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




 
                  SERVICE SHOULD NOT LEAD TO SUICIDE:

                   ACCESS TO VA'S MENTAL HEALTH CARE
=======================================================================



                                HEARING

                               before the


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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, JULY 10, 2014

                               __________

                           Serial No. 113-79

                               __________

       Printed for the use of the Committee on Veterans' Affairs


         Available via the World Wide Web: http://www.fdsys.gov
         
                                 __________
 
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

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


                            C O N T E N T S

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                                                                   Page

                        Thursday, July 10, 2014

Service Should Not Lead To Suicide: Access to VA's Mental Health 
  Care...........................................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    77

Hon. Michael Michaud, Ranking Minority Member....................     2
    Prepared Statement...........................................    77
Hon. Corrine Brown
    Prepared Statement...........................................    78
Hon. Scott Peters
    Prepared Statement...........................................    79

                               WITNESSES

Howard and Jean Somers, Parents of Daniel Somers, Deceased.......     4
    Prepared Statement...........................................    81

Susan and Richard Selke, Parents of Clay Hunt, Deceased..........     6
    Prepared Statement...........................................    83


Peggy Portwine, Mother of Brian Portwine, Deceased...............     8
    Prepared Statement...........................................    85


Josh Renschler, Sergeant, U.S. Army (Ret.).......................     9
    Prepared Statement...........................................    86


Maureen McCarthy M.D., Deputy Chief Patient Care Services 
  Officer, Veterans Health Administration U.S. Department of 
  Veterans Affairs...............................................    48
    Prepared Statement...........................................    93

    Accompanied by:

        Harold Kudler M.D., Acting Chief Consultant for Mental 
            Health Services, Veterans Health Administration U.S. 
            Department of Veterans Affairs

        David Carroll Ph.D., Acting Chief Consultant for 
            Specialty Mental Health, Veterans Health 
            Administration, U.S. Department of Veterans Affairs

        Michael Fisher, Program Analyst, Readjustment Counseling 
            Service, U.S. Department of Veterans Affairs

Alex Nicholson, Legislative Director, Iraq and Afghanistan 
  Veterans of America............................................    50
    Prepared Statement...........................................   100


Lt. General Martin R. Steele (USMC, Ret.), Associate Vice 
  President for Veterans Research, Executive Director of Military 
  Partnerships, Co-Chair of the Veterans Reintegration Steering 
  Committee University of South Florida..........................    52
    Prepared Statement...........................................   105


Warren Goldstein, Assistant Director for TBI and PTSD Program, 
  National Veterans Affairs and Rehabilitation Commission, The 
  American Legion................................................    54
    Prepared Statement...........................................   114


Jonathan Sherin M.D., Ph.D., Chief Executive Officer, Executive 
  Vice President for Military Communities, Volunteers of America.    56
    Prepared Statement...........................................   120

                        STATEMENT FOR THE RECORD

General Steele, Neurocognitive Perspectives on PTSD, mTBI and 
  Suicide in the Military........................................   124

American Foundation for Suicide Prevention.......................   130

CNS Response.....................................................   135

Swords to Plowshares.............................................   145

Vietnam Veterans of America......................................   158


Report by Citizens Commission on Human Rights International......   168

                        QUESTIONS FOR THE RECORD

Letter and Questions From: Ranking Member Michael Michaud, To: VA   198
Questions From: Ranking Member Michael Michaud and Responses 
  From: VA.......................................................   200


 SERVICE SHOULD NOT LEAD TO SUICIDE: ACCESS TO VA'S MENTAL HEALTH CARE

                        Thursday, July 10, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 9:15 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present:  Representatives Miller, Lamborn, Bilirakis, Roe, 
Runyan, Benishek, Huelskamp, Coffman, Wenstrup, Cook, Walorski, 
Jolly, Michaud, Brown, Takano, Brownley, Titus, Kirkpatrick, 
Ruiz, Negrete McLeod, Kuster, O'Rourke, and Walz.
    Also Present: Representatives Peters, and Sinema.

           OPENING STATEMENT OF JEFF MILLER, CHAIRMAN

    The Chairman. This hearing will come to order. Before we 
begin I would like to ask unanimous consent for our colleagues, 
Representative Scott Peters from California and Representative 
Kyrsten Sinema from Arizona to sit at the dais with us and 
participate in the proceedings today. Without objection, so 
ordered.
    I would like to welcome everybody to today's full committee 
oversight hearing entitled, ``Service Should Not Lead to 
Suicide: Access to VA's Mental Health Care.''
    Following a committee investigation which uncovered 
widespread data manipulation and accompanying patient harm at 
Department of Veterans Affairs medical facilities all across 
this nation, this committee has held a series of full committee 
oversight hearings over the last several weeks to evaluate the 
systemic access and integrity failures that have consumed the 
VA health care system. Perhaps none of these hearings have 
presented the all too human face of VA's failures so much as 
today's hearing will. A hearing that I believe will show the 
horrible human costs of VA's dysfunction and I daresay 
corruption.
    At its heart access to care is not about numbers, it is 
about people. Recently the committee heard from a veteran who 
had attempted to receive mental health care at a VA community 
based outpatient clinic in Pennsylvania. This veteran was told 
repeatedly by the VA employee he spoke with that he would be 
unable to get an appointment for six months. However, when that 
employee left another VA employee leaned in to tell this 
veteran that if he just told her that he was thinking of 
killing himself she would be able to get him an appointment 
much sooner, in just three months instead of six. Fortunately 
that veteran was not considering suicide. But what about those 
veterans who are? How many of the tens of thousands of veterans 
that VA has now admitted have been left on waiting lists for 
weeks, months, and even years for care were seeking mental 
health care appointments? How many are suicidal, or edging 
towards suicide as a result of the inability to get the care 
that they have earned?
    Despite significant increases in VA's mental health and 
suicide prevention budget, programs, and staff in recent years, 
the suicide rate among veteran patients has remained more or 
less stable since 1999 with approximately 22 veterans 
committing suicide every single day. However, the most recent 
VA data has shown that over the last three years rates of 
suicide have increased by nearly 40 percent among male veterans 
under 30 who use VA health care services, and by more than 70 
percent among male veterans between the ages of 18 and 24 who 
use VA health care services.
    This morning we are going to hear testimony from three 
families: the Somers, the Selkes, and the Portwines, who will 
tell us about their sons Daniel, Clay, and Brian. Three 
Operation Enduring Freedom and Operation Iraqi Freedom veterans 
who sought VA mental health care following combat. Each of 
these young men faced barrier after barrier in their struggle 
to get help. Each of these young men eventually succumbed to 
suicide. In the note he left behind Daniel Somers wrote that he 
felt his government had abandoned him and referenced coming 
home to face a system of dehumanization, neglect, and 
indifference. VA owed Daniel, and Clay, and Brian so much more 
than that.
    With that, I yield to our Ranking Member Mr. Michaud for 
his opening statement.

    [The prepared statement of Jeff Miller appears in the 
Appendix]

