[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
                         [H.A.S.C. No. 113-23] 

             UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS 

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             MARCH 21, 2013

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                               ----------

                         U.S. GOVERNMENT PRINTING OFFICE 

80-193 PDF                       WASHINGTON : 2013 



                   SUBCOMMITTEE ON MILITARY PERSONNEL

                  JOE WILSON, South Carolina, Chairman

WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
JOSEPH J. HECK, Nevada               ROBERT A. BRADY, Pennsylvania
AUSTIN SCOTT, Georgia                MADELEINE Z. BORDALLO, Guam
BRAD R. WENSTRUP, Ohio               DAVID LOEBSACK, Iowa
JACKIE WALORSKI, Indiana             NIKI TSONGAS, Massachusetts
CHRISTOPHER P. GIBSON, New York      CAROL SHEA-PORTER, New Hampshire
KRISTI L. NOEM, South Dakota
               Jeanette James, Professional Staff Member
                 Debra Wada, Professional Staff Member
                      Colin Bosse, Staff Assistant



                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2013

                                                                   Page

Hearing:

Thursday, March 21, 2013, Update on Military Suicide Prevention 
  Programs.......................................................     1

Appendix:

Thursday, March 21, 2013.........................................    33
                              ----------                              

                        THURSDAY, MARCH 21, 2013
             UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

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

                               WITNESSES

Bromberg, LTG Howard B., USA, Deputy Chief of Staff, G-1, U.S. 
  Army...........................................................     5
Garrick, Jacqueline, Acting Director, Defense Suicide Prevention 
  Office.........................................................     3
Hedelund, BGen Robert F., USMC, Director, Marine and Family 
  Programs, U.S. Marine Corps....................................     8
Jones, Lt Gen Darrell D., USAF, Deputy Chief of Staff for 
  Manpower and Personnel, U.S. Air Force.........................     7
Reed, Dr. Jerry, Ph.D., MSW, Vice President and Director, Center 
  for the Study and Prevention of Injury, Violence and Suicide, 
  Suicide Prevention Resource Center.............................     9
Van Buskirk, VADM Scott R., USN, Deputy Chief of Naval 
  Operations, Manpower, Personnel, Training, and Education, U.S. 
  Navy...........................................................     7

                                APPENDIX

Prepared Statements:

    Bromberg, LTG Howard B.......................................    55
    Davis, Hon. Susan A..........................................    38
    Garrick, Jacqueline..........................................    41
    Hedelund, BGen Robert F......................................    88
    Holt, Hon. Rush, a Representative from New Jersey............    39
    Jones, Lt Gen Darrell D......................................    79
    Reed, Dr. Jerry..............................................    98
    Van Buskirk, VADM Scott R....................................    67
    Wilson, Hon. Joe.............................................    37

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mrs. Davis...................................................   111
    Dr. Heck.....................................................   111
    Mrs. Noem....................................................   111
    Mr. Scott....................................................   111

Questions Submitted by Members Post Hearing:

    Ms. Shea-Porter..............................................   115
             UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                          Washington, DC, Thursday, March 21, 2013.
    The subcommittee met, pursuant to call, at 10:02 a.m., in 
room 2118, Rayburn House Office Building, Hon. Joe Wilson 
(chairman of the subcommittee) presiding.

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

    Mr. Wilson. I would like to welcome everyone to a meeting 
of the Military Personnel Subcommittee on the very important 
issue of military suicide prevention programs. Today the 
subcommittee meets to hear testimony on the efforts by the 
Department of Defense and the military services to prevent 
suicide by service members, military families, and civilian 
employees.
    I want to preface my statement by recognizing the 
tremendous work the Department of Defense and the service 
leadership has done to respond to the disturbing trend of 
suicide in our Armed Forces. This has not been an easy task and 
I thank you for your hard work.
    Suicide by members of our Armed Forces is particularly 
distressing to me because I consider military service an 
opportunity for a person to achieve their highest ability of 
fulfilling life. I also consider military service as a family, 
where we want the best for each other and we care about each 
other.
    I want service members to know they are talented people who 
are important and appreciated by the American people. They can 
overcome challenges.
    Suicide is a difficult topic to discuss. Last year 350 
service members took their own lives. Each one of them is a 
tragedy.
    Every one of them has a deeply personal story. We cannot 
rest until we have created every opportunity to change such an 
awful statistic.
    Suicide is a multifaceted phenomenon that is not unique to 
the military. Unfortunately, in addition to the hardships of 
military service, our service members are subject to the same 
pressures that challenge the rest of society. They are exposed 
to the same stressors that may lead to suicide by their 
civilian counterparts.
    I am deeply concerned about the uncertainty of 
sequestration and the coming budget challenges, how that will 
affect our service members and their families. Each of the 
military services in the Department of Defense has adopted 
strategies to reduce suicide by our troops.
    I would like to hear from our witnesses whether those 
strategies are working. How do you determine whether your 
programs incorporate the latest research and information on 
suicide prevention?
    I am also interested to know how Congress can further help 
and support your efforts. Lastly, I am interested in learning 
how our civilian experts are tackling the problems across the 
Nation and how private organizations, like Hidden Wounds of 
Columbia, are assisting and making a difference.
    With that, I want to welcome our witnesses and I look 
forward to your testimony.
    Before I introduce our panel, let me offer Congresswoman 
Susan Davis from San Diego an opportunity as ranking member to 
make her opening remarks
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 37.]

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

    Mrs. Davis. Thank you, Mr. Chairman.
    And welcome to all of you. Thank you so much for being here 
and sharing your expertise with us.
    I am pleased that the subcommittee is continuing its 
attention on suicides in the military. It has been nearly a 
year and a half since our last hearing, and during this time we 
have only seen increased numbers of service members taking 
their own lives. And behind each statistic we know there are 
families with shattered lives.
    While Congress has pushed forward a number of initiatives 
to support the Services and the Department of Defense in their 
efforts to develop policies and programs to reduce and prevent 
suicides in the force, we know that these numbers continue to 
grow.
    And yet, we also know that military service members are not 
alone. Over 38,000 individuals die by suicide every year.
    In 2010, suicide was the 10th leading cause of death in the 
United States and the fourth leading cause of death for adults 
between the ages of 18 and 65. While suicide among young 
individuals from 15 to 25 years continues to be a concern, the 
rate of suicide among older Americans is even higher.
    It is important that we share what we learn in the military 
and what is learned by others in our country if we are to be 
successful in addressing this societal issue. The establishment 
of the Department of Defense Task Force on the Prevention of 
Suicide by Members of the Armed Forces in the Duncan Hunter 
National Defense Authorization Act of Fiscal Year 2009 was a 
start, only a start.
    The task force made 76 recommendations, and I am interested 
in where the Department and the Services are in implementing 
these recommendations. Have we walked back all the cases that 
we are aware of and understanding the dynamics involved in all 
of those?
    Have we completed all of these recommendations? And if so, 
what metrics are being used to track success? What other 
efforts can be undertaken to address suicide in the military?
    I welcome all of you, our witnesses, and look forward to 
hearing from you about what has been done, what is being done, 
and where do we go from here in our efforts.
    Thank you, Mr. Chairman.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 38.]
    Mr. Wilson. Thank you, Mrs. Davis.
    I ask unanimous consent to include into the record a 
statement from Congressman Rush Holt of New Jersey.
    [The prepared statement of Mr. Holt can be found in the 
Appendix on page 39.]
    Mr. Wilson. Without objection, so ordered.
    We are joined today by an outstanding panel. Given the size 
of our panel and the desire to give each witness the 
opportunity to present his or her testimony and each member an 
opportunity to question the witnesses, I would respectfully 
remind the witnesses to summarize, to the greatest extent 
possible, the high points of your written testimony in 3 
minutes. I assure you that your written comments and statements 
will be made part of the record.
    Let me welcome our panel: Jacqueline Garrick, Acting 
Director, Defense Suicide Prevention Office; Lieutenant General 
Howard B. Bromberg, U.S. Army, Deputy Chief of Staff, G-1, U.S. 
Army; Vice Admiral Scott R. Van Buskirk, Director, Military 
Personnel, Plans and Policy, U.S. Navy; Lieutenant General 
Darrell D. Jones, Deputy Chief of Staff for Manpower and 
Personnel, U.S. Air Force; Brigadier General Robert F. 
Hedelund, Director, Marine and Family Programs, U.S. Marine 
Corps.
    And, General, thank you for being here today. This is your 
first appearance before this committee.
    Jerry Reed, Ph.D., Vice President and Director, Center for 
the Study and Prevention of Injury, Violence and Suicide, the 
Suicide Prevention Resource Center.
    We will proceed, beginning with Ms. Garrick, with opening 
statements, and it is imminent that we will be having votes. We 
will, at a prudent time, suspend and then return.
    And, Ms. Garrick.

   STATEMENT OF JACQUELINE GARRICK, ACTING DIRECTOR, DEFENSE 
                   SUICIDE PREVENTION OFFICE

    Ms. Garrick. Thank you, sir. Of concern for DOD [Department 
of Defense] is the rate of suicide among its forces, which rose 
in the past decade from 10.3 to 18.3 per 100,000.
    While we saw leveling in 2010 and 2011, the suicide rate 
for 2012 is expected to increase. DOD has closely tracked every 
suicide and attempt published in the DODSER [Department of 
Defense Suicide Event Report] since 2008.
    Therefore, we know the majority of our suicides were 
completed by Caucasian males below 29, enlisted, and high-
school educated. In some cases, relationship, legal or 
financial issues were present.
    Service members primarily used firearms and died at home. 
They did not communicate their intent, nor did they have known 
behavioral health histories. Less than half had deployed and 
few were involved in combat.
    Nonfatal suicide attempters were similar to those who died. 
However, those used primarily drugs and had at least one 
documented behavioral health disorder.
    A DOD task force report made 76 recommendations, with the 
first establishing the Defense Suicide Prevention Office to 
oversee all strategic development, implementation, 
standardization, and evaluation of DOD's suicide and resilience 
activities.
    NDAA 13 [National Defense Authorization Act for Fiscal Year 
2013] codified this office, which enhances its authority to 
implement the remainder of the legislation.
    A general officer steering committee established priority 
groups on data, stigma, lethal means, investigations, research, 
and evaluations, and the Department has made significant 
strides.
    The Defense Suicide Prevention Program Directive will set 
policy and assign responsibilities. DOD and V.A. [U.S. 
Department of Veterans Affairs], along with CDC [Centers for 
Disease Control and Prevention], created a suicide repository 
going back to 1979, so that now the DOD can affirm military 
service for the CDC, enhancing its ability to track Guard and 
Reserve and service member deaths overseas. This will enhance 
our research, longitudinal studies, and population health 
surveillance.
    DSPO [Defense Suicide Prevention Office] program evaluation 
approach tracks requirements, funding, and will unite 
efficiency measures with effectiveness for continuous process 
improvement reporting on shortfalls and duplications. We are 
evaluating training to develop core competencies for peer, 
command, clinical, and pastoral requirements.
    A critical aspect of preventing suicide is eliminating 
stigma that prevents service members or families from seeking 
help. DOD and V.A. are implementing President Obama's executive 
order and have a 12-month help-seeking ``Stand By Them'' 
campaign to encourage service members, veterans, and their 
families to contact the military crisis line by phone or 
online.
    We are expanding it in Europe and we are expanding it to 
Japan and Korea. It is at larger bases in Afghanistan, and 
where it is not available we have trained medics to initiate a 
peer support call line, similar to the Guard's Vets4Warriors 
program.
    Since service members often believe that seeking care is 
career-ending, training is key. In reality, denials and 
revocations involving mental health are less than 1 percent. 
Therefore, service members must understand that seeking help is 
a sign of strength and it does not jeopardize their clearances.
    Postvention has implications for prevention and reducing 
suicide contagion. A postvention guide was published for 
Reserve Component commanders, and we do a debriefing with TAPS 
[Tragedy Assistance Program for Survivors] on factors leading 
up to a service member's death, as reported by the families. 
And this dialogue builds a frame of reference that the DODSER 
alone does not provide.
    DOD is clarifying the NDAA 13, which authorizes mental 
health professionals and commanders to inquire about privately 
owned firearms, ammunition, and other weapons, and we have 
developed a family safety curriculum with Yellow Ribbon and the 
Uniformed Services University, and have distributed over 75,000 
gun locks.
    Since we know suicide and attempts are associated with 
prescriptions, DOD started a drug take-back study, allowing 
beneficiaries to return unused medications in compliance with 
DEA [Drug Enforcement Agency] rules.
    We continue to improve access to quality of care, with 
behavioral health providers being embedded at the unit level, 
and we will continue to evaluate that.
    DOD has developed a research plan and created teams to 
translate findings from studies into policies and practices. We 
have responded to the NDAA 12 by creating a community action 
team, partnering with nonprofits, universities, and others to 
assess practices and share lessons learned in family and peer 
support.
    We have expanded Partners in Care, a chaplain program in 
which faith-based organizations provide support to the Guard 
and Reserve. And we are exploring therapeutic sentencing 
techniques for military justice proceedings, as used in 
Veterans Treatment Courts.
    We have worked with the Action Alliance on the National 
Suicide Prevention Strategy, and we have partnered with the 
Department of Veterans Affairs on the Veterans Crisis Line, 
making sure that material is at preseparation counseling and is 
incorporated into transition briefings.
    So in closing, DOD fervently believes that every one life 
lost to suicide is one too many and prevention is everybody's 
responsibility. No stone is being left unturned, and this is a 
complex issue. The challenges are great. However, this fight 
will take enormous collective action and the implementation of 
proven and effective initiatives.
    DOD remains optimistic that it will find better solutions 
that will save more lives.
    Thank you, sir.
    [The prepared statement of Ms. Garrick can be found in the 
Appendix on page 41.]
    Mr. Wilson. And thank you, Ms. Garrick.
    And, General Bromberg, we will proceed. And the moment you 
get through, the buzzers indicate it is a vote, and so we will 
then suspend.

