patient advocacy organizations have 
already endorsed this collaborative effort.
    As physicians, researchers and family members, the APA has noted 
with increasing concern the increase in suicide attempts and completed 
suicides by veterans and those currently serving, and has advocated for 
direct action to address this major problem. Beginning in 2002, the 
suicide rate among soldiers rose significantly, reaching record levels 
in 2007 and again in 2008 despite the Army's major prevention and 
intervention efforts. In response, the Army and NIMH partnered to 
develop and implement ``STARRS'' (Study To Assess Risk and Resilience 
in Servicemembers) the largest study of suicide and mental health among 
military personnel ever undertaken. Many APA members are involved in 
the NIMH- Army study which will identify--as rapidly as possible--
modifiable risk and protective factors related to mental health and 
suicide. It also will support the Army's ongoing efforts to prevent 
suicide and improve soldiers' overall wellbeing. The length and scope 
of the study will provide vast amounts of data and allow investigators 
to focus on periods in a military career that are known to be high-risk 
for psychological problems. The information gathered throughout the 
study will help researchers identify not only potentially relevant risk 
factors but potential protective factors as well. Study investigators 
will move quickly to provide information that the Army can use 
immediately in its suicide prevention efforts and use to address 
psychological health issues.
    Finally, the APA lends its voice to the many others who continue to 
ask that the VA and DOD develop a seamless--or at least more 
transparent and collaborative approach--to mental health and substance 
use disorders. We know that many active military do not seek treatment 
early--when it is the most effective--because of stigma. We believe 
adjustments in leadership culture and command structure can change the 
perception that treatment is a career-ender.
    We at the APA are hopeful that the Senate Committee hearing on 
November 30 will help to reduce waiting times and access to appropriate 
care in some VISNs by shining a light on this pernicious issue. The APA 
encourages expanded support for research to promulgate evidence-based 
care, and enhance the ability of returning military and their families 
to advocate effectively for the treatment they need and deserve.

    Thank you for the opportunity to submit a statement for the record. 
We welcome any opportunity to assist the Committee with their critical 
endeavors on behalf of the Nation's military, veterans and their 
families.
      

                                  
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