 OPENING STATEMENT OF MICHAEL MICHAUD, RANKING MINORITY MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman, for holding 
this very important hearing. We have had many discussions and 
debates about how to deliver the best health care services to 
our nation's veterans and how to ensure accountability within 
the leadership ranks of the Department of Veterans Affairs. 
Over the course of these recent hearings and discussions we 
have touched on a number of important issues. But one that we 
have not zeroes in on too much yet has been access to mental 
health care and suicide prevention services for our veterans. 
That is why this hearing today is so important. And I would 
like to thank all of the panelists for joining us today. But 
particularly I want to thank the family members joining us who 
have lost a loved one.
    I know that speaking about a loss of a loved one, 
particularly a child, can be an incredibly difficult and 
exhausting experience. But in this case I think we have to 
listen to your stories, identify what went wrong, and we can 
take action to ensure that those failures are not repeated 
again. So I want to thank you very, very much for joining us 
today to share your stories.
    Eighteen to 22 veterans commit suicide each day. In my 
opinion that is 18 to 22 brave men and women each day who our 
system has let down in some capacity. It is totally 
unacceptable. When a veteran has experienced depression or 
other early warning signs that may indicate mental health 
issues or even suicide, that must be treated like an immediate 
medical crisis. Because that is exactly what it is. Veterans in 
that position should never be forced to wait months on end for 
a medical consult. Because quite frankly that is time that they 
may not have.
    We have taken steps to help put in place programs and 
initiatives aimed at early detection and we have significantly 
increased our funding. The Department of Veterans Affairs 
funding on mental health has doubled since 2007 but it is not 
working as well as we had hoped. And we have to figure out why, 
and how we can correct these problems.
    Our veterans are the ones paying the price for this 
dysfunction. A 2012 IG report found that VHA data on whether it 
was providing timely access to mental health services is 
totally unreliable. And a GAO report from that year not only 
confirmed that disturbing finding, but also said that 
inconsistent implementation of VHA scheduling policy made it 
difficult, if not impossible, to get patients the help that 
they need when they need it. That is why we have to look at 
this situation. That is a problem that we have seen repeatedly 
as we dig into the VA's dysfunctions, and enough is enough.
    Our veterans and their families deserve a VA that delivers 
timely mental health services that cover a spectrum of needs, 
from PTSD, to counseling for family members, to veterans, to 
urgent round the clock response to a veteran in need. A recent 
VA OIG report found that in one facility patients waited up to 
432 days, well over a year, for care.
    For once again, we are finding that our veterans deserve 
much better than the care that they are receiving in all of the 
areas that we must address. We have to look at it 
comprehensively. And I would argue that fixing mental health 
services is among the most important area. And I look forward 
to a productive discussion that will begin today as we look 
forward to trying to solve some of the problems with a 
dysfunctional department that we have seen over the last 
several months.
    And once again, Mr. Chairman, I want to thank you very much 
for having this very important hearing and for the panelists 
for coming today to tell your stories. With that, I yield back 
the balance of my time.

    [The prepared statement of Michael Michaud appears in the 
Appendix]

    The Chairman. Thank you very much to the ranking member. We 
are humbled and honored to be joined by our first panel of 
witnesses this morning. Family members of the three veterans 
who sadly and tragically lost their lives to suicide, and I am 
sure that I speak for each of my colleagues when I say that 
each of you have our deepest sympathies for your loss. I am 
both grateful and at the same time angry that you have to be 
here to share your stories of your sons with each of us. So if 
you could approach the witness table, please?
    Joining us is Dr. Howard and Jean Somers, the parents of 
Daniel Somers; Susan and Richard Selke., the parents of Clay 
Hunt; and Peggy Portwine, the mother of Brian Portwine. We are 
also joined on our first panel by Josh Renschler, a veteran of 
the United States Army who will share his very personal story 
of attempting to seek mental health care through the Department 
of Veterans Affairs. Thank you, sir, for your service, and for 
being here today. Dr. and Mrs. Somers, please proceed with your 
testimony.

              STATEMENT OF HOWARD AND JEAN SOMERS

    Mrs. Somers. Chairman Miller, Ranking Member Michaud, and 
committee members, we are grateful for this opportunity to 
testify today. We are especially pleased to see Arizona 
Representative Ann Kirkpatrick; and Daniel's Representative 
Kyrsten Sinema; and our own California Representative Scott 
Peters; who have been great allies to us in our efforts to 
advance reforms of the VA based on the experiences of our son.
    Dr. Somers. As many of you know our journey started on June 
10, 2013 when Daniel took his own life following his return 
from a second deployment in Iraq. At that time he suffered from 
Post Traumatic Stress Disorder, Traumatic Brain Injury, and 
Gulf War Syndrome. Daniel spent nearly six futile and tragic 
years trying to access the VA health and benefits systems 
before finally collapsing under the weight of his own despair. 
We have attached the story of Daniel Somers to our testimony, 
which provides the details of his efforts and we hope you will 
read it if you have not already done so.
    Today it is our objective to begin the process which will 
ultimately provide hope and care to the 22 veterans today who 
are presently ending their lives.
    Mrs. Somers. Just over a year ago and four days after 
Daniel's death, feeling fortunate that we at least had a letter 
from him, Howard and I, Howard is a urologist and I spent 30 
years in the business of health care, sat down with Daniel's 
wife, who has a Bachelor of Science in nursing, and his mother-
in-law who is a psychiatrist. Together we felt uniquely 
qualified to prepare a 19-page report that we titled Systemic 
Issues at the VA. We have shared that document with several of 
you over the last year and it is also attached to our 
testimony.
    The purpose of the report remains the same as when we wrote 
it, to improve access to first rate health care at the VA; to 
make the VA accountable to veterans it was created to serve; 
and to make every VA employee an advocate for each veteran.
    Dr. Somers. At the start Daniel was turned away from the VA 
due to his National Guard Inactive Ready Reserve status. Upon 
initially accessing the VA system he was essentially denied 
therapy. He had innumerable problems with VA staff being 
uncaring, insensitive, and adversarial. Literally no one at the 
facility advocated for him. Administrators frequently cited 
HIPAA as the reason for not involving family members and for 
not being able to use modern technology.
    Mrs. Somers. The VA's appointment system, know as VISTA, is 
at best inadequate. It impedes access and lacks basic 
documentation. The VA information technology infrastructure is 
antiquated and prevents related agencies from sharing critical 
information. There is a desperate need for compatibility 
between computer systems within the VHA, the VBA, and the DoD. 
Continuity of care was not a priority. There was not succession 
planning.
    Dr. Somers. No procedures in place for warm hand offs, no 
contracts in place for locum tenens, and a fierce refusal to 
outsource anyone or anything.
    At the time Daniel was at the Phoenix VA, there was no pain 
management clinic to help him with his chronic and acute 
fibromyalgia pain. There were few coordinated interagency 
goals, policies, and procedures. The fact that the formularies 
of the DoD and VA are separate and different makes no sense 
since many DoD patients who are stabilized on a particular 
medication regimen must rejustify their needs when they 
transfer to the VA. There were inadequate facilities and an 
inefficient charting process.
    Mrs. Somers. There was no way for Daniel to ascertain the 
status of his benefits claim. There was no VHA/VBA appointments 
system interfacing, nor prioritized proactive procedures. There 
was no communication between disability determination and 
vocational rehabilitation. This report is offered in the spirit 
of a call to action and reflects the experiences of Daniel with 
VA program services beginning in the Fall of 2007 until his 
death last June through our eyes.
    Dr. Somers. As seen through our eyes. Our concern then was 
that the impediments and deficiencies which Daniel encountered 
were symptomatic of deeper and broader issues in the VA, 
potentially affecting the experiences of a much broader 
population of servicemembers and veterans. Unfortunately this 
has been proven true as dramatically evidenced by recent 
revelations.
    Many of the reforms outlined in our report will require 
additional funding for the VA. But with that new funding should 
come greater scrutiny and a demand for better measurable 
results.
    Mrs. Somers. There is, however, an alternative to 
attempting to repair the existing, broken system. We believe 
Congress should seriously consider fundamentally revamping the 
mission of the VA health system. In the new model we envision 
the VA would transition into a center of excellence, 
specifically for war related injuries, while the more routine 
care provided by the rest of the VA health care system would be 
open to private sector service providers, much like Tricare. 
That approach would compel the current model to self-improve 
and compete for veterans' business. This would ultimately allow 
all veterans to seek the best care available while allowing the 
VA to focus its resources and expertise on the treatment of 
complex injuries suffered in modern warfare. Dr. Somers. We 
thank you for your time and would be happy to further discuss 
our recommendations and suggestions. We sincerely hope that the 
systemic issues raised here will provide a platform to bring 
the new VA administration together with lawmakers, VSOs, 
veterans, and private medical professionals and administrators 
for a comprehensive review and reform of the entire VA process. 
And if the VA Committee or Congress as a whole make the 
decision to involve other stakeholders in a more formal reform 
process, we would be honored to be among those chosen to 
represent the views of affected families. Thank you.
    Mrs. Somers. Thank you.

    [The prepared statement of Howard and Jean Somers appears 
in the Appendix]

    The Chairman. Thank you both for your testimony. Mr. and 
Mrs. Selke, you are recognized for five minutes.