   STATEMENT OF LTG HOWARD B. BROMBERG, USA, DEPUTY CHIEF OF 
                     STAFF, G-1, U.S. ARMY

    General Bromberg. Yes, sir.
    General Wilson, Ranking Member Davis, distinguished members 
of the subcommittee, on behalf of our Army, thank you for 
continued strong support and demonstrated commitment to our 
soldiers, civilians, and families.
    As you know, our Nation has been at war for nearly 12 
years. Our soldiers, families, and civilians remain the 
strength of our Nation and have demonstrated unprecedented 
strength, performance, and resilience. And while physical 
injuries may be easier to see, there are many invisible wounds, 
such as depression, anxiety, post-traumatic stress, that also 
take a significant toll on our service members.
    Army leaders at all levels are committed to eliminating the 
negative stigma associated with seeking help; building 
physical, emotional, and psychological resilience in our 
soldiers and families and civilians; and ensuring that anyone 
who may be struggling gets the help he or she needs.
    Tragically, though, the Army has had 324 potential suicides 
during 2012, the highest annual total on record. Of those, 183 
deaths occurred within the Active Component and Reserve 
Component on Active Duty. The Reserve Component not on Active 
Duty, a total of 141, is the second highest on record.
    While most Army suicides continue to be among junior 
enlisted soldiers, the number of suicides by noncommissioned 
officers has increased each of the last 3 years. And almost 
one-third of our Army suicides have no deployment history and 
almost 18 percent have never been mobilized from the Reserve 
Component.
    By far, most Army suicides are in the 21- to 30-year-old 
age range, and that trend has held since 2010.
    And, as already mentioned, suicide is not solely a military 
problem. It is a rising national issue. And while it is 
difficult, we must use extreme caution when directly comparing 
the Army population with the general population.
    The 2010 national suicide rate is slightly higher than the 
Army Active Duty rate for 2010 and 2011. This very general 
comparison strongly supports the idea that suicidal behavior is 
an urgent national problem that affects all Americans across 
all dimensions of society, including those who have chosen to 
serve the Nation by serving in the Army.
    And we believe we have an historic opportunity to 
understand the lessons of the last 12 years and make our force 
even stronger. And the Army is now moving forward with our 
Ready and Resilient Campaign plan. This campaign is focused on 
making resilience a part of our culture and integrates and 
synchronizes multiple efforts and programs designed to improve 
the readiness and the strength and resilience of the Army team.
    I assure the members of this committee there is no greater 
priority for myself and other senior leaders of the United 
States Army than the safety and well-being of our soldiers.
    Suicide does remain a complex issue. It is a hard enemy, 
both for the Army and the Nation. The loss of any life is 
tragic, and it is imperative that we make a holistic approach 
to addressing this complex challenge.
    Mr. Chairman, Representative Davis, members of the 
committee, thank you and I look forward to your questions.
    [The prepared statement of General Bromberg can be found in 
the Appendix on page 55.]
    Mr. Wilson. General, thank you very much.
    And we will suspend and we will begin immediately with 
Admiral Van Buskirk.
    Thank you.
    [Recess.]
    Mr. Wilson. The Subcommittee on Military Personnel update 
on military suicide prevention programs shall resume.
    And, Vice Admiral Van Buskirk.

 STATEMENT OF VADM SCOTT R. VAN BUSKIRK, USN, DEPUTY CHIEF OF 
NAVAL OPERATIONS, MANPOWER, PERSONNEL, TRAINING, AND EDUCATION, 
                           U.S. NAVY

    Admiral Van Buskirk. Chairman Wilson, Ranking Member Davis, 
distinguished members of the committee, thank you for holding 
this hearing and affording the Navy the opportunity to provide 
an update on our suicide prevention and resiliency programs.
    Sadly, last year the Navy experienced 65 suicides in our 
Active and Reserve forces, an increase of six over the previous 
year. We have already suffered the loss of 13 shipmates this 
year.
    We clearly have more to do. Suicide prevention remains a 
top priority of the Navy leadership, and we remain committed to 
doing everything possible to save lives.
    We continue to vigilantly monitor the health of the force 
and investigate every suicide and all suicide-related behavior. 
We take what we learn from our investigations and adapt our 
education, programs, and prevention strategies.
    Operational Stress Control is a centerpiece of our 
strategy. It is the way we inculcate our new accessions, the 
way we deliver our training to the fleet and to our leaders. It 
is a method we use to increase the awareness and strengthen our 
resilience.
    Our Operational Stress Control Program provides an 
integrated structure of health promotion. It focuses on 
building resilience, addressing problems early, and promoting a 
healthy and supportive command climate. We continue to evaluate 
the response to this critical asset.
    Our Navy leaders recognize that they are the key to 
destigmatizing help-seeking behaviors. The unity of effort at 
the deckplates is where we strengthen our sailors.
    The deckplates is where we identify and mitigate the signs 
of stress and help our sailors cope and acquire necessary 
treatment for stress injuries. By teaching sailors better 
problem-solving skills and coping mechanism for stress we will 
make our force a much more resilient one. We will continue to 
do everything possible to support sailors so that they know 
their lives are valued and are truly worth living.
    Thank you, and I look forward to your questions.
    [The prepared statement of Admiral Van Buskirk can be found 
in the Appendix on page 67.]
    Mr. Wilson. Thank you very much, Admiral.
    General Jones.

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

    General Jones. Chairman Wilson, Congresswoman Davis, and 
distinguished members of the committee, thank you for allowing 
me to testify before you today on behalf of the Chief of Staff 
of the United States Air Force and all airmen stationed around 
the world.
    Air Force leaders at all levels are committed to suicide 
prevention through our wingman culture. Suicide prevention is 
not the purview of the personnel or the medical community. It 
belongs to commanders and leaders at all level. This is the 
overarching premise on which the Community Action Information 
Board was built and the cornerstone of the Air Force Suicide 
Prevention Program. Evidence shows this is the necessary 
framework for effective intervention across the force.
    Suicide prevention is a contact sport. It starts with 
leadership involvement, from the chief of staff to the newest 
first-line supervisor.
    In a wingman culture, airmen look out for their fellow 
airmen. We teach them to identify risk factors and warning 
signs for suicide and to take appropriate action once these 
indicators are identified.
    We realize we must continue to reevaluate and enhance our 
prevention efforts. And, with this in mind, we have taken on 
several initiatives across the Air Force.
    We require front-line supervisor training for our most at-
risk career fields and one-on-one training for this program. We 
are also increasing our mental health provider staff by 335 
people of additional trained professionals through fiscal year 
2016. And we are revising our Air Force Guide to Managing 
Suicidal Behavior, which has proven to be an effective clinical 
tool over the past 10 years.
    Within the Air Force, we have not experienced a link 
between suicides and deployment. The most significant risk 
factors for suicide in the Air Force continue to be problematic 
relationships, legal or administrative issues, work-related 
problems, or a combination of these factors.
    We continue to research how we can better identify those at 
risk to achieve the earliest possible intervention. One such 
study explores how social media impacts their relationships, 
help-seeking behavior, and emotional well-being. We are also 
conducting several research projects examining the role of life 
events and social stressors in the suicides of our military 
members.
    We continue to collaborate with the Defense Suicide 
Prevention Office, our sister services, and the Department of 
Veterans Affairs. Our goal is to leverage our internal 
resources, combining our experiences and best practices to 
improve suicide prevention across the force.
    We need every airman as we face the difficult challenges 
ahead. All leaders are responsible for promoting our wingman 
culture and removing any barriers to a healthy force.
    Thank you for your attention to our efforts and for your 
support in these endeavors to keep all of our airmen healthy 
and ready. I look forward to answering your questions.
    [The prepared statement of General Jones can be found in 
the Appendix on page 79.]
    Mr. Wilson. Thank you very much, General Jones.
    And we now proceed to General Hedelund

 STATEMENT OF BGEN ROBERT F. HEDELUND, USMC, DIRECTOR, MARINE 
             AND FAMILY PROGRAMS, U.S. MARINE CORPS

    General Hedelund. Chairman Wilson, Ranking Member Davis, 
and distinguished members of the committee, it is my privilege 
to appear before you today and I would like to thank you for 
allowing me to testify on behalf of Lieutenant General 
Milstead.
    Like our Commandant, we both are engaged and committed to 
tackling the complex problem of suicide amongst our marines. It 
is an all-hands effort to us.
    As our Commandant has said, one suicide is one too many. 
Each suicide has far-reaching impact on families, friends, and 
fellow marines.
    Regardless of the total number, every single suicide is a 
profound tragedy. Whether we have one or many, we will expend 
whatever effort is required to gain ground and get ahead of 
this problem.
    As we all know, discovering, and ultimately understanding, 
what leads one to suicide is elusive. It is very difficult to 
identify one trend or factor as a key to unlocking the secret 
to suicide for our population.
    However, through our data, tracking, and research, we have 
found that the primary stressors and risk factors associated 
with marine suicides and attempts are legal and disciplinary 
problems, relationship problems, behavioral health diagnoses, 
financial problems, and substance abuse, or a combination 
thereof.
    Regardless, we are committed to exploring every potential 
solution, using every resource we have available, and making 
the right investments toward saving marine lives. We deeply 
believe that preventing suicide requires engaged leaders who 
are alert to those at risk and take action to help marines 
before they reach crisis.
    We take care of our own. Thus, we are committed to breaking 
the stigma that may still exist in pockets around our Corps for 
those who seek help. We never leave a marine behind on the 
battlefield and we won't leave a marine behind at home.
    We thank you for bringing attention to this national 
problem, and I look forward to your questions.
    Thank you.
    [The prepared statement of General Hedelund can be found in 
the Appendix on page 88.]
    Mr. Wilson. Thank you, General Hedelund.
    And we now will conclude testimony with Dr. Jerry Reed

  STATEMENT OF DR. JERRY REED, PH.D., MSW, VICE PRESIDENT AND 
   DIRECTOR, CENTER FOR THE STUDY AND PREVENTION OF INJURY, 
    VIOLENCE AND SUICIDE, SUICIDE PREVENTION RESOURCE CENTER