              STATEMENT OF SUSAN AND RICHARD SELKE

    Mrs. Selke. Thank you. Chairman Miller, Ranking Member 
Michaud, and distinguished members of the committee, thank you 
for the opportunity to speak with you today about this 
critically important topic of mental health care access at the 
VA, suicide among veterans, and especially about the story and 
experience of our son, Clay. My name is Susan Selke, and I am 
accompanied here by my husband Richard. I am here today as the 
mother of Clay Hunt, a Marine Corps combat veteran who died by 
suicide in March, 2011 at the age of 28.
    Clay enlisted in the Marine Corps in May, 2005 and served 
in the infantry. In January of 2007 Clay deployed to Iraq's 
Anbar Province, close to Fallujah. Shortly after arriving in 
Iraq Clay was shot through the wrist by a sniper's bullet that 
barely missed his head. After he returned to Twenty nine Palms 
in California to recuperate, Clay began experiencing symptoms 
of Post Traumatic Stress, including panic attacks, and was 
diagnosed with PTS later that year.
    Following the recuperation from his gunshot wound, Clay 
attended and graduated from the Marine Corps Scout Sniper 
School in March of 2008. A few weeks after graduation Clay 
deployed again, this time to Southern Afghanistan.
    Much like his experience during his deployment to Iraq, 
Clay witnessed and experienced the loss of several fellow 
Marines during his second deployment.
    Clay received a 30 percent disability rating from the VA 
for his PTS. After discovering that his condition prevented him 
from maintaining a steady job, Clay appealed the 30 percent 
rating only to be met with significant bureaucratic barriers, 
including the VA losing his files. Eighteen months later, and 
five weeks after his death, Clay's appeal finally went through 
and the VA rated Clay's PTS 100 percent.
    Clay exclusively used the VA for his medical care after 
separating from the Marine Corps. Immediately after his 
separation, Clay lived in the Los Angeles area and received 
care at the VA Medical Center there in L.A. Clay constantly 
voiced concerns about the care he was receiving, both in terms 
of the challenges he faced with scheduling appointments as well 
as the treatment he received for PTS which consisted primarily 
of medication. He received counseling only as far as a brief 
discussion regarding whether the medication he was prescribed 
was working or not. If not, he would be given a new medication. 
Clay used to say, ``I am a guinea pig for drugs. They will put 
me on one thing, I will have side effects, and they put me on 
something else.''
    In late 2010 Clay moved briefly to Grand Junction, Colorado 
where he also used the VA there, and then finally home to 
Houston to be closer to family. The Houston VA would not refill 
the prescriptions that Clay had received from the Grand 
Junction VA because they said that prescriptions were not 
transferrable and a new assessment would have to be done before 
this medications could be represcribed. Clay had only two 
appointments in January and February of 2011 and neither was 
with a psychiatrist. It was not until March 15th that Clay was 
able to see a psychiatrist at the Houston VA Medical Center. 
But after that appointment, Clay called me on his way home and 
said, ``Mom, I cannot go back there. The VA is way too 
stressful and not a place I can go. I will have to find a Vet 
Center or something.''
    Just two weeks after his appointment with the psychiatrist 
at the Houston VA medical center, Clay took his life. After 
Clay's death I personally went to the Houston VA Medical Center 
to retrieve his medical records and I encountered an 
environment that was highly stressful. There were large crowds. 
No one was at the information desk. And I had to flag down a 
nurse to ask directions to the medical records area. I cannot 
imagine how anyone dealing with mental health injuries like PTS 
could successfully access care in such a stressful setting 
without exacerbating their symptoms.
    Clay was consistently open about having PTS and survivor's 
guilt and he tried to help others coping with similar issues. 
He worked hard to move forward and found healing by helping 
people, including participating in humanitarian work in Haiti 
and Chile after the devastating earthquakes. He also starred in 
a public service advertising campaign aimed at easing the 
transition for his fellow veterans and he helped wounded 
warriors in long distance road biking events. Clay fought for 
veterans in the halls of Congress and participated in Iraq and 
Afghanistan Veterans of America's Annual Storm the Hill in 2010 
to advocate for legislation to improve the lives of veterans 
and their families.
    Clay's story details the urgency needed in addressing this 
issue. Despite his proactive and open approach to seeking care 
to address his injuries, the VA system did not adequately 
address his needs. Even today we continue to hear about both 
individual and systemic failures by the VA to provide adequate 
care and address the needs of veterans. Not one more veteran 
should have to go through what Clay went through with the VA 
after returning home from War. Not one more parent should have 
to testify before a congressional committee to compel the VA to 
fulfill its responsibilities to those who have served and 
sacrificed.
    Mr. Chairman, I understand that today you are presented the 
Suicide Prevention for American Veterans Act. The reforms, 
evaluations, and programs directed by this legislation will be 
critical to helping the VA better serve and treat veterans 
suffering from mental injuries from War. Had the VA been doing 
these thing all along, it very well may have saved Clay's life.
    Mr. Chairman, Richard and I again appreciate the 
opportunity to share Clay's story and our recommendations about 
how we can help ensure the VA will uphold its responsibility to 
properly care for America's veterans. Thank you.

    [The prepared statement of Susan and Richard Selke appears 
in the Appendix]

    The Chairman. Thank you both for your testimony this 
morning. Ms. Portwine, you are recognized for five minutes.

                  STATEMENT OF PEGGY PORTWINE

    Ms. Portwine. Thank you, Mr. Chairman, Mr. Michaud, 
distinguished committee members. My son Brian Portwine gave 100 
percent to every task he performed and his military service was 
no exception. By the time he was 19 years old Brian was awarded 
the Purple Heart and the Army Commendation Medal. I am before 
you today to share Brian's story.
    At 17 Brian enlisted in the Army. After his training in 
infantry, he was deployed to Baghdad where he patrolled in Sadr 
City on the Haifa Streets. It was an extremely daunting 
serviced. This occurred before the surge of troops. During this 
tour, Brian lost 11 brothers.
    While serving in Iraq in 2006, Brian's Bradley tank was 
struck by an RPG. The flames swiftly engulfed the tank. The 
driver was knocked unconscious and the men fought for their 
lives as the driver was unable to hydraulically lower the ramp. 
The five soldiers scrambled through the flames, manually 
lowered the ramp, and exited, all with injuries. Brian suffered 
a blast concussion along with lacerations to his face and legs 
due to shrapnel and bone fragments. This was his first 
experience with traumatic brain injury.
    On yet another mission Brian and his First Sergeant were 
patrolling in Humvee when his Sergeant signaled for Brian to 
switch seats with him. They switched seats so Brian was now in 
the passenger seat. Twenty minutes later an IED hit the Humvee 
on the driver's side, killing his First Sergeant, and throwing 
Brian from the vehicle.
    Besides these two incidents he experienced six other IED 
explosions during his 15-month deployment. I would like to 
pause here and ask is this not enough to warrant a thorough 
evaluation and further testing? The powers that be apparently 
thought of sending Brian to Walter Reed Hospital, but did not. 
Are these experiences with the physical and mental injuries not 
enough to possibly exempt him for another deployment? 
Apparently the VA felt his care was iffy enough to stamp a no 
go on his clearance form but then it was crossed out and 
written go. How and why this decision was made is beyond me
    After his first deployment Brian was ecstatic to be home 
again. He enrolled in Daytona State College. He worked in the 
admissions counseling office. He created videos to share 
resources with students, hosted events, and linked students 
with part-time employment around their school schedules. But 
Brian suffered with short term memory loss. He would have to 
write everything on his computer, his iPhone, or his calendar. 
Many times his friends told me when he was out with them he 
would say, ``Where are we going again? You know I have got 
scrambled brains from Iraq.'' To help cope he posted all his 
events on his computer, his calendar, and his phone.
    In 2010 the military recalled Brian one month before the 
college year ended. Brian immediately dropped his classes that 
he excelled in. When I asked him why he said, ``Mom, there is 
no point. You have to get your mind in a completely different 
place. You have no idea what is coming.''
    During the second deployment Brian did not email or call 
home to any family or friends. Little did we know how he was 
struggling with anxiety attacks, panic attacks, traveling the 
same roads as the first tour. He knew the stigma of admitting 
PTSD, as all soldiers do. So they just man up and move on.
    Upon returning from the second deployment Brian was 
evaluated. He was diagnosed with PTSD, TBI, depression, and 
anxiety. At this time I would like you to refer to the 
documents that you received, Brian's medical documents. It is 
documented that Brian could not remember that questions asked 
from the therapist during the interview. He had extensive back 
pain. He could not sleep. He felt profound guilt. He suffered 
from low self-esteem and as a result he was a risk for suicide. 
Nonetheless he was just immediately discharged and told to 
follow up. How in the world you can ask someone who cannot 
remember the questions asked to follow up with the VA is beyond 
me.
    Brian deteriorated quickly from December, 2010 to May 27, 
2011 when he took his life. He could not stand how he would be 
angry, depressed, anxious. But he did not know how to cope. It 
took a to1l on his relationships. If the DoD and VA assessed 
Brian for suicide risk, it was their duty to treat him but he 
received nothing. He applied for disability but was unable to 
wait.
    Brian's unit has lost three others besides himself to 
suicide since the 2006 to 2008 tour. As you know, suicides 
surpassed combat fatalities for the first time in history. It 
is a very slippery slope from PTSD and TBI to death, something 
our VA should realize.
    Our soldiers never hesitated in their mission to protect, 
serve, and sacrifice for our country. Now it is time for the VA 
to prove their commitment to our soldiers. I never knew of 
Brian's PTS, TBI, or suicide risk. I think he felt, ``If I can 
survive two tours of Iraq, I can survive anything.'' I think it 
is a life threatening situation like this and it should be 
shared with the family so we are able to help. The VA needs to 
work with the service organizations, including the families in 
the plan for care.
    I am requesting, I am begging this committee to pass Act 
2182, the Suicide Prevention for Americans Act. This has been a 
most devastating war in history in terms of suicide. Our whole 
nation continues to suffer and everyday we continue to lose 22 
Brians a day.
    I promised my son at his funeral that I would stop this 
injustice. These are quality young men who potentially had so 
much to offer society. Please pass this Act 2182 and support 
any legislation that gives our soldiers and timely and loving 
care that they deserve. Thank you.