    Mr. Reed. Good morning, Chairman Wilson, Ranking Member 
Davis, and members of the subcommittee.
    My name is Jerry Reed and I serve as the director of the 
national Suicide Prevention Resource Center and as co-director 
of the Injury Control Research Center for Suicide Prevention.
    Suicide is not just a challenge for the defense or veteran 
communities. It is an American challenge that calls us all to 
action. Every suicide is a tragedy.
    In the United States, suicide is the 10th leading cause of 
death, claiming more than 38,000 lives in 2010. By comparison, 
homicide was the 16th leading cause of death, claiming more 
than 16,000 lives, or fewer than half the deaths than by 
suicide.
    There is no single cause for suicide, no single solution, 
and no single agency, department, or person can fight this 
battle alone. We all have a role to play.
    While suicide touches all ages across the lifespan, in the 
general population it is the third leading cause of death for 
those 15 to 24 years old and the second leading cause of death 
for those 25 to 34 years old. Suicide rates generally increase 
with age.
    A few similarities between the military and the general 
population are: more men die by suicide than women, firearms 
are used in both populations and the outcome is often lethal, 
and substance use is often a factor in both attempts and 
completions.
    Intuitively, we would expect the military to have lower 
rates because service members are screened for mental illness 
and drug abuse on entry into Active Duty, they are healthier 
than the general population, they are fully employed and fully 
insured, they are routinely screened for drug use, and they 
have access to mental health care. Yet, rates in the military 
have been rising over the past 10 years and this is cause for 
concern.
    What we don't know is why rates are rising and what can be 
done to reverse this trend. We need to more fully understand 
the role of combat, deployment, and exposure to traumatic 
events on suicide risk. We also need to explore why rates are 
higher among junior enlisted personnel, some of whom have not 
been exposed to combat, and to better understand the process of 
help-seeking in our military.
    From what we know nationally, some of what has been shown 
to yield positive results include: following a comprehensive 
approach, combining several initiatives that target different 
behaviors, populations and settings. Examples of this that have 
been or are being pursued in DOD are the Air Force Suicide 
Prevention Program or the No Preventable Soldier Deaths 
Campaign at Fort Bliss.
    We know that no one program or intervention by itself will 
suffice. We need to ensure a cohesive approach is taken.
    The National Registry for Evidence-Based Programs and the 
Best Practices Registry include over 100 programs, materials, 
and practices that science and experience show can prevent 
suicidal behaviors and reduce risk.
    Following a public health approach, we need to look at the 
data, develop a comprehensive strategy, implement 
interventions, measure their effects, and evaluate outcomes.
    In my closing comments, I would like to offer the 
subcommittee a few recommendations to consider as we move 
forward: Follow a battle plan that is comprehensive and 
incorporates both public health and mental health perspectives. 
We will not simply treat ourselves out of this challenge.
    Our current battle plan is the recently released National 
Strategy for Suicide Prevention. It is a comprehensive document 
and guides our national effort.
    We also should take steps to successfully integrate DOD and 
the V.A. activities where possible, and efforts with those 
going on with the Action Alliance for Suicide Prevention, 
chaired by former Senator Gordon Smith and Secretary of the 
Army John McHugh.
    This public-private partnership, launched in 2010 by 
Secretaries Gates and Sebelius, holds great promise for suicide 
prevention. The alliance has set a goal to save 20,000 lives 
over 5 years, and we are serious about advancing steps that 
will move us in this direction.
    We should explore ways to ensure that those at risk for 
suicide do not have access to lethal means, ensure seamless 
care for those transitioning from Active service to veteran 
status and from Active service to inactive Guard or Reserve 
status, and ensure service members know how and where to 
receive help. And we should also build upon success stories and 
implement, evaluate, and most importantly, scale up when we see 
initiatives that are making a difference.
    When we implement a program that works, we need to ensure 
it is sustained over time. And we need to think from both an 
individual perspective, focused on the service member in need, 
and from a systems perspective, ensuring that every door a 
service member enters is the right door and that there is 
continuity in the care provided between systems.
    Finally, we need to change the way we talk about suicide by 
including stories of hope and resilience through public 
awareness campaigns, such as DOD's Real Warriors and V.A.'s 
Make the Connection.
    It is important to remember that suicide prevention is a 
relatively new field of study. And as we have observed from 
working on other public health issues, the effects of 
prevention require us to be patient, deliberate, and most 
importantly, to stay the course.
    Thank you for the opportunity to join you this morning. We 
need to approach this battle with the collective attitude of 
one team with one fight. It is important to remember that our 
military comes from the general community and will someday 
return to the general community.
    The more we can do together, the better for those we wish 
to serve. By working together I am confident that we can and 
will save lives.
    Thank you.
    [The prepared statement of Dr. Reed can be found in the 
Appendix on page 98.]
    Mr. Wilson. Thank you very much, Dr. Reed.
    And we now will proceed to each member of the subcommittee 
asking questions for 5 minutes. The time will be determined by 
Jeanette James, our professional staff personnel. And she 
herself is a retired Army nurse, and she has been so helpful 
being a resource to this subcommittee and to the committee at 
large.
    As we begin, from Ms. Garrick and for our service personnel 
who are here, as a 31-year veteran of the Reserves and Guard 
myself, as the proud dad of three members of the Army National 
Guard, I really appreciate Guard service and Reserve service, 
and we have really relied on the Guard and Reserve as never 
before, successfully, with overseas operations. But when our 
Guard members return they don't have the 24/7 support of 
military facilities; equally, they have the stress of military, 
but also civilian stress.
    Beginning with Ms. Garrick, what programs are there that 
could and do apply to Guard members?
    Ms. Garrick. We have several programs that we are looking 
at with the Guard. The one I mentioned, the Partners in Care 
project, leverages the faith-based communities and is a 
chaplain program specifically, so that is very helpful in terms 
of providing some very specific boots on the ground.
    And then, of course, our Yellow Ribbon Reintegration 
Programs are very important, very vital to the pre-, during, 
and post-deployment phases of the Guard and Reserve 
deployments. We also have a postvention guide that we have 
worked on for Reserve component commanders, if there is--had 
been a death in their unit, that they have the tools and the 
techniques that they need to be able to respond to a suicide in 
the unit.
    We are doing a Safe at Home program, specifically, that 
would roll out under Yellow Ribbon. We have distributed about 
75,000 gun locks; most of those have been through the Guard. 
And I think our Vets4Warriors, the call center that utilizes a 
peer support model, has been very helpful.
    So those are some of the programs that I have seen that I 
think have been working really well with the Guard and Reserve.
    Mr. Wilson. Thank you.
    General Bromberg.
    General Bromberg. Yes, sir. All our programs in the Army, 
we are mirroring those at the--trying to mirror those at the 
State and local level through both the United States Army 
Reserve command and also through the National Guard. The 
increased capacity for behavioral health touch points and 
services available to our Guards, or it has already mentioned 
the Vet4Warriors peer lines is very good.
    Additionally, the United States Army Reserve has reached 
out to the employer network as well, to link up returning 
veterans with employers to solve that challenge, which I think 
is very key. Because we have seen, as I looked at eight recent 
suicides in the National Guard across the Nation were all 
linked--one of the causes was--we think was linked to 
unemployment. So how can we employ that employer network back?
    Additionally, Health Promotion & Risk Reduction Councils 
that we do on the Active side, we are mirroring those at the 
State and local level also with additional capacity, so they 
can look inside their units.
    And as you know, sir, the challenge of connecting to a 
guardsman who is not seen every day by a leadership or a chain 
of command is something we have asked the Guard and Reserve to 
get after as well.
    But, again, a complete mirroring of our programs.
    Mr. Wilson. Thank you.
    Admiral Van Buskirk.
    Admiral Van Buskirk. Yes, sir. In addition to all of our 
operational stress control programs, which are available to our 
reservists, we specifically have a Navy and Marine Force 
Reserve Psychological Health Outreach Program that specifically 
targets our Reserve Components, both in the Navy and the 
Marines.
    These are 55 specific individuals that we embed with our 
reservists and that are part of a team that have the behavioral 
health specialists with them to meet the needs of those 
personnel who may need to seek their professional help, and 
also for those people to be able to recognize where help is 
needed.
    In addition to that, we have our Returning Warriors 
Program, where our--all of our people who are returning--
mobilized who are returning back to the States from the 
deployment go through returning warrior workshops, where 
additionally we have health professionals embedded to help our 
people cope--not just our personnel, but their families as 
well, because it isn't just about the individuals, it is about 
the families being able to cope with the stress that our 
personnel have endured.
    Mr. Wilson. Thank you.
    And, General Jones.
    General Jones. Sir, I echo the challenges that we have with 
Guard and Reserve members as they come home and disperse back 
into the community. But we are trying to mirror many of the 
same programs we have found success with on the Active Duty 
side. The Community Action Information Board in the Guard and 
the Reserves followed suit, establishing a wing director of 
psychological health to help monitor these programs and just 
check on how our airmen are doing when they get back home.
    The Guard and Reserve, over the last few years in the--on 
the Guard side of the house since 2007, have averaged about 
16\1/2\ suicides a year. On the Reserve side it was somewhat 
less, about 7\1/2\. But it is positive to report that on the 
Reserve side, the numbers significantly dropped between 2011 
and 2012. On the Guard side, we saw a slight spike in 2012, but 
since 2013, so far this year we have had zero suicides in the 
Guard or the Reserve, which we are very excited about that. And 
we know that is just a temporary trend but we want to see how 
long we can keep that going to help our airmen.
    Mr. Wilson. Very encouraging.
    Concluding with General Hedelund
    General Hedelund. Yes, sir, thank you.
    Many of the relationships that have already been mentioned, 
the Marine Corps maintains with its Reserve community as well. 
And I think that in this current environment where we are 
deploying fewer Reserve units in full, but we continue to 
deploy Reserves as individuals; we have to ensure that we are 
making that transition to services for them in a more 
individual way.
    We, too, take advantage of the Yellow Ribbon Program, of 
course, and we have a Reserve Component that is investing in 
additional behavioral health specialists to put in key places 
around the country to address needs in the Reserve community.
    But every directive, MARADMIN [Marine Administrative 
Message], or initiative that goes forward, you will see at the 
bottom of it, ``this applies to the total force.'' So every 
requirement, all the training, education, et cetera, that 
Active Duty marines are required to fulfill, those commanders 
and marines that are in the Reserve force are also required to 
fulfill. So the same support that we give to our Active Duty we 
provide to our reservists, although delivery sometimes varies.
    Mr. Wilson. Well, thank you all. And as part of the 
military family I particularly want to thank you.
    And we now proceed to Congresswoman Susan Davis, the 
ranking member.
    Mrs. Davis. Thank you. Thank you, Mr. Chairman.
    We all know that there are a multitude of programs that 
have been in existence for some time and are relatively new. I 
wonder if you could talk more about how we are evaluating them.
    This is difficult because you can't necessarily evaluate a 
nonevent either. If in fact we have people who are not moving 
to suicide as a result of programs, which we hope is what 
exactly is happening, but we know in many cases it is not.
    Could you talk more about that and about the tools that are 
being used? And how are really knowing that they are evaluating 
what we need to know?
    Ms. Garrick. Yes, ma'am. As you recall, the task force 
report made some recommendations about doing some program 
evaluation, so that is one of the priority areas that we are 
concentrating on.
    So we have developed what we call a capacity analysis 
program evaluation approach, where we have taken actually the 
national strategy, the task force recommendations, the NDAA 12 
and 13. So we have outlined all the strategies and then we have 
looked at the programs and we have started to line up--and we 
work very closely with the Services; they are providing us with 
the data and the inputs on what their programs are, what they 
look like, so that we can start beginning to flesh out what are 
the programs, what strategic objective are they supporting, and 
then what are some of the costs that bounce up against those 
programs.
    And then when we look at the strategy we can see, so where 
are the gaps and overlaps?
    Mrs. Davis. Ms. Garrick, do you have a sense of a timeline, 
because we have been with this for a while? Obviously, you can 
gather data for a pretty long time and we don't--you don't 
always know what is going to happen a few years down the line.
    I am just wondering at what point we will have a comfort 
level that, in fact, there are some programs that actually 
aren't doing what we would like them to do and that we are able 
to shift some of those resources or, you know, activities that 
are different and that are making a difference.
    Ms. Garrick. Correct. So we started this process of just 
beginning the--pulling the inventory together about 4 or 5 
months ago, and we have made quite a bit of progress in what 
that inventory is, and we have developed sort of a rough order 
of magnitude on what have we covered down on. And I am hoping 
by the end of this fiscal year, all things considered, that we 
will actually be able to start reporting out on what we are 
seeing in terms of some gaps and overlaps.
    And we couple that with an effort we have with the 
Department of Veterans Affairs on developing a surveillance 
database. That is where we have taken the DOD data from DMDC 
[Defense Manpower Data Center], the V.A. data, and the CDC data 
and we put surveillance data together so we can start looking 
at the--what do we know about suicides, what are some of the 
risk factors, how can we do better longitudinal studies, how 
can we do better population health surveillance like Mr. Reed 
described.
    So marrying up some of those initiatives--again, it is a 
big-picture perspective.
    Mrs. Davis. Yes. It sounds like that in some ways we have 
identified some age groups, and also the fact that a firearm 
has been used in many of the cases. Is it clear that there are 
more firearms used in military or not?
    I thought, Dr. Reed, you suggested that that is not 
necessarily----
    Mr. Reed [continuing]. Population is about 50 percent of 
the completed suicides in the civilian population are completed 
with a firearm; in the military I think it is closer to 60 
percent.
    Mrs. Davis. Sixty percent, okay. I thought that I had heard 
that it was more than that.
    Would that be considered a metric, then? I mean, if we 
think about metrics and what we are looking for, what--how do 
you describe that for the general public?
    General Bromberg. Ma'am, if I could add----
    Mrs. Davis. General Bromberg.
    General Bromberg [continuing]. One of the things that we 
have studied with our Ready and Resilient Campaign plan, one of 
our major lines of effort is getting exactly at what you are 
talking about. So, we have already peeled out like 122 programs 
to start delving into them.
    One of the areas we are looking heavily into right now is 
does resiliency training or other events like--with our Strong 
Bonds campaigns and training that deals with reducing stressors 
in relationships--does that training have a direct effect? So 
can I take the Strong Bonds training and see if I have a 
decrease in domestic abuse or relationship issues. And we are 
starting to gather that data now over this course of the year.
    Additionally, what we are looking at with the resiliency 
training, ma'am, is for those soldiers that have had resiliency 
training, is there a reduce in gestures, attempts, and 
ideations. We have one unit we have already looked at, and over 
the last 18 months we are starting to see a turn.
    Mrs. Davis. May I just really quickly turn to General 
Hedelund for a second?
    At Pendleton I believe they are doing a program and they 
have had--actually, they haven't had the suicides in this 
particular unit. It is a pilot. Are you aware of that?
    General Hedelund. I would have to check and get you more 
information on that, ma'am.
    [The information referred to can be found in the Appendix 
on page 111.]
    Mrs. Davis. All right.
    General Hedelund. But I would like to echo that it is an 
area where we do need to get in and make sure that we have got 
the evidence-based approach going.
    Mrs. Davis. Thank you.
    General Hedelund. Thank you.
    Mr. Wilson. Thank you, Mrs. Davis.
    And we now proceed by order of appearance to Congressman 
Austin Scott, of Georgia.
    Mr. Scott. Thank you, Mr. Chairman.
    And thank you all for being here. It is certainly an issue 
that I think is a big concern not only to the members of the 
committee and the military, but to Americans in general.
    And I guess two quick questions I have, and then to get to 
one more specific.
    Ms. Garrick, are there any differences among the trends in 
the different branches? And is there a correlation behind the 
men and women who are attempting suicide and the V.A. backlog?
    Ms. Garrick. I think overall and in general what we see 
with--among all the Services are, the big driving forces are 
these young white males, junior enlisted, with relationship, 
financial, and legal issues. And I think that is why a lot of 
the programs I think speak to targeting that. That is why the 
resilience piece is so important is to help these young people 
adjust to the military.
    We have seen about the same amount with deployments versus 
nondeployments, combat, noncombat. So we know that there are 
other driving forces and factors that come into play.
    So we look at those populations, we look at the differences 
between some of those issues and try to target programs that 
are very specific. The Services have all blended programs that 
meet their unique needs as--in their unique environments, 
whether it is aboard a ship, or in theater in Afghanistan. We 
have seen some programs that we have done there, as well. I 
mean, I got to spend some time with the Combat Operational 
Stress Control Team in Kandahar and did some training with them 
very specific on peer support and crisis-line work.
    So we are trying to be very specific in what we are 
targeting. And then, in terms of the DES [Disability Evaluation 
System] issue, I don't know that we see a higher number of 
suicides among those going through a disability process, 
although we do know that pain and pain management can be a risk 
for those who have died by suicide. So there is some 
correlations there.
    Mr. Scott. Thank you for that. I would be interested, as 
time permits--I know you have a lot of programs--to know, 
essentially, what percentage of our men and women that do 
commit this are caught up in a V.A. backlog.
    [The information referred to can be found in the Appendix 
on page 111.]
    Ms. Garrick. Yes.
    Mr. Scott. Because that can lead to a tremendous amount of 
additional stress, as well as the financial conditions that 
caused the problems.
    And so, Dr. Reed, I think I will focus my next question to 
you, as the doctor. And one of the issues that is brought up 
again and again is the stigma that is affiliated with the need 
for assistance and even seeking treatment. That makes it hard 
for people sometimes to actually reach out to others. I know 
that we are training people on the warning signs and the 
seriousness of the issues, which, I think, is wonderful.
    And I guess my question is going to get back to the use of 
a specific therapy with regard to animals, whether it be dogs 
or some other type of domestic animal that the person is able 
to establish a friendship with.
    But I want to focus on that area, specifically on 
equestrian facilities. I have got one in my area, Hopes and 
Dreams Riding Facility. It is in Quitman.
    They have a lot of men and women in. They seem to have had 
a tremendous amount of success with regard to working with 
people.
    And my question is, is there ongoing research with regard 
to that particular therapy? What are the successes there? And 
how do we, if it is working--because it does appear to be 
working from what I see, and again, what I see--how do we get 