    [The prepared statement of Peggy Portwine appears in the 
Appendix]

    The Chairman Thank you, Ms. Portwine. Sergeant Renschler, 
you are recognized for your statement.

              STATEMENT OF SERGEANT JOSH RENSCHLER

    Sergeant Renschler. Chairman Miller, Ranking Member 
Michaud, members of the committee, I appreciate the opportunity 
to discuss VA mental health care. And I certainly want to 
acknowledge the loss and the courage of these family members 
ensuring that they were not in vain. And I struggle with the 
similarities of the stories. As an infantryman who lost so many 
in the Iraq War in injures, and struggled with thoughts of 
suicide from overwhelming chronic pain and other injuries, I 
just thank you all for being here.
    My experience with the VA health care system began in 2008. 
Sorry.
    The Chairman. That is okay. You have got plenty of time.
    Sergeant Renschler. After I was medically retired from the 
Army due to severe injuries from a mortar blast in Iraq. Excuse 
me. I have been a patient but I am also an advocate for other 
warriors who are struggling with deployment related traumas. 
For a period of about 12 months I did receive excellent mental 
health care at a VA facility. It provided easy, one-stop access 
through a deployment health model staffed by medical, mental 
health, pharmacy, and social work providers. Unfortunately, 
though, hospital administrators decided that this well-staffed 
interdisciplinary care was too costly. Now veterans at the 
facility go through an impersonal intake assessment process and 
then have to find their way around a sprawling facility to 
access the care that they need. For many warriors just 
navigating around the facility is anxiety provoking in itself, 
and for others it is so frustrating that they just drop out of 
care altogether.
    There is lessons to be learned here. First, veterans with 
mental health issues will seldom open up and discuss painful, 
private issues with a clinician that they have never met. They 
are more likely to discuss surface level issues, like 
difficulty sleeping. It takes time to build the trust to talk 
about the deeper issues. And not every clinician is skilled at 
winning the trust, or insightful enough to sense when there is 
deeper problems. Working with a team increases the likelihood 
of someone to see something that others may have missed.
    This has implications for suicide prevention as well. 
Veterans will rarely volunteer to clinicians that they are 
contemplating suicide and there are not necessary obvious signs 
that a veteran is a suicide risk. One thing is for sure, we 
will not prevent suicides by doctors mechanically going down a 
mandatory list asking questions like have you contemplated 
suicidal thoughts lately, or harming others. Sometimes there is 
red flags that an astute clinician can spot, like the break up 
of a relationship or other major life events that could lead a 
person to take a desperate act. But in a treatment system where 
I get sent to Building 3 for a neurologist for chronic back 
pain, Building 61 to see a psychiatrist for sleep problems, and 
Building 81 to see a social worker for relationship issues, no 
one is getting the full picture. So it is likely that no one is 
going to see if my life is spinning recklessly out of control.
    As an integrated health care system the VA can provide the 
kind of care that I want to receive from an interdisciplinary 
health team. There the team members shared observations and 
could see potential problems before they became explosive. So I 
think that the most important step that the VA can take to 
prevent suicide is to dramatically improve its mental health 
care delivery.
    Access is certainly an issue but we have to ask ourselves, 
access to what? Access to mental health care is not enough 
unless that care is effective. For example, providers who work 
with combat veterans need to understand the warrior mentality 
and they may have to work hard to earn that veteran's trust. If 
a clinician lacks that cultural awareness, or has too many 
patients to give each enough time, veterans will get frustrated 
and drop out of treatment.
    Also, veterans who are not ready for intense exposure based 
therapy will drop out of these multi-week treatment programs 
even though they are hailed as evidence-based therapy. The 
bottom line is that the VA care must be veteran centered. That 
has to mean recognizing each veteran's unique situation and 
individual treatment preferences and building a flexible system 
to meet the veteran's needs and preferences, not the other way 
around.
    The warriors that I am describing do not come into 
treatment for PTSD or anxiety when the textbooks say that they 
should. Most do not come in to treatment until they have 
reached a crisis point in their lives. Certainly a veteran in 
distress who finally asks for help for a combat incurred mental 
health condition needs to get into treatment immediately. But 
we will not solve that problem by establishing an arbitrary 
requirement like a 14-day rule. It does not help a warrior who 
is at the end of his rope to get assessed within 14 days but 
not actually begin treatment within three months. This is the 
way that the VA has currently implemented such policies. They 
have added additional steps to get into treatment so that you 
can see someone within 14 days. They have added a second intake 
process so now you intake-to-intake to finally get the 
treatment that you need.
    I know that some believe that the way to solve the veteran 
problem is to expand veteran access to non-VA care. I really 
personally doubt that that is any kind of silver bullet 
solution. The two big concerns with that is first detailed in 
my full statement. Many reports and studies point to a national 
shortage of mental health providers within the community. 
Secondly there is real quality of care issues here. VA could 
certainly benefit from a greater use of purchased care where 
and when it is available, and when it can be effective. But it 
would not help veterans just to be seen by providers who are 
not equipped to provide effective care, whether because of lack 
of training in treating combat related PTSD, or cultural 
competence, or any other reason. Again, it is not just a matter 
of access, but access to what? It has to be effective 
treatment. I do believe that there are VA facilities that are 
providing veterans with timely access to effective patient 
centered care but it is not systemwide.
    From my perspective the starting point for VA leadership at 
all levels is to adopt the principle that providing timely, 
mental health care for those with service incurred mental 
health conditions must be a top priority. The VA achieved that 
with its efforts to combat veteran homelessness recently. That 
tells me the VA can have a real impact when the direction and 
priorities are clear. When artificial performance requirements 
do not create distortions, and when clinicians have latitude to 
provide good care.
    Improving mental health care definitely requires a 
comprehensive approach. One part of that approach in my view 
should be to institute the kind of interdisciplinary team based 
model I described earlier. But the core of any approach has to 
center on the veteran and that patient's needs and preferences. 
We need a system that serves the veteran, not one that requires 
the veteran to accommodate the system.
    I hope that this hearing brings us a step closer to that 
kind of VA care system. And I thank you for the time, and I 
would be happy to answer any further questions that you may 
have.