more people involved in those treatment methods that, quite 
honestly, are at very little cost to us?
    Mr. Reed. When we were asked by Congress to set up the 
National Suicide Prevention Resource Center back in 2002 one of 
the things we were asked to do specifically was to create a 
Best Practices Registry to begin to serve as a clearinghouse 
for that which is being done that works.
    Today, as I mentioned in my testimony, there are over 100 
programs that are listed in the registry. What we need to see 
happen--I have been to some of the equestrian programs myself; 
I was out in a tribal community and saw just the benefits of 
that program for people who might have a difficult time 
connecting in other ways.
    And I think what we have to accept with suicide prevention 
is,as I mentioned, it is a relatively new field--there is not 
one solution. It is not necessarily a therapy session in a 
therapist's office, but it could be an alternative therapy. It 
could be approaching a connectedness issue through animals or 
through other kinds of ways to engage a person.
    Because part of the challenge is people who struggle with 
thoughts of suicide don't feel connected to the larger 
community. And if we can enhance that connectedness through 
programs such as you have mentioned, and then encourage the 
program developer to submit that program to the Best Practices 
Registry for review and hopeful inclusion, we then make it a 
whole lot more able to be disseminated to the Nation at large 
to be able to replicate that program if it has got evidence 
behind it that shows effectiveness.
    Mr. Scott. Well, thank you for that answer, Dr. Reed. And I 
guess the one thing that I would, you know--the review process 
and the other things, I think, if we could expedite them I 
think that would be a big help.
    Thank you, gentlemen, for being here, and ma'am.
    Mr. Wilson. Thank you, Congressman Scott.
    Now we proceed to Congresswoman Niki Tsongas, of 
Massachusetts.
    Ms. Tsongas. Thank you, Mr. Chairman.
    And thank you all for being here. I commend the work that 
you all have done, the really focused effort you are bringing 
to this. And, you know, we all hope going forward we are going 
to see great progress on this because it is an issue of such 
deep concern to all of us here, as well as those across the 
country who hear about the great increase in the numbers of 
suicides.
    But I am concerned that in our current budgetary 
constraints, in particular sequestration, that this could 
really undermine all your good efforts and exacerbate the--this 
particular epidemic. My concern is two-pronged: one, because 
the strained resources will inevitably force our men and women 
in uniform to take on more responsibility than ever--in other 
words, all the pressures of the workplace.
    You have looked at, sort of, the legal issues, I mean, that 
they tend to have relationship issues, financial issues, legal 
issues--but just the demands of the workplace. We have heard 
about the multiple deployments, but in reality there are more 
suicides taking place in people who are not deployed. So is 
there something in the workplace itself and the demands of the 
workplace that are exacerbating and causing increased stress?
    As one of our witnesses at a recent Oversight and 
Investigations Subcommittee hearing on the QDR [Quadrennial 
Defense Review] noted, they said, ``You can't, in reality, do 
more with less.'' And as we have less, you are asking often 
very young people to do quite a bit more.
    Second, I am also worried that the budgetary environment 
could potentially impede all your prevention efforts from being 
researched, because a lot of research is certainly going on or 
fully implemented. So I would welcome all of your comments on 
just, you know, the stresses in the workplace, how the various 
cuts coming about one way or the other may, in fact, exacerbate 
those stresses, and whether or not you see any kind of 
correlation or are concerned at all as we have to continue to 
make these cuts. And then second of all, are you worried that 
it will also have an impact on your--all the other efforts you 
have put in place?
    Ms. Garrick. Well, ma'am, clearly yes. If we furlough our 
civilian workforce it means that the military will be picking 
up some of that workload, so there will be that stress. That 
stress is ongoing already. We are starting to figure out how we 
are going to manage that as best we can but it is definitely a 
concern for everybody across the spectrum, across the 
Department.
    There are some recognition that the workplace stress is 
certainly a piece of what happens in the nondeployed 
environment, that we have been at war for 10 years. There is an 
operational tempo that we are all very conscientious about and 
that leadership needs to be able to train and mentor junior 
officers and bring people on board in such a way that helps 
facilitate a resiliency and mentor them through their careers. 
And that doesn't always happen when you have the high 
operational tempo that we have right now.
    So I think your points are well taken and are definitely 
issues that we are all grappling with and challenges that we 
will have to face and overcome as we move forward through 
sequestration, continuing resolutions. I mean, I know you have 
had many of our senior leaders here discussing those very 
issues, and clearly, I think there will be ripple effects 
throughout the Department if sequestration actually goes into 
effect.
    General Bromberg. Ma'am, with respect to the budget, we are 
all concerned. But as far as behavioral health and support 
goes, that is one of our primary areas that we will do 
everything we can not to furlough in the behavioral health 
department. And we are going to ask for those exceptions not to 
do that, to keep that workforce steady so we don't lose that 
progress.
    With respect to the overall workplace stressors, I think 
the relationship stressors and those other things you have 
heard about, alcohol abuse and other things, are just as 
important as the stress in the workplace. And so working 
through our Resiliency Campaign, as we continue to train master 
resilience trainers to teach people how to deal with the 
adversities is really key to what we have to do during this 
time period. And that is one of our major focuses.
    Ms. Tsongas. So the adversities of the workplace as well as 
the adversities of that which you confront outside the 
workplace.
    General Bromberg. Disappointments in your family 
relationships, disappointments if you get in trouble with the 
law. How do you work your way through that and not get into 
what they call the ``spiral of negative thinking,'' the spiral 
of going down, down, down--how you can help pull yourself out 
along--and having the leadership engaged with that.
    The master resiliency trainers are starting to take effect 
as put those across all our formations to include families and 
civilians.
    Ms. Tsongas. Quickly. I have a few more seconds.
    Admiral Van Buskirk. Yes, ma'am.
    Just, I was in Norfolk 2 days ago doing all-hands calls, 
one for about 1,200 people, one for about 500--and men and 
women in uniform, both in the Navy and the Marine Corps. To 
answer your question, yes. The pressure of the budgetary 
atmosphere that we are in, the stress, it was significant in 
terms of the uncertainty that our people are feeling that is 
being added to the already environment where OPTEMPO 
[Operations Tempo], PERSTEMPO [Personnel Tempo] are part of the 
norm in terms of what they are dealing with on a daily basis.
    So we have added to that uncertainty with sequestration and 
the continuing resolution debate that we have been having here 
and the uncertainty that goes with that.
    But from a program standpoint, we remain committed to our 
programs and we are working to maintain those fully functional. 
There will be some areas that have more strain than others, but 
for the behavior health programs that we have, to--keep those 
fully functional, and we have made those a priority.
    Ms. Tsongas. Thank you.
    I think I have run out of time, so thank you, though.
    Mr. Wilson. Thank you, Ms. Tsongas.
    We now proceed to Congresswoman Kristi Noem of South Dakota
    Mrs. Noem. Thank you, Mr. Chairman.
    And thank all the witnesses for being here.
    This is a tough issue for any family that has lost someone 
that has taken their own life. And I have a constituent back in 
South Dakota that is dealing with this, a loss of a son. And, 
you know, it is a grief that no parent should have to go 
through.
    So I want to thank you for all your work in this area, but 
obviously we have a long ways to go.
    Some of my questions--and, frankly, I have some concerns, 
and I will direct them at Lieutenant General Bromberg because 
this young man served in the Army, but after a soldier reaches 
out for help, what exactly happens at that point?
    General Bromberg. Yes, ma'am.
    If the soldier reaches out for help, depends how he reaches 
out for help. Does he go to a chaplain, does he go to a peer, 
or does he go to behavioral health? So there are multiple 
pathways, what we call multiple touch points.
    If you start with the unit, training the unit on ask, care, 
and escort training that teaches the peers to say--ask 
questions, care about the individual, and escort them to 
behavioral health. And if they are in the behavioral health 
network, of course, they go into seeing the behavioral health 
specialist, and they are treated as they are needed to repair 
them and get them back to their full capacity. If they go to a 
chaplain, they can still be referred to that way.
    So there are several pathways that the soldier can go down.
    Mrs. Noem. Well, what can happen if the soldier is in 
counseling then, yet they are soon to be deployed. How is that 
balanced with their mission that they have in front of them?
    General Bromberg. There are many avenues. For example, if 
they are in counseling there is a decision made is if the 
soldier should even deploy. And any soldier that is put on any 
type of medication, the psychotropic medication, we 
automatically don't deploy them for at least 90 days to see the 
effects of the medication.
    If the soldier can deal with a mild medication and still 
deploy, that is a chain of command and a medical decision to 
make. But there is a 90-day period right there.
    Mrs. Noem. So if they are deployed then they are under the 
supervision of their commanding officer?
    General Bromberg. And the medical facilities that are 
forward----
    Mrs. Noem. Medical facility would be--I have that 
information----
    General Bromberg. Yes, ma'am.
    That is tracked in his medical record and it should go 
forward. I am sure we are not absolutely 100 percent perfect 
and we have had problems over the past 12 years, but we have 
improved that to include putting behavioral health forward. So 
we have behavioral health teams with our forward-deployed 
organization, which is a step we are doing to standardize that 
across the Army out through 2016. Because putting behavioral 
health with the units at the point of action is very key. We 
have learned that over these last several years.
    Mrs. Noem. You know, I understand that after a suicide 
occurs that there is an after-action review that it happens 
with the family. Is there contact with the family during this 
review?
    General Bromberg. Yes, ma'am. The first is the unit does an 
after-action review as well as we do after-action reviews all 
the way up to the Department level. In fact, we meet monthly; 
the Vice Chief of Staff of the Army hosts a suicide review 
group with all senior commanders where we look at general 
trends and cases. And there is also information provided to the 
family.
    Mrs. Noem. But during that review is the family contacted? 
I mean, that is the concern that I have with this individual 
situation is this family was not contacted during that 
investigation whatsoever.
    They were certainly given the advantage of having an after-
action review, but I would think if they were really going to 
understand what happened in that individual situation that 
there would have to be some kind of communication with the 
family during the investigation.
    General Bromberg. Yes, ma'am. If you like I can get that 
follow-on information. We can, you know, dig into the details 
of this case.
    Each one is different. We will normally finish our 
investigation first. But I will be happy to take that on.
    [The information referred to can be found in the Appendix 
on page 111.]
    Mrs. Noem. Yes, I would really appreciate that, because I 
think that is a key missing link. And what I am concerned about 
is that while we are very action-oriented in our military in 
our national defense, that I don't want us to approach these 
situations such as checking the box, that we have completed 
what we feel are requirements, that we need to have the 
adaptability, the flexibility to care about the individual to 
take the action that is necessary, because these are crisis 
situations and just checking the box isn't going to get us the 
kind of results that we really need and deserve for our service 
men and women.
    Thank you.
    I yield back, Mr. Chairman.
    Mr. Wilson. Thank you very much, Mrs. Noem.
    And we now proceed to Dr. Brad Wenstrup of Ohio
    Dr. Wenstrup. Thank you, Mr. Chairman.
    And I applaud all the work that you are doing. I have done 
some temporary duty at Fort Lewis dealing with suicide 
prevention. I am familiar with the difficulties in trying to 
assess and try to prevent and then to try to treat. And I know 
that your assignment is difficult.
    Of course, we are always looking for numbers; we are always 
looking to try and figure out where are the common trends, and 
you have identified some of them already, such as legal, 
financial, and domestic problems.
    I know you compare with the civilian numbers, but do we 
compare, say, 30 and under, of the civilian population? As you 
mentioned, so many within the military are 29 or younger, so I 
was curious if we compared in that way and what kind of results 
you have seen there. Is it pretty similar to the general 
population?
    Ms. Garrick. Yes, sir. I think Dr. Reed addressed some of 
that as well. We see a lot of similarities between ourselves 
and suicide in the civilian population. It is pretty much a 
mirroring demographic, with young white males with these types 
of issues and problems. I think there are some studies they 
have done with college students that look very similar to our 
population.
    Dr. Wenstrup. So we can't really conclude that this trend 
within the military is military specific, that that may not be 
the issue; it may be more societal rather than just military, 
right, Dr. Reed?
    Mr. Reed. Great point. And I think that is one thing we 
really have to tease out. The rate of suicides for 18- to 25-
year-olds in the general population is high. It is the third 
leading cause of death.
    So the question really is, what percent of the suicides 
that are happening in the military in the same demographic are 
similar, in terms of their cause, to the general population, or 
perhaps unique to the experience of being in the military?
    When you look at another group, the same age group--the 
college-age student--this population has half the suicide rate 
of their peers that don't attend college. So what is it that is 
protecting college-age 18- to 25-year-olds that is not 
protecting the general population, or perhaps some of those 
that are in the military?
    These are questions we really have to look at, because it 
may not be a military-specific explanation for the 18- to 25-
year-old suicide rate. It may be more of the fact that these 
are young people whose brains are still developing. Problem 
solving skills, coping skills, impulsivity are factors that 
affect all 18- to 25-year-olds. And maybe we need to look from 
that perspective as well as we try to address the problem.
    Dr. Wenstrup. Thank you. And so it seems, as often is the 
case with military research, it tends to benefit the entire 
country, and I think that this will be a case of that.
    The preventive side is often very difficult, obviously. I 
look at like the ACE [Ask, Care, Escort] program with the Army.
    Is there any way of measuring how many saves we have had?
    General Bromberg. Sir, we are just starting to do that now. 
Earlier example, we looked at one infantry division where they 
have done now 24 months of resiliency training, and we were 
tracking the gestures, attempts, and ideations, and to see how 
many peer-to-peer interventions there were.
    And the initial results are--is that while the gestures 
have remained generally about the same, the number of peer-to-
peer interventions has increased dramatically, and therefore 
the number of cases having to go to behavioral health have 
really reduced. But we are in the really early stages of doing 
that and we are trying to link that training to outcome.
    Admiral Van Buskirk. I think I would like--just like to add 
on to that, and that is, sir, that we can't exclusively look at 
just suicides and suicide-related behavior. I think one of the 
good things that is happening as we have all investing in our 
behavioral health specialists and embedding those people in our 
units. We look at all of the other things that are related to 
stress and see how that is being managed. Are incidents of 
alcohol abuse going down? Domestic abuse was mentioned earlier.
    So there are these other areas that are also related to 
stress, to where we see the benefits of when we get the 
professionals in there, we reduce the stigma. When it is a 
total leadership, down to the deckplate level, we see success 
in these areas and start to see the needles move, I think, in 
terms of the other behaviors that might be associated with 
stress, which might be indicators of a potential suicide-
related behavior later on or an event.
    Dr. Wenstrup. I appreciate you taking on this difficult 
challenge and thank you for being here today.
    And I yield back my time.
    Mr. Wilson. Thank you, Dr. Wenstrup.
    And we now proceed to Congressman Chris Gibson, of New 
York.
    Mr. Gibson. Thank you, Chairman.
    And I thank the ranking member, as well, for calling this 
hearing, and all the panelists for your service commitment to 
our country.
    I am encouraged, actually, by the dialogue here in this 
hearing, and find particularly interesting some of the 
responses.
    Dr. Reed, the recent one you just gave with my colleague 
here, looking at the data, trying to understand it, how 
difficult this is that we are just not going to be able to 
point to--we are not going to know, you know, by precise 
numbers.
    But I think the focus on resiliency will come through. And 
over time I think we will see a very positive impact on this.
    I want to also mention that Mr. Scott, he brought up 
equine, and we have a couple of programs going on in our 
district in upstate New York with initial very favorable 
reviews. So I am encouraged by that and we are going to 
continue to work that.
    Former commander, 3 years ago a brigade commander in the 
82nd--and, you know, can appreciate firsthand how serious our 
commanders and sergeant majors, first sergeants, are taking 
this issue and all the emphasis that is put in in a period of 
enormous stress coming through over a decade of war, the budget 
situation, the drawdown. All of these pressures, exogenous and 
impacting. And yet we have a leadership very focused on making 
a positive difference. Greatly appreciate it.
    Ms. Garrick, like you, my wife, Mary Jo, is a licensed 
clinical social worker. She is part of a congressional spouse's 
group trying to make a difference on this very issue, and they 
are partnered with the American Foundation for Suicide 
Prevention. And, you know, I think they are doing important 
work.
    I went to an event recently in Albany where General Graham 
and his wife Carol were there. I just can't say enough positive 
about this event. It was well attended. It was focused on 
education, on warning signs, actions that could be taken.
    So to follow up with the Chairman, you know, having 
firsthand experience in terms of the Active Component and 
seeing how engaged we are, my question really is a followup on 
the Reserve Component and veterans side of this, because as 
concerning as the data is for our service men and women, we 
know the veterans' situation is worse.
    And I think you are already making a positive impact on the 
work that you are doing in the DOD. And so, you know, coming 
away from this event last week, I thought that the American 
Foundation for Suicide Prevention is really engaged and making 
a difference on this. And so I am interested to know what 
partnerships we have with the DOD and what is your review of 
that and your intentions going forward?
    Ms. Garrick. Yes, we have established a community action 
team approach, as described by, actually it was Admiral Mullen 
when he wrote the ``Sea of Goodwill.'' So we took that concept 
and we have started to have these community action roundtable 
discussions where we bring in from the community organizations 
like the Tragedy Assistance Program for Survivors, the suicide 
association you have just mentioned. Dr. Reed and I talk quite 
a bit and I work very closely with the Department of Veterans 
Affairs.
    Our last roundtable we held we had several university 
participation--Harvard, UCLA, the universities in North 
Carolina and South Carolina were both on the phone, Penn State. 
So we had some really great university dialogue on looking at 
peer support and curriculum for peer counselors.
    So we are doing a lot of these kinds of outreach efforts. 
And my partnership with the Department of Veterans Affairs 
truly does allow us to leverage looking at building a joint 
data repository across the Department with HHS [Department of 
Health and Human Services], the CDC data as well. And I think a 
really important step forward is that the DOD will now confirm 
for CDC Guard Reserve deaths, so that will really help us 
understand the reach into the States and what that looks like 
at the local level.
    So those kinds of partnerships, they may--it may take us a 
while, but those things are certainly the steps that I see that 
we needed to take and I think are going to be very helpful in 