    [The prepared statement of Josh Renschler appears in the 
Appendix]

    The Chairman. Thank you very much, Sergeant. Thank you, 
again, to all of the witnesses. Sergeant, if I could go back to 
you since you were the most recent person to testify. You 
talked about the interdisciplinary care team that you had for 
12 months. And then after that you alluded to the fact that the 
hospital director or somebody said that it cost too much to do 
it that way. I think we would all benefit from you elaborating 
a little bit about how that occurred and what did you transfer 
to? What type of a care?
    Sergeant Renschler. Yes, sir. In 2008 to 2009 the VA rolled 
out I believe four different deployment health care models 
nationwide. The deployment health care model that I speak of 
was one that was rolled out in Washington State for the 
American Lake VA Medical Center and it was put together by Dr. 
Steve Hunt with the VA. And this model provided one wing of a 
hospital floor in which an interdisciplinary care team for 
deployment health, Post 9/11 veterans exclusively, that had a 
pharmacist, social workers, psychiatrists, psychologists, and 
primary care on one team and weekly they would meet to discuss 
the caseload of that team. And the wait times were short for 
care, the quality of care was up, the management of our 
medications were the best that we had seen within the VA.
    However, after 12 months the team began to dissipate. And 
what I was told and have been told since by Dr. Steve Hunt and 
others within the VA is that this was a temporarily funded 
program and it was too costly to provide this level of care to 
exclusively Post 9/11 veterans within the VA Center when a 
facility director has to provide care for all veterans, to set 
aside the amount of funding that it required to provide this 
level of care for only one portion of that population was not 
practical.
    The Chairman. Mr. and Mrs. Somers, I would like for you to 
elaborate if you would just a little bit on the fact that you 
talked about Daniel having innumerable problems with VA staff 
being uncaring, insensitive, and adversarial. Saying literally 
no one at the facility advocated for him. Could you give us any 
specific examples, or generic examples?
    Mrs. Somers. Absolutely. Probably the most--if I do not 
make it through this Howard will finish--probably the most 
egregious event was when Daniel presented to their ER----
    Dr. Somers. It took Daniel a lot to go to the VA facility 
and some of the things that have been mentioned here were part 
and parcel of the fact. I mean, even along the highway in 
Phoenix there were speed traps on the highway. And when the 
lights flashed, that would give him flashbacks. Even if he was 
not the speeding, if he was going by on the highway at the 
time. So it was very difficult for him to drive down to the VA. 
It is busy. But he presented there in crisis. He presented to 
one of the departments, to the Mental Health Department. He 
said he needed to be admitted to the hospital. Now this is 
something that we have been told by his wife, who as Jean 
mentioned has a B.S.N. in Nursing, and his mother-in-law who is 
a psychiatrist. And he told them this on multiple occasions. So 
he was told that the Mental Health Department, they had no 
beds. And he was told by the same department that there were no 
beds in the Emergency Department.
    So this brings up another few issues. But the fact is that 
he went into the corner, he was, he laid down on the floor, he 
was crying. There was no effort made to see if he could be 
admitted to another facility. There are two major medical 
centers within a mile and a half of the Phoenix VA. The VISN 
issue is another issue that we need to discuss at some point. 
But he was told that you can stay here, and when you feel 
better you can drive yourself home. That is just an example of 
the lack of advocacy, the lack of compassion that we know that 
not only Daniel has encountered through the VA system. We have 
met other veterans, specifically in Oklahoma City, who had 
very, very similar circumstances at different VAs.
    The Chairman. Do you know if he ever spoke to any VA 
official about how he was treated?
    Dr. Somers. We do not. The other problem, of course, is 
that these visits are never, the appointment system is so 
antiquated that things are not even documented. There is no way 
to go back into the system and to document a contact in the 
system. So no, as far as we are aware, Daniel did not speak to 
anybody at the VA about this. It is just something he would not 
do. He just would not do. It was a feeling of I tried, and this 
is just another example of what the pressures that are brought 
to bear. We brought not only the VHA but the VBA issues into 
account. And these are just things that altogether just became 
overwhelming.
    Mrs. Somers. My believe is that he still had that military 
mentality. You know, this is what somebody in authority told 
you. I have to accept it. I cannot go above and beyond. I just 
need to accept what they are telling me.
    The Chairman. Thank you. Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman. Once again, 
I want to thank the panel for coming today to talk about your 
stories and your family. And I really appreciate it. I know it 
cannot be easy.
    So Dr. Somers, my question is can you go into further 
detail on about why you think it is important to encourage 
every veteran suffering with PTS and other combat related 
mental health issues to supply a list of points of contact and 
get a HIPAA waiver?
    Dr. Somers. Interesting that you say HIPAA. Because once 
somebody says HIPAA that sort of stops the conversation. We 
have been trying to deal with this issue because it takes a 
village, a large village, to not only treat but to recognize 
and to approach our veterans who might be in crisis. We feel it 
is critically important to expand what we call the support 
network. And actually at this point a HIPAA change would be 
wonderful. We really, we ran a medical practice and Jean can 
tell you that what we have come to learn is what HIPAA really 
says is not what, is not how, well is not how it is practiced. 
People are afraid of HIPAA. So they take the regulation that is 
actually there and they take it to the nth degree. And really 
you do have some options under HIPAA, especially if you feel 
that somebody is a threat to himself or to his family or to the 
community where you can reach out to family members or a 
caregiver in a situation like that.
    But we feel it is absolutely critical to identify prior to 
deployment, certainly during deployment, and after deployment 
what we call the support network so that these people can be 
educated as to what experiences their loved one, or maybe it is 
not even a loved one. Maybe it is a high school football coach, 
or maybe it is your, you know, math teacher, or maybe it is 
your best friend from the second grade. But so these people can 
be educated as to what the experiences might have been, what 
the signs and symptoms of crisis might be, and educated to the 
fact that you do not take no for an answer. And if you see that 
somebody is in trouble that you can direct them to the proper 
treatment, to the proper authority, to the proper medical 
facility. And that is not actually something that you have to 
worry about with HIPAA. So that is one way that we feel that 
HIPAA does not even come into the equation.
    HIPAA would come into the equation when you are in 
treatment. And we really feel that if you are treatment and 
there is an issue, then the therapist should certainly take the 
opportunity to contact the closest people to the patient.
    Mr. Michaud. Thank you. My second question related to 
HIPAA, because actually I heard a case where even though it is 
the Department, the Veterans Administration, where VHA 
employees could not talk to VBA employees and they used the 
excuse of HIPAA. Have you heard that, have you had that problem 
with your son?
    Dr. Somers. Well we have not heard that that was a HIPAA 
issue. We just felt that it was a total communication break 
down issue, the fact that the computer systems were not 
compatible within the VA system itself. And the fact that as 
far as we know Phoenix still uses a postcard system for 
appointments. And nobody could document the fact that postcards 
were even sent. And we know for a fact that after Daniel died, 
and the suicide prevention coordinator contacted his widow, and 
they were talking, and they were going to send her some 
information as to what kind of counseling facilities were 
available for her, and she asked where are you going to send 
it? They in their system had an address that was four years 
old. And he had been involved with the VBA and with the VHA 
over that entire period of time.
    Mr. Michaud. Thank you. I guess my time is quickly running 
out. For Mr. and Mrs. Selke, how long had Clay been taking 
medication for his PTS and how long was he denied medication 
through the VA?
    Mrs. Selke. He began taking medication in 2007 when he was 
back at Twenty nine Palms recuperating from the gunshot wound 
in Iraq. My understanding is that he, again, received 
medication that he needed when he was active duty. His care 
seemed to be good and he felt comfortable with it. When he 
transitioned to VA care he was never denied medication. What 
happened when he moved to Houston he was told that they could 
not refill his prescription that had, that followed him from 
the L.A. VA and he had been in Grand Junction, Colorado for a 
short time. He basically was having to start over as a new 
patient. And I had this reinforced yesterday in a meeting, that 
it was, that was one of his major frustrations and that I have 
heard from fellow veterans of his. That when they go to another 
facility they have to go back through everything. All the, you 
know, just recounting everything. And it, that seems ridiculous 
to have to have that type of redundant system.
    When he was told in Houston that they could not refill his 
prescription, he was told you need to call the VA that 
prescribed it, wrote the prescription earlier, and see if they 
will refill it for you. He was leaving the country. He was 
going to Haiti for a couple of weeks and he needed to have 
enough medication while he was gone. And Clay was proactive 