moving us forward and understanding this from a perspective 
that Dr. Reed described.
    Mr. Gibson. Well, I appreciate that comment. And just to 
put a finer point on the Albany area, it is about 3 hours or so 
from Fort Drum, and about 2 hours from West Point. But the 
population--about 15 percent of the population, veterans. So 
this is why this event was so critically important, because 
they were educating the social workers and some of the 
volunteers who are at the V.A.--the Stratton V.A.--and also 
support some of the Active Duty and the National Guard that are 
in the Albany area, whether it be on recruiting, ROTC, or the 
42nd Infantry Division right there in New York.
    So I am going to be working with the committee and see if 
there is maybe more we can do on this partnership, but I 
appreciate everything that everyone is doing.
    Thank you, and I yield back.
    Mr. Wilson. And thank you, Mr. Gibson. And thank you for 
your family's commitment and service.
    We now proceed to Congresswoman Carol Shea-Porter, of New 
Hampshire.
    Ms. Shea-Porter. Thank you very much, Mr. Chairman.
    And thank you all for being here and the great work that 
you are doing.
    I have to say, it is frustrating. I wish that we had one 
name across the military spectrum. I am reading about all these 
various programs, and through the years while I have had the 
privilege of serving here there have been different titles--
all, you know, working to serve this purpose and try to help 
enlisted men and women and officers as well. But the complexity 
of just the titles and the program has to throw a lot of the 
intended recipients.
    So my first question is, how many people are you aware of, 
no matter how hard you try for your outreach, how many victims 
or their families have said they didn't know where to turn?
    Ms. Garrick.
    Ms. Garrick. Yes, I don't know that I have an exact number 
of how many, but I have certainly heard that as well. And that 
is why, again, part of what we have done, and all of the 
Services in their statements noted that we have tried to craft 
one message for moving forward, and that is if you need help, 
get it. Treatment works.
    And when we work with the military crisis line we have an 
``It's Your Call'' campaign, and then this year we launched the 
``Stand By Them'' campaign, which is a V.A.-DOD single-message, 
single point of contact, 1-800 number. And if you type--if you 
call the number it is the same number as the SAMHSA [Substance 
Abuse and Mental Health Services Administration] suicide 
hotline number so that regardless of whether you press one or 
don't press one you are getting funneled into the same help 
with the same protocols in place, so that our service members 
and their families are using the same services that veterans 
and their families have available to them so that there is that 
pull-through.
    And that is why it is so important that at transition we 
are going to be able to provide them that information, as well. 
So as they move forward, the message never changes. It is the 
``It's Your Call,'' the ``Stand By Them'' campaign, and the 
same 1-800 number.
    Ms. Shea-Porter. But do we keep any statistics? Is the 
question asked: Did you know where to turn? Did you know this 
service was available? Because my interaction with service men 
and women and veterans, and certainly we know this from the 
Vietnam era for all the outreach, you know, that somehow or 
another there was still a curtain there--were not aware of it. 
And I know that our V.A. in Manchester, New Hampshire, has been 
reaching out and going to where veterans actually are, trying 
to draw them into the system so they can have access to needed 
benefits.
    So there is still some kind of a curtain there, and is 
there any way that we are measuring how effective we are? Are 
we asking, did you know where to turn? Did the family know once 
they were aware things weren't right? Because I think that is 
an important part, to make sure that we are actually reaching 
them.
    Ms. Garrick. Yes, I think going back to the previous 
question from Congressman Gibson, that is why these community 
action teams and that approach is so important. Because we 
can't do this alone, we really do need our community members 
involved and engaged so that that message is getting out there, 
that our veterans service organizations know how to facilitate 
a rescue, they know how to call the 800 number, how to go 
online, how to do the texting, the chatting, so that all that 
is out there.
    We just did do a study with the Guard and Reserve, 
actually, on suicide prevention and resilience. We asked 
support professionals and commanders, so what resources are you 
aware of? What do you use? What do you like? What don't you 
like? So that we could get a better understanding of that exact 
issue.
    Ms. Shea-Porter. But again, you know, does it actually 
arrive through the individual's curtain and do they know that? 
And so I have a very simple suggestion. I thought, everybody 
has to go to the grocery store. You know, we don't have to go 
look for resources to help ourselves or our family members. 
Maybe we know to do that; maybe we don't. But everybody has to 
go to the grocery store.
    Can we put the number on grocery bags? Can we ask various 
companies and all of the great corporations and small family 
businesses to put this telephone number on grocery bags to--
because there is still some kind of problem there where they 
are just not all aware of the resources there.
    So for all the great work you are doing, if there are 
individuals that are not tied into VSOs [Veterans Service 
Organizations], if they are not tied into various 
organizations, if they think in their minds that it is better 
not to be connected to the military or to the Veterans 
Administration for whatever reason, how do we still reach those 
who have not reached out and we have not noticed yet?
    Ms. Garrick. No, and I think that is a great suggestion.
    Ms. Shea-Porter. So I yield back.
    Ms. Garrick. We have had some conversation about doing that 
with the commissaries.
    Ms. Shea-Porter. Right, so I--but past the commissaries, 
because a lot of them will not be using commissaries. I think 
this is going to call for the effort, and it has already been 
developed for a long time, I know, but continuing to make sure 
that our business community and our nonprofits as well as those 
who are in the military and veterans community can work 
together to put this out there.
    Because these programs are there, they are wonderful, but 
some people still do not access them.
    So thank you, and I yield back.
    Mr. Wilson. Thank you, Ms. Shea-Porter.
    We now proceed to Dr. Joe Heck, of Nevada.
    Dr. Heck. Thank you, Mr. Chairman.
    Thank you all for what you are doing and for being here. I 
am sorry that I missed your testimony. I had another hearing to 
attend, but I did read through your written statements prior to 
today.
    First, I want to thank Ms. Garrick for bringing up the TAPS 
program and forging a community partnership with them, not just 
for the Services that they provide to the family members but 
for looking at the information that they glean from the family 
members during their debriefings and how that may help us 
identify future risk. I was just at their anniversary dinner a 
couple nights ago, so an incredible program and I am glad that 
you are involved with them.
    I approach the issue, I think, a little bit differently, as 
a military health care provider and as a brigade commander who 
over the last 2 years has had one successful and two threatened 
suicides within my command. So it is a real issue for me that 
hits home.
    You know, when the Army launched its health promotion, risk 
reduction, and suicide prevention campaign in 2009 and it stood 
up the task force, the Army Reserve participated and came up 
with four pillars that they were going to concentrate their 
efforts on, and I want to talk about two of them. One was 
reducing the stigma associated with asking for help, which has 
been addressed somewhat here today, and the second was 
providing resources to geographically dispersed personnel.
    I tell you, fortunately, for the two threatened suicides 
that we had, it was fortunate that those individuals were 
located within the community where the unit was based. Again, 
you know, being geographically dispersed in the Reserves can 
mean a lot, and in my brigade I have got soldiers that are 3 
hours or more away from the unit.
    But these individuals made statements to their first-line 
leaders. Their first-line leaders then utilized the ACE 
mnemonics and went out and asked, took them and escorted them 
to care. And both of them were then enrolled in behavioral 
counseling services, and I truly believe that that program 
saved those two soldiers' lives.
    Unfortunately, the completed suicide, although having taken 
place in the same town as where the unit was located, had no 
previously seen indicators.
    And actually, his first-line leader and he were friends and 
they happened to be out that night together. And then 2 hours 
later, after they departed company, the first-line leader was 
called and told that the person he was just with had 
successfully committed suicide.
    So the issue I bring up about stigma is, as we try to put 
more and more of this responsibility on first-line leaders, 
especially in the Reserves, we are looking at 25-, 26-year-old 
E-5s, and I can tell you that in the successful case, that 
first-line leader is still beating himself up over the fact 
that not only was he a friend but he was his first-line leader, 
and he feels like he failed in recognizing what happened.
    And I can tell you that as we talk--about seeing in the 
written statement the stigma reduction campaign that is being 
developed, I mean, but stigma reduction was identified in 2009. 
I identified it when I returned from my deployment in 2008, 
because you knew that if you checked the box on your post-
deployment health risk assessment that you had seen a dead body 
or anything like that you were not going to be released. You 
were going to spend another 2 to 3 days going through 
additional counseling, and obviously everybody is waiting to 
get home to their families and so they knew not to check the 
box--not because they didn't want to ask for care but they knew 
it was going to delay their ability to get back to their 
families.
    So why is it taking until--why are we still developing a 
stigma reduction campaign when this had been identified well 
before 5, 6 years ago?
    General Bromberg. Yes, sir. I just think over all--and I 
understand the frustration and the challenges--think this is a 
cultural change. I think it is not that we are developing a 
campaign or failing to recognize it. I think as I talk to young 
men and women, and the numbers are getting better as far as 
people that think stigma is improving, but not as fast as we 
would like.
    This is a huge cultural change for us, whether your 
background or how you were raised all the way through your 
background in the military. And I think it is the engaged 
leadership and the evasive leadership, and then success stories 
of where you can seek help and not be penalized for that help.
    There is just a recent data I looked at this week, we have 
seen very slight improvement this last year, but great 
improvement over 4 or 5 years--about 20 percent improvement is 
in stigma reduction. We are just going to have to stay at it 
and keep leadership engaged.
    Dr. Heck. And I just have a couple seconds remaining. I 
just want to bring up the issue about help to the 
geographically dispersed.
    It seems like a lot of the concentration has been on 
getting them access to care, but again, if they are remote from 
their unit, we have got to identify them. Who are they going to 
identify themselves to?
    And have we done anything with, you know, our--you know, 
units within the same compo [component], whether National Guard 
units, sister service units, Active Duty installations, the 
V.A., so that if somebody calls their unit and they are 3 hours 
away, and they say, ``I am having a problem,'' that we can get 
them plugged in with somebody in a uniform who they are going 
to be able to relate to much easier than somebody showing up in 
civilian clothes on their doorstep. Have we looked at trying to 
branch out across Services and compos?
    General Bromberg. Yes, sir, we are working at it diligently 
right now, and I will provide you some more additional 
information on the specifics of how we are getting after that.
    [The information referred to can be found in the Appendix 
on page 111.]
    Dr. Heck. I appreciate it.
    Thank you, Mr. Chair, for--and the ranking member for 
holding this very important hearing, and I yield back.
    Mr. Wilson. And thank you, Dr. Heck.
    And indeed, this is an important hearing and it is obvious 
the commitment of everyone here. And while we have this 
opportunity, we will proceed with additional questions.
    And, Dr. Reed, in particular, the Center for Disease 
Control has indicated suicide is the third leading cause of 
death among 15- to 24-year-olds, and is the second leading 
cause of death between 25- to 34-year-olds. And you have 
already actually brought up something interesting, and that is 
there is a differential between college-age--young people who 
are attending college, not attending college, the suicide rate. 
Are there practices within the civilian community that could be 
adopted to the military?
    Mr. Reed. Yes, sir. One of the things that happened in 2005 
was after the tragic death of Garrett Smith, the son of Senator 
Gordon and Sharon Smith, the Congress passed the Garrett Lee 
Smith Memorial Act. It has been in place since 2005. It is 
really the first Federal appropriation that has been authorized 
and funded to fund States, tribes, and territories, as well as 
college campuses, to really aggressively look at early 
intervention and prevention in suicide prevention amongst this 
age group.
    These cohorts have been funded since 2005. It is still 
active today, and we gather the cross-site evaluation that is 
providing SAMHSA some very valuable information in terms of 
what seems to be working. And each grantee has been required to 
assess their own performance, and those performances each year 
are shared with others who are trying to do the same thing.
    So this is a perfect example of where, working with Ms. 
Garrick, we can share some of what we are learning in the 
civilian community that may have relative value to what is 
happening in the military community as well, especially for 
those younger military members who may not have taken their 
life or thought about taking their life as a result of a combat 
experience, but may be more of a developmental issue with 
regards to their place and age.
    Mr. Wilson. Well, thank you for providing that.
    And, Ms. Garrick, I, too, am--was very appreciative of 
TAPS. I know firsthand the Yellow Ribbon Campaign. I want to 
thank you.
    We proceed to Mrs. Davis
    Mrs. Davis. Thank you, Mr. Chairman. I appreciate just a 
second round quickly to try and mention a few issues that are 
out there, I think, that we talk about.
    One of them is a guilt factor, that, in fact, people came 
home, someone came home and felt that their buddies did not. 
And I don't know to what extent you find that that is a large 
factor that is being addressed or you think maybe is not 
getting the attention that it deserves.
    I think the other issue is just the loss of hope, which we 
know is probably more than any other thing that people can 
express or that family members can express about a loved one, 
that they didn't see that coming perhaps, but that was a big 
factor. People have talked about the issue of contagion.
    And I think, Dr. Reed, you mentioned it is how we speak 
about suicide that makes a difference.
    I am recalling, Mr. Chairman, that one of the first 
hearings that we had here where we had a father talk about his 
son, and of course, it was very emotional, and trying to 
understand, essentially, the question of, how come nobody--how 
come we didn't know, and what services were out there?
    So I don't know to what extent you want to address those, 
but those are all issues.
    But the one that I think you can maybe, you know, get your 
head around a little bit is the factor that at least 10 
percent, as we know, in the service have perhaps access to guns 
at a greater level than in the general population. And the fact 
that we have the literature indicating that restricting access 
to means--firearms, of course--is an effective strategy for 
preventing suicides.
    Now, in the military, are we using and thinking about that 
and the preventive strategies that are required, knowing that 
our service members have access, of course, and perhaps are not 
getting to help because, you know, they--it is just too--in 
some ways it may be too easy. Can anybody like to talk about 
that?
    Ms. Garrick. Sure. First of all, the NDAA 13 just gave us 
some really good clarifying language on who can, when can you 
ask about personally owned firearms, ammunition, and other 
weapons, and so we are working on a guidance for that so that 
we can get that information out to the Services and make sure 
that everybody, that the clinicians as well as the commanders, 
are tracking that on what you can do. So, I think, that was an 
important step for us.
    And I do want to go back and just sort of comment on what 
you said about trauma, hope, and contagion, because this is 
clearly not just a mental health issue. Suicide is a behavior 
and it is a--and I think that is why it is so important that we 
have chaplains involved in this process as well as commanders 
and mental health providers. This really will take a community 
response within the military community and outside of the 
military community to address some of those key points.
    And I think the research we need to do--and I just met with 
General Patton the other day, who heads our Sexual Assault 
Program office [Sexual Assault Prevention and Response Office], 
I think marrying up, so what are the different issues? What are 
the areas of concern? And how can we learn more about trauma 
and the--its implications, and hope and resilience and its 
implications? I think those are all very key factors.
    And then the means restriction is certainly important. I 
think the Services can certainly tell you more about what they 
are doing in that regard.
    Mrs. Davis. And if there is anything more that Congress 
could or should be doing to help. In addition, obviously, we 
talked about the--just the resource issue, in terms of 
assistance.
    I think just one other thing to add--I know my time is 
running out--is just, how do we determine the quality of care 
that is being provided, as well? I mean, I don't doubt that we 
have the bulk of our caregivers who are providing that quality 
care, but we also sometimes talk to people that don't go 
additionally because they don't help them out.
    General Bromberg. Yes, ma'am, it is to protect the 
weapons--on our installations, of course, that is no issue. 
Commanders have the authority to get in what I call almost that 
invasive leadership, asking those questions to withdraw those 
weapons. And the NDAA did help us significantly by opening up 
the aperture for those that live off-post or off the 
installation so we can ask the right questions to try to 
retrieve those weapons.
    The commands are going after that very aggressively. So the 
weapons piece, I think, is absolutely essential.
    As far as the quality of care, I think, it is the positive, 
continuous dialogue in reaching out to those individuals to 
find out what else they need, because it may not be just 
behavioral health. It may be some other type of relationship 
issue or financial issue. Where can we provide that additional 
support?
    General Jones. Ma'am, in the Air Force, we have had--rather 
than going after looking at who carries and has access to 
weapons we look at career fields. Three of our most at-risk 
career fields are security forces, aircraft maintenance, and 
intelligence. Obviously, security forces would have access to 
weapons.
    We target those career fields with special first-line 
supervisor training, must be done one-on-one, must be done in 
small groups. And we found a lot of success with that.
    The other thing we are trying to do is make our health care 
providers more accessible without applying the stigma. Eighty-
three percent of all of our primary care clinics have mental 
health providers embedded in the clinic, so if you go in to see 
one physician he can take you next door to talk to a mental 
health care provider without having to take you down the hall 
to the mental health care clinic.
    And I think that really gets at some of the stigma. And I 
think the stigma is really the metric that shows us that we are 
making some headway here. Ninety percent of everybody in the 
2012 Air Force climate assessment survey said they believe 
leadership was interested in suicide prevention and felt that 
was a great thing.
    And also in the 2012 survey, 84 percent of the people said 
they knew who to talk to. They would talk to their coworkers, 
they would talk to their supervisors and their branch chiefs--
not for mental health care but for the first contact to tell 
someone that they had trouble--ma'am, much to your question of 
where they would take them. And that leads to the ACE care, 
where you ask the person--do they have an issue, you care for 
them, you escort them over to a real professional.
    And in that same survey, 95 percent of the people in the 
Air Force said--and this was Active Guard and Reserve--said the 
leadership was genuine. Ninety-five percent said the family, 
friends, and coworkers would support them if they had mental 
health issues and sought help. And 83 percent said that they 
would feel comfortable talking about suicide to their coworkers 
and to professionals. And we think that is a big plus in our 
numbers.
    Mrs. Davis. Big improvement. Thank you.
    Thank you, Mr. Chairman.
    Mr. Wilson. Thank you, Mrs. Davis.
    And as we conclude, I want to thank all of you for your 
genuine, very thoughtful compassion toward our service members, 
military families, and veterans.
    At this time we shall be adjourned. Thank you.
    [Whereupon, at 12:15 p.m., the subcommittee was adjourned.]

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                            A P P E N D I X

                             March 21, 2013

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             March 21, 2013

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                      Statement of Hon. Joe Wilson

           Chairman, House Subcommittee on Military Personnel

                               Hearing on

             Update on Military Suicide Prevention Programs

                             March 21, 2013

    Today the subcommittee meets to hear testimony on the 
efforts by the Department of Defense and the military services 
to prevent suicide by service members, family members, and 
civilian
employees.
    I want to preface my statement by recognizing the 
tremendous work the Department of Defense and the service 
leadership has done to respond to the disturbing trend of 
suicide in our Armed Forces. This has not been an easy task and 
I thank you for your hard work. Suicide by members of our Armed 
Forces is particularly distressing to me because I consider 
military service an opportunity. I want service members to know 
they are talented people who are important and appreciated by 
the American people. They can overcome challenges.
    Suicide is a difficult topic to discuss. Last year 350 
service members took their own lives. Every one of them is a 
tragedy; every one of them has a deeply personal story. We 
cannot rest until we have created every opportunity to change 
such an awful statistic.
    Suicide is a multifaceted phenomenon that is not unique to 
the military. Unfortunately, in addition to the hardships of 
military service, our service members are subject to the same 
pressures that plague the rest of society today. They are 
exposed to the same stressors that may lead to suicide by their 
civilian counterparts. I am deeply concerned about how the 
uncertainty of sequestration and the coming budget challenges 
will affect our service members and their families.
    Each of the military services and the Department of Defense 
has adopted strategies to reduce suicide by our troops. I would 
like to hear from our witnesses whether those strategies are 
working. How do you determine whether your programs incorporate 
the latest research and information on suicide prevention? I am 
also interested to know how Congress can further help and 
support your efforts. Lastly, I am interested in learning how 
our civilian experts are tackling this problem across the 
Nation and how private organizations like Hidden Wounds of 
Columbia, South Carolina, are
assisting.

                    Statement of Hon. Susan A. Davis

        Ranking Member, House Subcommittee on Military Personnel

                               Hearing on

             Update on Military Suicide Prevention Programs

                             March 21, 2013

    I am pleased that the subcommittee is continuing its 
attention on suicides in the military. It has been nearly a 
year and a half since our last hearing on military suicides, 
and during this time, we have only seen increased numbers of 
service members taking their own lives. While Congress has 
pushed forward a number of initiatives to support the Services 
and the Department of Defense in their efforts to develop 
policies and programs to reduce and prevent suicides in the 
force, sadly these numbers continue to grow.
    Yet, military service members are not alone. Over 38,000 
individuals die by suicide every year. In 2010, suicide was the 
10th leading cause of death in the United States, and the 
fourth leading cause of death for adults between the ages of 18 
and 65. While suicide among young individuals, 15-25 years old, 
continues to be a concern, the rate of suicide among older 
Americans is even higher. It is important that we share what we 
learn in the military and what is learned by others if our 
country is to be successful in addressing this societal issue.
    The establishment of the Department of Defense Task Force 
on the Prevention of Suicide by Members of the Armed Forces in 
the Duncan Hunter National Defense Authorization Act of Fiscal 
Year 2009 was a start. The task force made 76 recommendations 
and I am interested in where the Department and the Services 
are in implementing these recommendations. Have they all been 
completed, and if so, what metrics are being used to track 
success? What other efforts can be undertaken to address 
suicide in the military?
    I welcome our witnesses, and look forward to hearing from 
them on what has been done, what is being done, and where do we 
go from here in our efforts.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
      
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             March 21, 2013

=======================================================================
      
              RESPONSE TO QUESTION SUBMITTED BY MRS. DAVIS

    General Hedelund. Yes, I am aware of the pilot program in 
mindfulness training. The goal of the program is to provide Marines 
with another tool to combat stress through the use of meditative 
techniques. We're expecting the results from the study in the fall of 
2013. [See page 15.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MR. SCOTT
    Ms. Garrick. Since the VA claims backlog issue falls under the VA, 
we would have to defer to them for the percentage of those who were 
waiting for their VA claims.
    However, we do know that from the initiation of the Disability 
Evaluation System (DES) Pilot (November 2007) through November 2012 
(the most recent update from Military Departments, there were 156 
deaths reported of Service members enrolled in the DES. Of these, 32 
determined to be suicide. During the same time period (2007-2012), 
there were approximately 1700 Service members who died by suicide. 
Therefore, approximately 1.9 percent (32/1700) of the total Active Duty 
and Reserve suicides were in the DES process at the time of their 
death. [See page 16.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MRS. NOEM
    General Bromberg. The investigating officer (IO) did not interview 
the Soldier's Family because he did not feel it was pertinent to 
addressing the lines of inquiry in Army Directive (AD) 2010-01. He 
initiated his investigation by looking at the County Sheriff's 
Department report, which included depositions from the two individuals 
who had found the Soldier after the incident. He then developed a list 
of acquaintances and members of the chain of command who knew the 
Soldier, and after these interviews the IO believed he was able to 
answer each question of each line of inquiry in AD 2010-01.
    The policy states that during an investigation, ``any contact or 
communications with a Family member of the Soldier should be pursued 
only when absolutely essential to the conduct of the investigation.'' 
AD 2010-01 directs the IO to answer a series of questions which largely 
are focused on the Soldier's interactions with his/her peers, 
superiors, and subordinates. [See page 21.]
                                 ______
                                 
               RESPONSE TO QUESTION SUBMITTED BY DR. HECK
    General Bromberg. The unit chain of command represents the center 
of gravity for the health and care of our Soldiers and Families. The 
uniqueness of our geographically dispersed population mandates 
sustained partnerships with local community leaders and resources. Our 
leadership is committed to health, safety and welfare of all Soldiers 
and Family members; providing the appropriate linkage to available 
resources and assistance closet to where they live is a key component 
of that commitment. Venues such as the Yellow Ribbon Reintegration 
Program and Strong Bonds facilitate this connection with education and 
awareness of local networks of community support most appropriate and 
available to our Soldiers. Other resources like our Fort Family 
Outreach Center and Army Strong Community Centers assist in virtually 
bridging the gap with commensurate services inherent to an active duty 
installation. These resources provide geographically relevant 
information. We continue to work collaboratively with our sister 
components in order to capitalize on both inherent capability and 
capacity to connect our Soldiers and Families with the resources and 
assistance needed. [See page 28.]
      