enough and was able to do that. He just was determined, and he 
said okay, and he took care of it. And he did get it from the 
Grand Junction VA. When he came back from Haiti and went to his 
appointment in February, that was with a psychologist, a 
clinical psychologist. And my understanding was he was never, 
he was not given a new prescription until he saw the 
psychiatrist on March 15th. So his first appointment was 
January 6th, second appointment February 10th or 11th, finally 
March 15th, sees a psychiatrist.
    Also part of that issue was when he was active duty Lexapro 
was finally found to be the drug that worked best for him. Name 
brand drug, no generic. But they, he had been on Paxil, he had 
been on Zoloft, he had been on just a variety of drugs. Lexapro 
seemed to work the best with the least side effects. When he 
came out of active duty and into the VA system, apparently 
generic drugs are the drugs of choice and he was given. I 
believe it is the generic for Celexa, which is close but it is 
not the same thing. At that time there was not a generic for 
Lexapro. When he arrived at the Houston VA and asked for a 
refill, and also somewhere in those first couple of 
appointments he said that he would like to go back on Lexapro 
as that worked better for him with less side effects, when he 
met with the psychiatrist he said, okay, I understand from your 
background that that has worked before. And he did give him a 
prescription for Lexapro.
    So Clay leaves on March 15th the psychiatrist's office, 
goes downstairs to the pharmacy at the VA to fill his 
prescriptions. He spent two hours in the pharmacy. He was 
called up to the pharmacy desk to pick up his prescriptions and 
given the Ambien for sleep. I have more on that that I want to 
share with you. And then given, told that they cannot give him 
Lexapro, they do not stock it because it is not a generic, that 
it will have to be mailed to him. So it was mailed to him 
sometime within the next week, I think they told him a week to 
ten days that he would get this.
    A couple of issues there. If you know about anti-
depressant, anti-anxiety medications, you cannot stop them 
cold. You cannot wait for it to come in the mail and then 
expect that it is going to work quickly. It takes a while for 
these to work. They have to stay built up in your system. He 
was extremely frustrated. He called me, as I said in my 
testimony, on the way home and said, ``I just, I cannot go back 
there.''
    The doctor at the Houston VA, I have spoken with him 
several times since Clay's death. He has been very forthcoming. 
I appreciate very much the information that he has given me. 
Something in our last conversation, which was just a couple of 
weeks ago that I had not heard before, I had been concerned 
about Ambien. There have been just a lot of conversations among 
parents and spouses and family members of veterans who have 
died of suicide and they have been on Ambien for sleep 
problems. Whether there is a connection or not, I do not know. 
But it is a high number that are given that when they have 
sleep problems. And sleep problems are a common, huge problem 
with Post Traumatic Stress. The doctor the other day in talking 
about specifically Ambien and sleep medications, he said, well 
actually Ambien would not be the best drug for the type of 
sleep problems, and I believe the term is hyperarousal but I am 
not 100 percent sure on that, for the type of sleep problems 
that come from Post Traumatic Stress. The nightmares, and 
flashbacks, and that sort of thing. There is another drug, it 
starts with a P. I do not have it with me. It is like----
    Sergeant Renschler Prazosin.
    Mrs.  Selke. Prazosin. And he said that really is the drug 
that actually works best for that type of sleep difficulty. And 
I was so stunned that I could not ask the question, well why 
did you not prescribe that drug for him as opposed to Ambien 
that he had been given over and over different times before? So 
that haunts, that has been something that has haunted us for 
three years.
    Because in that two-week window, something went wrong. Clay 
had moved back home. He had just returned from Haiti doing 
volunteer work, which gave him great, just great hope. That was 
great therapy for him. He had started a job. He had bought a 
truck. The Friday before he had called and asked me to meet him 
and he bought a truck for work. And by Thursday the next week, 
he was dead. We were with him over the weekend on that 
Saturday. The whole family at various points during the day saw 
him. He had lunch with his dad. We went to a movie, Richard and 
I went to a movie with him that evening. I could, I just, I 
just could not believe it, that within five days he was dead.
    So we know he suffered Post Traumatic Stress, we know he 
was treated for it. He was very open about it, sought help. And 
that, that two-week window is just a mystery that haunts us. 
And we have done everything we can to try to find out answers. 
So----
    The Chairman. Thank you. Mr. Lamborn for five minutes.
    Mr. Lamborn. I want to thank you all for being here. You 
have given so much. And I thank you, I know the committee 
thanks you, and I know our country thanks you.
    I would like to ask about the role of families in treatment 
and therapy. I have a constituent who came to me and her 
husband was stationed with the 10th Special Forces at Fort 
Carson, Colorado, where I represent. And he took his life. And 
she is an advocate for a program that has a holistic approach 
involving families, whether it is parents or spouses. And I 
would like to ask any one of you who has insight as to whether 
there should be more of a role for families in the treatment 
programs that are offered through the VA? Or is there a lack 
there?
    Mrs. Somers. We certainly during the time that Daniel was 
with the VA, certainly feel that there was a lack. And again, 
we feel it has a lot to do with fear of repercussions under the 
HIPAA law and also a total misunderstanding of what the law 
currently is. And I would like to take your point further and 
say it should not just be family. I think we would all like to 
say we did not have dysfunctional families, but we know that 
there are dysfunctional families out there and that is why we 
started using the term support network. A lot of young men and 
women undoubtedly joined the service to get away from families, 
but it does not mean that they do not have a support network. 
So we would kind of like to get away from the whole blood, 
kinship viewpoint and say it is a support network.
    I think it goes without saying, I recently read a report by 
National Association of Mental Illness. There is no question 
that family involvement is beneficial. There is just no 
question. It becomes more of an issue I believe, and it is why 
Howard and I have actually been trying to work with the DoD to 
get them to identify a support network. Because certainly in 
Daniel's case, Daniel was a geek. But he was at his absolute 
healthiest, mentally and physically, after he joined the Army. 
And he went through basic training, he was in great shape. If 
they could have identified right then, and said, Daniel, give 
us a support network for you. Who would you write down? You 
know, I mean, he had really, really good friends. We hope we 
would have been on it. Certainly his wife would have been on 
it. His mother-in-law probably would have been on it, his 
brother-in-law. It would have been so helpful to have that list 
then. Because when he got back home he was not capable of that 
anymore. I like to say, you know, not from a legal standpoint, 
but he had diminished capacity. He was not making correct 
decisions.
    Mr. Lamborn. Okay, okay. Anyone else? Mr. Selke.
    Mr. Selke. Thank you. Our experience, like most, probably a 
lot of families is, we did not know what PTS was. We had no 
idea. Clay was again very open about it, told us that he had 
been diagnosed with it, told us that he was on medication, 
seeking counseling. But we did not know the ramifications of 
that. And like most of our warriors, they are strong. And so he 
was, you know, put on a real good act. Had we known the extent 
of even what he talked to his counselors about, the idea that 
the Somers have broached about regardless of the HIPAA 
legalities of that, for if in fact somebody has that 
conversation with their, that counselor, somebody outside of 
that counselor and the patient needs to know. The patient could 
identify somebody who would then be able to be aware of what is 
going on and to say, you know, this person needs help.
    Clay, looking back, there was all kinds of things going on 
in his life that were just red flags. And we did not know. And 
there is a lot of literature out there, there is a lot of 
information. I believe that any family who has an individual 
involved in the military after they come back, or really kind 
of anytime, they should probably just assume that there may be 
some sort of PTS involved there.
    The suicide deal, Clay actually had a conversation with 
Susan. And said, ``Hey Mom, you know, I thought about it but I 
would never do that to you all.'' You know, he actually 
addressed the issue and then lied about it, you know, to us. So 
the family plays a huge part in really being advocates for the 
individual and being able to just watch, and watch for signs, 
and then maybe be able to do something about it.
    Mr. Lamborn. Well in conclusion I would just have to say 
the VA needs to learn best practices and have programs 
available that include families everywhere.
    Mrs. Selke. If I could add something to that? Going back 
through Clay's medical records, for whatever reason when he 
died I immediately wanted his medical records. I just wanted to 
read everything I could and try to grasp what was going on. He 
had apparently as early as November or December of 2009 spoken 
to someone in the VA in the L.A. VA about suicidal ideation, 
suicidal thoughts. That is on one of his reports at the end of 
2009. He had separated from the Marines at the end of April, 
2009. I knew nothing of that. We did not learn until the Fall 
of 2010 when he told us. He said, ``I have struggled with this 
thought, but I could never do that to you all. I just cannot.'' 
And I do not think, I think in his mind he believed, ``I am 
thinking these thoughts but I could never do that.'' As far as 