=======================================================================

              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             March 21, 2013

=======================================================================
      
                 QUESTIONS SUBMITTED BY MS. SHEA-PORTER

    Ms. Shea-Porter. 1) What steps are the Defense Suicide Prevention 
Office and the Services taking in terms of support and treatment, to 
meet the mental health challenges facing spouses and children? There 
are some innovative National Guard Yellow Ribbon Programs, like that of 
our own New Hampshire National Guard, that follow and support families 
as well as Guard members before, during, and after deployment. Are you 
talking to the States and incorporating the best practices of such 
programs?
    Ms. Garrick. Yes. The Department of Defense (DOD), through the 
Defense Suicide Prevention Office, has formed a Community Action Team 
process comprised of representatives from non-profit organizations, 
universities and others to discuss suicide prevention best practices. 
In addition, it has recommended policy changes for military justice and 
civilian court processing adjudicating Service members who appear in 
civilian courts under state jurisdiction diagnosed with psychological 
conditions. DOD has expanded the National Guard Chaplain Partners In 
Care program, which leverages state community faith-based organizations 
responding to Service members, Reserve members and their families.
    Family members may be able to recognize warning signs and see 
changes in their Service member's behaviors before anyone else since 
they interact with them in a less-guarded state. DOD is drafting an 
Info Guide ``Supporting Military Families In Crisis: A Guide to help 
You Prevent Suicide.'' It is designed to empower military families by 
introducing them to the warning signs of suicide, reduce the stigma and 
uncertainty associated with seeking behavioral health, and provide ways 
to avail resources, get help, and build family resilience.
    Ms. Shea-Porter. 2) Do DSPO and the Services have a strategy and 
the capacity, to provide adequate mental health screening and care for 
families? If not, how are they partnering with civilian social services 
and non-profit organizations to fill the support gaps? New Hampshire's 
National Guard Yellow Ribbon Program, for example, partners with Easter 
Seals to provide needed support.
    Ms. Garrick. Yellow Ribbon Reintegration Programs (YRRP) and 
Returning Warrior Workshops are retreats that facilitate family member 
involvement in the reintegration process. YRRP offers specific pre, 
during, and 30, 60 and 90 day post deployment sessions that focus on 
managing the stressors related to deployment and the resources for 
reintegration.
    Military Treatment Facilities and the TRICARE network offer 
behavioral health care and support to all beneficiaries. The Patient 
Centered Medical Home--Behavioral Health Team (PCMH-BHT) model is 
leveraging a primary care behavioral health case management approach 
and the Psychological Health Council has incorporated suicide 
prevention and family issues into its scope.
    The Services have dedicated military family support centers (MFSC) 
that help Service members successfully balance and integrate their 
military and civilian lives. MFSCs provide relocation assistance, 
financial training, and family education/advocacy services. For 
National Guard/Reserve members, military and family life counselors 
(MFLC) are available to provide short-term, non-medical counseling 
during drill weekends and other events or locations where Service 
members and their families gather. Family members can also benefit from 
Military OneSource's 12 (non-medical brief intervention) sessions to 
resolve marital or family challenges. Section 706 of the 2013 NDAA 
authorizes the Department to conduct a pilot study on enhancement of 
mental health in the National Guard by partnering with community 
agencies. The National Guard Bureau has developed a draft pilot 
program.
    Ms. Shea-Porter. 3) Are family member (spouses and children) 
suicides being tracked by DSPO and/or the Services? If not, why not?
    Ms. Garrick. DOD does not track at the Department level suicide 
deaths for families of Service members, because DOD has no reliable 
means to do so. Suicide deaths among spouses or dependents are 
determined by a civilian authority and not a medical examiner from the 
Armed Forces Medical Examiner System (AFMES). As a result, DOD must 
rely on civilian authorities and Service members to report spouse/
dependent deaths. DOD has no authority to require civilian health and 
mortality authorities to forward autopsy findings to DOD. Service 
members do report dependents' death for beneficiary purposes, but there 
are often lags in that information, and manner of death is not always 
included.
    Ms. Shea-Porter. 4) What authority will DSPO have to ensure the 
suicide prevention policies they develop will be implemented by the 
Services?
    Ms. Garrick. DSPO activities are under the authority of the 
Secretary of Defense, who exercises authority, direction, and control 
over the Military Department and Services.

    Ms. Shea-Porter. 5) What steps are the Defense Suicide Prevention 
Office and the Services taking in terms of support and treatment, to 
meet the mental health challenges facing spouses and children? There 
are some innovative National Guard Yellow Ribbon Programs, like that of 
our own New Hampshire National Guard, that follow and support families 
as well as Guard members before, during, and after deployment. Are you 
talking to the States and incorporating the best practices of such 
programs?
    General Bromberg. Yes, we are talking to the states to ensure the 
best practices are being incorporated. Two major barriers in obtaining 
Behavioral Health (BH) care for Military Children and Families are 
limited Access to Care and Stigma.
    The Army, in an effort to reduce these barriers, established School 
Behavioral Health Programs (SBH) and Child and Family Assistance 
Centers (CAFAC), specifically designed using the Public Health and 
Communities of Practice Models. SBH Programs and CAFACs are currently 
in varying stages of development and provide services at a limited 
number of Army Installations. These programs are at risk of being 
reduced for numerous reasons to include: a critical national shortage 
of BH Child and Family providers; lack of sustained funding in the 
current fiscal environment; sustainment of programs and proliferation 
of new programs supporting the BH needs of Children and Families.
    SBH programs currently operate in 46 schools on eight installations 
(Tripler, Joint Base Lewis-McChord, and Forts Carson, Campbell, Meade, 
Bliss, Bavaria and Landstuhl, Germany). SBH programs, by design, 
support resiliency, promote access and reduces stigma. SBH is currently 
limited to providing services to on-post schools; however, a pilot 
program to provide the services to Military Children in off-post 
schools is underway in the communities surrounding Schofield Barracks, 
Hawaii.
    Child and Family Assistance Centers (CAFAC), are being developed on 
10 installations (Schofield Barracks, Joint Base Lewis-McChord, and 
Forts Carson, Wainwright, Bliss, Hood, Polk, Bragg, Campbell and Drum); 
the majority not being fully operational due to limited BH provider 
resources and difficulties in hiring, particularly at more ``rural'' 
installations.
    Ms. Shea-Porter. 6) Do DSPO and the Services have a strategy and 
the capacity, to provide adequate mental health screening and care for 
families? If not, how are they partnering with civilian social services 
and non-profit organizations to fill the support gaps? New Hampshire's 
National Guard Yellow Ribbon Program, for example, partners with Easter 
Seals to provide needed support.
    General Bromberg. The Child, Adolescent, and Family Behavioral 
Health Office (CAFBHO), U.S. Army Medical Command, has established 
collaborative working relationships with national and state 
organizations and professional entities in order to identify and share 
best practices in terms of prevention and interventions for behavioral 
health problems for Army children and Families. CAFBHO has also 
developed, and is implementing, a comprehensive training curriculum for 
Army Pediatric Primary Care Providers by using evidence-based practices 
for preventing, screening, identifying and treating common behavioral 
health disorders in children within the primary care setting.
    Partnerships have been established with the following national 
organizations and universities in order to collaborate on best 
practices and disseminate knowledge:

          American Psychological Association
          Academy of Child and Adolescent Psychiatry
          American Academy of Pediatrics
          Center for School Mental Health, University of 
        Maryland
          IDEA Partnership and the National Community of 
        Practice, Office of Special Education, United States Department 
        of Education
          Military Child Education Coalition
          National Association of State Directors of Special 
        Education
          Center for Deployment Psychology
          The Beach Center on Disability, University of Kansas
          University of South Carolina
          University of Washington
          Mayo Clinic/REACH
          U.S. Department of Agriculture, Operation Military 
        Kids
    Ms. Shea-Porter. 7) Are family member (spouses and children) 
suicides being tracked by DSPO and/or the Services? If not, why not?
    General Bromberg. The Army tracks Family member suicides of Active 
Duty Soldiers; regardless of whether or not the death occurred on a 
military installation. Suicides of non-Active Duty Soldiers' Family 
members are not currently tracked due to challenges related to the 
collection of reliable and substantiated data, identification of data 
sources, and legal issues related to obtaining and maintaining civilian 
personal information.

    Ms. Shea-Porter. 8) What steps are the Defense Suicide Prevention 
Office and the Services taking in terms of support and treatment, to 
meet the mental health challenges facing spouses and children? There 
are some innovative National Guard Yellow Ribbon Programs, like that of 
our own New Hampshire National Guard, that follow and support families 
as well as Guard members before, during, and after deployment. Are you 
talking to the States and incorporating the best practices of such 
programs?
    Admiral Van Buskirk. Navy offers a full complement of programs 
designed to address the needs of Navy families. Working within the 
Department of Defense, with other federal agencies, and with state and 
local partners, Navy identifies best practices and incorporates them 
into our programs. Navy leadership recognizes the unique challenges our 
families face and is fully committed to providing them the best 
possible support as they support our Sailors and our mission.
    Navy's version of the Yellow Ribbon Program is the Returning 
Warrior Workshop (RWW). RWW participants have the opportunity to 
address personal, family, or professional situations experienced during 
deployment and receive readjustment and reintegration support from a 
broad array of resources, including: Navy Reserve Psychological Health 
Outreach Teams (PHOT), TRICARE Joint Family Support Assistance (JFSAP), 
Military and Family Life Consultants (MFLC), Personal Financial Council 
(PFC), Military OneSource (MOS), Chaplains, Fleet and Family Support 
Centers (FFSC) and Veterans Affairs (VA).
    Other Navy and DOD programs to help families cope with the 
challenges they face before, during and after deployment include:

    --  Ombudsman and Family Readiness Groups (FRG) are the primary 
method of family support, outreach and communication with families of 
deployed Sailors. The ombudsman program supports a volunteer associated 
with the command--typically a spouse, appointed by the commanding 
officer, to serve as a confidential liaison between command leadership 
and the families. Ombudsmen are trained and certified to disseminate 
information both up and down the chain of command, including official 
Department of the Navy and command information, command climate issues, 
local quality of life (QOL) improvement opportunities, and community 
support opportunities. Ombudsmen also provide resource referrals and 
are instrumental in resolving family issues.

    --  An FRG is a private organization, closely-affiliated with the 
command, comprised of family members, Sailors, and civilians associated 
with the command and its personnel, who support the flow of 
information, provide practical tools for adjusting to Navy deployments 
and separations, and serve as a link between the command and Sailors' 
families. FRGs help plan, coordinate and conduct informational, care-
taking, morale-building and social activities to enhance preparedness, 
command mission readiness and increase the resiliency and well-being of 
Sailors and their families.

    --  Commander Navy Installations Command (CNIC) Deployment 
Readiness Program. CNIC supports unit level family support and 
deployment readiness programs with a wide variety of complimentary 
training and support activities, including: unit level deployment cycle 
training, online information and individualized one-on-one counseling.

    --  Navy Project FOCUS (Families Over Coming Under Stress). FOCUS 
provides resiliency training to military families, including practical 
skills to meet the challenges of deployment and reintegration, 
communication techniques, effective problem-solving and family goal-
setting.

    --  The Navy Center for Combat & Operational Stress Control 
(NCCOSC). Dedicated to the mental health and well-being of Navy and 
Marine Corps service members and their families, NCCOSC promotes 
resilience, and investigates and implements best practices in the 
diagnoses and treatment of post-traumatic stress disorder (PTSD) and 
traumatic brain injury (TBI).

    --  The Defense Centers of Excellence are responsible for leading a 
national collaborative network of military, federal, family and 
community leaders; clinical experts; and academic institutions to best 
serve the urgent and enduring needs of warriors and their families with 
psychological health and/or traumatic brain injury concerns.

    --  The Real Warriors Campaign promotes the processes of building 
resilience, facilitating recovery and supporting reintegration for 
returning service members and their families.

    The Navy supports a comprehensive mental health strategy to provide 
high quality, evidence-based care for Active Duty Service members, 
reservists, and their families. Navy Medicine continues to improve and 
enhance access to care for Active Duty members and their families by 
increasing the size of the mental health work force and opportunities 
to interact with behavioral health providers. The Behavioral Health 
Integration Program in the Medical Home Port has being implemented 
across 67 Navy sites, as well as 6 Marine Corps sites. This program 
embeds behavioral health providers in the primary care setting to 
increase access and reduce
stigma.
    Navy Medicine continues to focus on the mental health needs of 
reservists. In FY12, the Navy and Marine Corps Reserve Psychological 
Health Outreach Program (PHOP) provided over 11,000 outreach contacts 
to returning Service members and provided behavioral health screenings 
for approximately 1,000 reservists. Similarly, as of December 2012 over 
12,000 military family members participated in our Returning Warrior 
Workshops (RWWs) for reservists. RWWs are funded through Defense Health 
Program and Navy appropriations.
    Ms. Shea-Porter. 9) Do DSPO and the Services have a strategy and 
the capacity, to provide adequate mental health screening and care for 
families? If not, how are they partnering with civilian social services 
and non-profit organizations to fill the support gaps? New Hampshire's 
National Guard Yellow Ribbon Program, for example, partners with Easter 
Seals to provide needed support.
    Admiral Van Buskirk. Yes; Navy Medicine continues to support a 
comprehensive mental health strategy to provide ready access to high 
quality, evidence-based, mental health care for military members and 
their families. This includes prevention and resilience-building 
services, as well as more traditional treatment. For instance, Navy's 
FOCUS program (Families Over Coming Under Stress), which is widely 
recognized as a model for prevention/intervention psychological health 
services for military families, provided services to over 91,000 
military family members in Fiscal Year 2012. Outcomes have shown 
statistically significant improvements in anxiety and depression among 
both children and parents.
    Family members can also access mental health care through our 
Behavioral Health Integration Program, part of Medical Home Port, which 
embeds behavioral health providers in the primary care setting to 
increase access and reduce stigma. This program has been implemented 
across 67 Navy and six Marine Corps sites.
    Navy Medicine also continues to place the highest priority on the 
mental health needs of reservists and their families. In Fiscal Year 
2012, the Navy and Marine Corps Reserve Psychological Health Outreach 
Program (PHOP) provided over 11,000 outreach contacts to returning 
service members and behavioral health screenings for approximately 
1,000 reservists. PHOP staff made over 500 visits to reserve units 
providing over 800 presentations to approximately 19,000 reservists, 
family members and commands. As of December 2012, over 12,000 service 
members and their loved ones have participated in 100 Returning Warrior 
Workshops (RWWs), which assist demobilized service members and their 
families in identifying immediate and potential issues that often arise 
during post-deployment reintegration.
    Ms. Shea-Porter. 10) Are family member (spouses and children) 
suicides being tracked by DSPO and/or the Services? If not, why not?
    Admiral Van Buskirk. Navy does not track family member suicides. 
There is no statutory or policy requirement to do so, and no reporting 
mechanism in place by which to track family member suicides.

    Ms. Shea-Porter. 11) What steps are the Defense Suicide Prevention 
Office and the Services taking in terms of support and treatment, to 
meet the mental health challenges facing spouses and children? There 
are some innovative National Guard Yellow Ribbon Programs, like that of 
our own New Hampshire National Guard, that follow and support families 
as well as Guard members before, during, and after deployment. Are you 
talking to the States and incorporating the best practices of such 
programs?
    General Jones. A variety of programs provide support for the mental 
health needs of spouses and dependent children. Each installation has a 
Family Advocacy Program, which provides outreach and prevention 
services to families. One novel Family Advocacy Program approach is the 
New Parent Support Program, which provides support and guidance in the 
home to parents screened as high risk for family maltreatment. 
Educational and Development Intervention Services are provided by a 
child psychologist for special education children in Department of 
Defense schools. Other programs provide education on common family 
issues like good parenting, couples communication, or redeployment 
integration. Counseling for families is also available. Military 
OneSource is a Department of Defense program using a civilian network 
that provides face-to-face, telephonic, or online counseling/
consultation to service members and families for up to 12 sessions. 
Also, Office of the Secretary of Defense-funded Military and Family 
Life consultants and Child and Youth Behavioral consultants offer 
confidential, non-medical, short-term counseling services, which 
address issues common in military families such as deployment stresses 
and relocation. Family members not able to be seen at military medical 
treatment facilities have access to services through community TRICARE 
providers. TRICARE network providers offer an array of services from 
individual counseling and group therapy, to inpatient behavioral health 
care. However, these services vary significantly from location to 
location. This is due to a nationwide shortage of doctoral level child 
and adolescent psychiatrists and psychologists.
    The Yellow Ribbon Program offers resources on behavioral health 
issues and suicide mitigation and is offered to Reserve and Air 
National Guard (ANG) Airmen and their families pre-deployment, during 
deployment, and post deployment. Funded by Yellow Ribbon, the 
Psychological Health Advocacy Program (PHAP) is designed to assist 
Reserve Airmen and their family members with a variety of needs, 
including mental health issues, financial assistance, relationship and 
family counseling, and substance abuse through referrals. The ANG 
Psychological Health Program (PHP) was developed to address 
psychological health needs of ANG Airmen and their families. The PHP 
places a licensed behavioral health provider at each of the ANG's 89 
wings throughout the 54 states, territories and the District of 
Columbia. The program provides three categories of service: leadership 
advisement and consultation; community capacity building; and direct 
services--to include assessment, referral, crisis intervention, and 
case management--that are available daily. The Wing Directors of 
Psychological Health are available 24/7 to operational leadership and 
provide services to ANG Airmen and their family members regardless of 
whether they are at home or on duty status. Both ANG Wing Directors of 
Psychological Health and AFRC Psychological Health Advocates work with 
their local communities to develop resources, referrals, and 
partnerships to maximize services for Airmen. Additionally, mental 
health and personnel leaders from ANG, Reserve and each of the services 
participate in the Department of Defense and the Department of Veterans 
Affairs level committees on suicide prevention and psychological health 
where they share best practices and ideas.
    TRICARE Reserve Select is available for Reserve Component Airmen 
and their family members and provides coverage for both outpatient and 
inpatient treatment. Access to military medical care is available to 
service members with duty-related conditions through TRICARE and the 
Department of Veterans Affairs.
    Since Air Reserve Component wingmen (e.g. family, friends) are 
often non-military personnel, the ANG's Wingman Project provides 
information and resources for suicide prevention on publicly-accessible 
websites. The ANG tailors marketing and resource materials for each 
state. The primary goal of the Wingman Project, located at http://
wingmanproject.org, is to reduce warfighter, Department of Defense 
civilian, and family member suicides through human outreach, education, 
and media. The Air Force Reserve Wingman Toolkit is a broad-based Air 
Force Reserve initiative designed to empower Airmen and their families 
to achieve and sustain health, wellness, and balanced lifestyles by 
using the four domains of Comprehensive Fitness. The toolkit is located 
at: http://AFRC.WingmanToolkit.org. The Wingman Toolkit provides 
Commanders, Airmen, families, and friends (i.e., Air Force Reserve 
Wingmen), access to a wide variety of resources, training 
opportunities, a dedicated Wingman Day page, promotion of the Ask, 
Care, Escort (A.C.E.) suicide intervention model, educational outreach 
materials, social media (Facebook, Twitter, Etc.), a mobile phone 
application, Short Message Service (SMS) texting capability (``WMTK'' 
to 24587), inspirational and training videos, a YouTube page, and 
partnerships with other organizations.
    Finally, the Military (or Veterans) Crisis Line, 1-800-273-8255 
(TALK), Press #1, www.militarycrisisline.net, or text to 838255 is 
available 24/7 to all service members and their families. It is a joint 
venture between the Department of Defense and the Department of 
Veterans Affairs' call center, which is associated with Substance Abuse 
and Mental Health Service Administration's National Suicide Prevention 
Lifeline. Resources include an online ``Veteran's Chat'' capability and 
the call center's trained personnel provide crisis intervention for 
those struggling with suicidal thoughts or family members seeking 
support for a Veteran.
    Ms. Shea-Porter. 12) Do DSPO and the Services have a strategy and 
the capacity, to provide adequate mental health screening and care for 
families? If not, how are they partnering with civilian social services 
and non-profit organizations to fill the support gaps? New Hampshire's 
National Guard Yellow Ribbon Program, for example, partners with Easter 
Seals to provide needed support.
    General Jones. Through the TRICARE network and community 
organizations, the Air Force Medical Service (AFMS) has a strategy and 
the capacity to provide mental health screening and care for families. 
Air Force family members' care typically is provided by TRICARE 
providers in the community. There are several options to purchase long-
term healthcare insurance for Air Reserve Component family members, to 
include TRICARE Reserve Select, if eligible. TRICARE provides coverage 
for both outpatient and inpatient treatment.
    The Air Force Reserve Wingman Toolkit and Air National Guard 
Wingman Project Websites provide 24/7/365 support and information. 
These websites provide links to local, city, state, and national 
organizations that provide behavioral health services to service 
members and their families. Organizations include, but are not limited 
to, the Substance Abuse and Mental Health Services Administration, 
Military Pathways, and The Center for Deployment Psychology.
    Air Force Reserve Psychological Health Advocacy Program (PHAP) 
staff are present and conduct break-out sessions for the members 
returning from deployment. During these sessions, the members are given 
instructions on accomplishment of mental health screening, as well as 
recommendations for follow-up. This information is also available on 
the PHAP website, as well as through each regional office.
    The Air National Guard Psychological Health Program (PHP) was 
developed to address psychological health needs of Air National Guard 
(ANG) Airmen and their families. The PHP places a licensed behavioral 
health provider at each of the ANG's 89 wings throughout the 54 states, 
territories and the District of Columbia. The program provides three 
categories of service: leadership advisement and consultation; 
community capacity building; and direct services--to include 
assessment, referral, crisis intervention, and case management--that 
are available daily. The Wing Directors of Psychological Health are 
available 24/7 to operational leadership and provide services to ANG 
Airmen and their family members regardless of whether they are at home 
or on duty status.
    Finally, Military OneSource is a nonmedical counseling option 
available to active duty, reserve component members and their adult 
family members.
    Ms. Shea-Porter. 13) Are family member (spouses and children) 
suicides being tracked by DSPO and/or the Services? If not, why not?
    General Jones. The Air Force does track family member (spouses and 
children) deaths to disburse monetary benefits and funeral 
entitlements; however, the Air Force does not track the cause of each 
family member death (specifically, suicides). We do not have access to 
specific information about family member deaths other than that in the 
public domain; the Centers for Disease Control and the American 
Association of Suicidality. The Air Force is collaborating with the 
Defense Suicide Prevention Office to study this issue and determine if 
a reliable process or database can be developed to track this 
information in the future.

    Ms. Shea-Porter. 14) What steps are the Defense Suicide Prevention 
Office and the Services taking in terms of support and treatment, to 
meet the mental health challenges facing spouses and children? There 
are some innovative National Guard Yellow Ribbon Programs, like that of 
our own New Hampshire National Guard, that follow and support families 
as well as Guard members before, during, and after deployment. Are you 
talking to the States and incorporating the best practices of such 
programs?
    General Hedelund. The Yellow Ribbon Reintegration Program supports 
reintegration efforts by providing access to programs, resources, and 
services geared to minimizing stressors before, during, and after 
deployments of 90 days or more. It is not used as a mental health 
screening vessel. Counselors are on-site for each event to address 
stress and finances as well as address the common challenges our 
Service members and their families face. These events are structured to 
follow a Reserve Marine and family (family is defined as mom, dad, 
spouse, children, significant other) or their designated 
representative, throughout their entire cycle of deployment from the 
call to mobilization and then their re-assimilation to civilian life. 
The more prominent focus of these events is addressing those areas most 
likely to trigger stress responses such as employment, finances, and 
education. By targeting these areas, and making counselors available at 
every opportunity, we hope to address issues prior to them building and 
causing a significant stress response by the individual. In FY12 
MARFORRES executed 209 Yellow Ribbon events nation-wide, supporting 
3,766 family members and designated representatives, and 5,984 Service 
members. Supporting programs at each of these events are the 
Psychological Health Outreach Team for the Unit/Region (PHOP), Unit 
Personal and Family Readiness Program, as well as local Unit 
Leadership. Additional assistance remains available on an on-going 
basis for every Marine and family through the DSTRESS Program, Unit 
Chaplains, and the Unit Personal and Family Readiness Program.
    Ms. Shea-Porter. 15) Do DSPO and the Services have a strategy and 
the capacity, to provide adequate mental health screening and care for 
families? If not, how are they partnering with civilian social services 
and non-profit organizations to fill the support gaps? New Hampshire's 
National Guard Yellow Ribbon Program, for example, partners with Easter 
Seals to provide needed support.
    General Hedelund. Medical treatment for diagnosable mental health 
conditions is available to family members through the TRICARE system 
(either military treatment facility or network providers). Should 
specialty care not be available within the system, patients may be 
referred to non-network providers. Marine Corps Community Services 
(MCCS) offers non-medical, short term counseling programs to Marines 
and their family members for problems such as anger management, coping 
with loss or separation, parenting, etc. Family members also have 
access to counseling from Military OneSource, where they can deal with 
a credentialed counselor telephonically or in person with a 
geographically local counselor. Both MCCS and OneSource ensure a warm 
handoff to the medical system should the family member's condition 
warrant a medical referral.
    Project FOCUS (Families Overcoming Under Stress), initiated by the 
Navy Bureau of Medicine and Surgery (BUMED) in 2008, provides state-of-
the-art family resiliency and psychological health services to military 
children and families at over 20 Navy and Marine Corps sites and online 
for those in remote locations. FOCUS is a family-centered resiliency 
training program developed from evidenced-based interventions that 
enhance understanding, psychological health, and developmental outcomes 
for highly stressed children and families facing challenges related to 
multiple deployments, combat operational stress, and physical injuries 
in a family
member.
    Ms. Shea-Porter. 16) Are family member (spouses and children) 
suicides being tracked by DSPO and/or the Services? If not, why not?
    General Hedelund. The Marine Corps tracks suicides by dependents of 
active duty Marines. The reporting of the information is not required 
by DOD.

                                  
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