we know there were two times during the Fall of 2010 that he 
did have enough serious suicidal thoughts that he did reach 
out. One time he called and talked with me. Another time he 
spoke with a close friend. And then after that second time he 
shared with me, you know, that, or with all of us.
    So we knew, in 2010 at the end of the year we knew that he 
had struggled with suicidal thoughts and we also knew that he 
was on medication and were assuming that with Post Traumatic 
Stress and suicidal thoughts and that the VA knew best how to 
take care of him. I begged him, ``Please, let us go to private 
care. We will pay for it. We know great psychiatrists, 
counselors in Houston. Let us do that.'' He would not do that. 
He was adamant. He said, ``I have served in the Marine Corps 
for four years. My medical care is to come from the VA. They 
owe that to me. I do not want to go to private care. I want to 
talk to someone who has either been in War or knows about War 
and Post Traumatic Stress and the things that I have seen and 
done in War. I do not want to go to private care.'' And that 
was just his personal feeling. We have heard that from other 
veterans as well. That is, as difficult as the system is, that 
is their comfort zone and they need to be, feel that they can 
be taken care of.
    Mr. Lamborn. Thank you so much. Thank you. My hearts go out 
to you.
    The Chairman. Mr. Takano, you are recognized for five 
minutes.
    Mr. Takano. Thank you, Mr. Chairman. It is very difficult 
to listen to your stories and I am very touched by them. So I 
definitely want to thank all of the families for being here 
today.
    So let me ask this, Ms. Selke, I believe a lot of veterans 
have that same feeling. And therefore I do believe that we have 
to, it is incumbent upon us to make sure that we get it right 
at every facility. Because veterans are expecting that. They do 
not want to see this be a burden to their families financially. 
I am very much open to making it easier for non-VA care to be 
available and with that I wanted to ask Dr. Somers, you are 
also a medical doctor, Dr. Somers.?
    Dr. Somers. I am a urologist.
    Mr. Takano. Okay. Can you, can you tell me about the 
state--you are from the Phoenix area?
    Dr.Somers. Actually, I practiced in Phoenix. We currently 
live in San Diego.
    Mr. Takano. Oh, in San Diego. I am from Riverside, which is 
north of San Diego, as you know. I went to visit my own VA in 
Loma Linda. They are able to get veterans to see a family 
practitioner in 24 hours if need be. I am not so sure about 
mental health care or a psychiatrist. They indicated to me 
there is a shortage of psychiatrists. And I recently visited a 
new Kaiser facility and the director of that Kaiser facility 
told me that, I asked him if there was a, what shortages he was 
experiencing, and he identified behavioral health and 
psychiatry. Can you tell me if there is, if there are general 
shortages in your area of these kinds of practitioners?
    Dr. Somers. There is a shortage of mental health 
professionals nationwide. And there are many issues that go 
into it. Certainly reimbursement is one. We know one of the 
people that Daniel has been seeing because, and this is another 
issue of continuity of care, he was forced to go outside the VA 
system just because he could not be seen in Phoenix. There was 
just no availability, no mental health available. And I think 
you have to divide psychiatry and psychology. And I think with 
these people who are suffering from PTSD, it is the 
psychologists and the psychiatric social workers who are 
providing most of the care as opposed to the psychiatrists 
themselves. But psychiatry and psychology are incredibly 
important and what happens is if we try to recruit into the VA 
then the community is losing that mental health component. And 
it is a huge issue. It is an issue that has to be addressed by 
our medical schools, by society in general. But it is not just 
an issue here and there.
    Mr. Takano. Well here is the thing. Dina Titus and I, 
Representative Titus and I, and O'Rourke have offered a bill 
that would increase the number of residencies at VA hospitals. 
And of course I expect a number of those residents, if we 
approve it, a number of those residents would stay----
    Dr. Somers. Right.
    Mr. Takano [continuing]. And practice at the VA, but also 
some of them would go into the community as well.
    Dr. Somers. Right.
    Mr. Takano. You know, my thing is if, even if we do approve 
non-VA, make it more easy, easier for----
    Dr. Somers. Right.
    Mr. Takano [continuing]. Vets to use that areas like mine, 
they are still going to have trouble finding that care, you 
know, in the community.
    Dr. Somers. They will. And they are going to have trouble, 
even if you have people in the community you are going to have 
trouble finding people in the community who are aware of 
military culture, and who are aware of the issues that veterans 
face. And again, that just brings up another whole issue, a 
whole other series of issues.
    Mr. Takano. Well, I wish I had more time. Maybe I could get 
your information to my staff.
    Dr. Somers. Absolutely.
    Mr. Takano. Because I am trying to understand also your 
criticisms of the Vista medical records. There is also an issue 
of the interoperability with the VA and non-VA practitioners, 
right? So----
    Dr. Somers. Right. And then that is something that we 
address also, especially if we are going to be trying to, with 
the PC3 program, and with the other issues that are being 
promulgated now, there has to be communication between the VA 
and the providers who are seeing the veterans who are being 
referred out. So huge, huge----
    Mr. Takano. Huge issues.
    Dr. Somers. [continuing]. Issues that have to be addressed.
    Mr. Takano. Sergeant, I think I understand your point of 
view as well about your doubts about, you know, radically 
restructuring it. We have got to try to get it right in the VA 
facilities because of that expectation that the Selkes' son 
had, you know, that was their comfort zone. So we have got to, 
I think, do both things at once. Make sure that every VA center 
has, you know, excellent mental health care as well as try to 
provide some options.
    Sergeant Renschler. Yes, sir. My concern with a bill that 
just increases the number of practitioners at a hospital, we 
are not solving the issue with effectiveness of care. So it 
really has to be a systematic approach to solve the efficacy of 
what care is being provided as well as the numbers to 
accommodate the sheer overwhelming amount of veterans that are 
trying to access that already broken system. So I just wanted 
to add that, sir.
    Mr. Takano Thank you. Mr. Chairman?
    The Chairman. Dr. Roe, you are recognized for five minutes.
    Dr. Roe. Thank you, Mr. Chairman. And I think as a father 
of three and a veteran I appreciate your courage to come here 
today and speak. It is really heartwarming. And I know that it 
is very difficult for you to do, and it has been difficult to 
sit and listen to the testimony. There are a good number of 
veterans sitting up here. I am a veteran of the Vietnam era. 
And I just want to thank you for that, and being here. And I 
can tell you this past weekend I returned to something very 
joyous for me. It was a reunion of a bunch of young boys 
growing up in the sixties who were all Eagle Scouts. And all 
but one was there that, of our friends, and he did not make it 
out of Vietnam. So I can tell you that this loss that you have, 
that you are sharing with us, is very, very helpful. But that 
loss will go with you, as it does for my friend of almost 50 
years. So thank you for your courage to be here. I know it is 
very difficult.
    And Sergeant Renschler, I think you bring up a great point, 
all of you have today, in the coordinated effort that you 
brought forward. That team approach I think was very good and I 
certainly do understand what the VA was saying was that if this 
works for the OEF veterans, it should work for all veterans. 
And the majority of the suicides that are occurring are 
veterans of my age. So I think that this needs to be expanded 
if that method that you put forward, it looked like it worked 
extremely well, should be looked at.
    Dr. and Mrs. Somers. bring up an incredible point. I know 
Dr. Somers you probably dealt with some, as I did, some primary 
care in your practice when you were a urologist. You do not 
just get to be a urologist. Your patients get to know you. And 
they share a lot of things with you. And dealing with this is 
very complicated. As you all point out, and Ms. Selke so 
eloquently pointed out, is that this approach of caring for 
people with PTS or chronic mental illness is extremely 
difficult. Dr. Somers and I can go into the operating room and 
remove a tumor. That is easy. This is much more difficult to 
do. And those signs and symptoms are very difficult to spot. 
Because Ms. Selke, you saw your son when he was actually, you 
thought, doing very well that week before he passed. And I 
think as a doctor that has been one of the things that troubled 
me all of my career, was trying to figure out when you would 
have a patient that would take their life was why did this 
happen? And many times that week or two before things seemed to 
be going well. You thought things were getting better.
    I think, Dr. Somers, you and your wife brought up something 
I think that is extremely important, that a good friend is 
probably as important as a good doctor. A good person to lean 
on. And I think you have to do what Sergeant Renschler was 
talking about, to have this very sophisticated team together 
for people in need. But you also just need someone. It may not 
be a family member, like you pointed out, it could be a coach, 
or a pastor, or whomever it might be in your life. It could be 
a family member. And I think putting all that together is a 
real challenge. And I know we will hear later from the VA about 
what they plan to do. But any further thoughts along that line 
would be helpful. If anybody would like to share just some of 
your thoughts about what we could do.
    Ms. Portwine. I think it is important for the transition 
program. I know that before Brian went to Iraq, the first tour, 
he went to California where they have a base where they teach 
them, like they make it like a Iraqi town. So they learn how to 
control crowds, take buildings, and all that. But when they 
come back, it is just boom, you are there for a week and then 
you are out in the community. There is no transition. Why 
cannot they use those centers that they use to send them where 
they could have psychiatrists, psychologists, and look at them, 
give them assignments, see if anybody has poor concentration, 
poor memory. You know, and use these resources that we have. 
You know say, okay, now you need to go do laundry, give them a 
list of things to do. See if they are able to do that and 
observe them. We cannot just take them like cattle and put them 
through a bunch of questions and then let them go in the 
community where they do not have their brothers to confide in. 
When they come back they have put their life on the line to 
trust these other brothers. They would die for them. They come 
home, they do not have anybody they are going to trust that 
much. And nobody that has not been in war is going to 
understand so they do not open up. The most people they open up 
to is their brothers.
    Michigan has a program called Buddy to Buddy that they put 
together one veteran, you know, that has been home with the 
veteran so that if they have any problems they are going to 
open up to that person much more than they are a therapist. Or 
have group therapy. Let the veterans talk among themselves. 
They could, you know, have a group of eight, ten veterans and 
then have group therapy. And maybe they could confide in each 
other. Because it is going to take a while to build up trust 
with a therapist, if you do.
    Dr. Roe. I totally agree. Thank you very much for your 
courage in being here today. Mr. Chairman, I yield back.
    The Chairman. Ms. Brownley, you are recognized. I 
apologize. Ms. Kirkpatrick, you are recognized for five 
minutes.
    Ms. Kirkpatrick. Thank you, Mr. Chairman. I want to thank 
all of your for your courage in being here today. And I 
appreciate what you said about once a diagnosis is made and 
medication is prescribed, staying on that medication. And I 
really want to know how often our veterans have to refill those 
prescriptions. And I would just like to hear from each of you 
what you have learned about that experience. Are they given a 
30-day supply? They have to go constantly back? Sergeant, can 
we start with you? And then we will just work our way down the 
panel.
    Sergeant Renschler. Yes, ma'am. So at our facility in 
Washington State, medications are given on a 30-day supply. 
There is an option for mail refills. The system is pretty 
confusing and I normally mess it up pretty well so my wife has 
to manage that for me for the most part. You have to be able to 
put in a request three weeks before you need it and I usually 
forget until I am about to run out. And so then I am off my 
meds for a long period of time, which is never good.
    As far as the other medication issues that have been 
discussed, continuity of medications from one facility to the 
next, I am in the southern part of Washington State. And people 
who are coming up from Portland, Oregon, which is about an hour 
away, are on medications that are not transferrable to the VA 
facility where I am at. And so they have to start all over as a 
guinea pig, as what was discussed earlier, trying medications 
that they may have already tried in the past to get to the 
point where they are able to approve a non-formulary medication 
that they had at another facility, as well as the transition 
from DoD to VA care. It took about four years for the DoD to 
balance about nine medications for myself. And when we 
transitioned to VA care many of those medications were not on 
the formulary and we had to go back to the guinea pig phase 
again, and we ended up on 14 in order to utilize medications 
available through the VA. So it is, there are many issues as we 
are talking about that.
    Ms. Kirkpatrick. That is just unbelievable. Any other 
families want to----
    Ms. Portwine. Brian was never put on any medication. They 
diagnosed that he had depression, Traumatic Brain Injury, PTS, 
but he was never put on any medication. He was put on 
medication for his back when he was thrown from the Humvee, 
Naprosyn, and a muscle relaxer, and that was just temporary. 
But they never even prescribed, screaming out three times a 
week with nightmares and having your brothers wake you up, and 
then telling the therapist how embarrassing that was, I think 
you need to be on some medication.
    Ms. Kirkpatrick. Agreed.
    Mr. Selke. These medications are so subtle and they are so 
particular to the individual, it is just mind boggling that 
there is not an easy way to identify and work with the 
individual vet to determine exactly what the cocktail, if you 
will, looks like, and then be able to without, you know, to 
just seamlessly transfer that to wherever that vet is. These 
people are young and they are on the move. And you know, they 
are all over the place.
    Ms. Kirkpatrick. Right.
    Mr. Selke. And so that, those barriers just need to be 
taken down.
    Ms. Kirkpatrick. Dr. and Mrs. Somers?
    Dr. Somers. Yes, thank you. And thank you, Representative 
Kirkpatrick, for being such a support and a help for us. There 
is multiple issues that have to do with the medications. Just 
the fact that the formularies are not the same is a huge issue. 
And it just does not affect veterans at the VA system. There 
are veterans who are retired from the military who see 
physicians both at the VA and the DoD. So they are seeing 
people at both different medical centers and they cannot be on 
similar medications from one to the other because the 
formularies are not the same.
    The problem is that not only does the VA use 99 percent 
generics, but they use the cheapest generics. So Daniel, who 
had not only PTSD and TBI, but full blown Gulf War Syndrome, 
which included irritable bowel, had only certain medications 
that he could tolerate. So maybe the chemical in the medication 
is the same, but the bonding agent is different. Maybe he is on 
a medication that he only has to take once or twice a day, but 
the VA gets a better price, so now he has to take it three or 
four times a day. And the change in the medication changes 
everything. So I mean the issues, the issues are just huge. It 
is not only that, and the other thing that we have heard, and 
from unimpeachable sources, is that VAs vary, as we heard, with 
their pharmacy policies. There are some VAs where you can go 
and you can get a brand name medication with no problem. Other 
VAs that essentially it is possible to get a brand name 
medication. So, I mean, that just brings up this huge issue 
that we have, is why there is so much variation in the entire 
system, why we cannot have more uniformity within the VA system 
as a whole.
    Ms. Kirkpatrick. Thank you, Dr. Somers. My time is up. And 
thank you.
    Dr. Somers. Sorry.
    Ms. Kirkpatrick. But let me just conclude by saying your 
testimony is heartbreaking and I can barely hold back my tears, 
and I thank you for being here. I yield back.
    The Chairman. Thank you. Mr. Runyan, you are recognized for 
five minutes.
    Mr. Runyan. Thank you, Chairman. And thank all of you for 
sharing your stories and truly being great Americans and great 
patriots because your stories are going to help people in the 
future. And thank you for all that.
    A couple of points, and I think Dr. Somers was just talking 
about it. And I think we see it all day. And we talked about 
this in the hearing the other night. It almost seems like the 
VA is so fragmented that there is no overwhelming mission from 
the top with flexibility below. That is, and I think we are 
admitting there is a structural breakdown in how you are 
actually going to conduct business. And that is really where we 
are at, whether you are talking VHA or VBA. It is the same 
issue. And we have yet to hear, I think next week we are 
digging into some of the VBA issues, also. It is a culture.
    And one other point and then I will ask one question. And I 
know Mrs. Somers was talking about it, and Dr. Roe also 
validated it. When you talk about community and you talk about 
support networks, these men and women are spending more time 
away from the health care facility than they are in the health 
care facility. So friends, family members, you know, 
classmates, buddies all have to be part of the healing process. 
We are not doing that. And I know the term holistic has come up 
a few times. I think Sergeant mentioned it a couple of times. 
It is part of the healing process. There is no silver bullet to 
cure somebody. You have got to be able to help them in many 
different ways.
    That being said, in the VA's testimony they mention suicide 
prevention coordinators are supposedly placed at all VA medical 
centers and the large clinics. They are supposed to follow up 
with veterans that are at high risk. Were any of your sons ever 
contacted in that first month after they were designated high 
risk by a VA suicide prevention coordinator?
    Mrs. Somers. We are not aware of that. I mean, the fact 
that they did not even know where he lived would bear proof of 
that.
    Dr. Somers. And that is one of the issues that we are 
dealing with also, and that goes into the whole support network 
issue. Is that, and we have spoken to so many, so many families 
in the same situation, is that Daniel was married. And that 
basically shut us out of the equation. And that is where if we 
had the opportunity, if we could do some changes in this 
misinterpreted HIPAA regulation where we could have been more 
in touch with his therapist and they would have felt free to 
talk to us, where we feel that we could have been more help. 
But since he was married it was as if we did not exist.
    Ms. Portwine. I think that is an important point is like 
when Brian was injured in the tank explosion, I was notified. 
You know, it was three in the morning and they called me from 
Fort Hood saying that he was injured, where they had taken him, 
you know, he is back with his unit, you know. But yet you 
diagnose somebody with PTSD and TBI, which are, can be life 
threatening injuries, and nobody notifies you. I mean, that 
just does not make sense to me.
    Mr. Runyan. Anyone else?
    Mrs. Selke. Your point or question of being flagged as a 
high risk, this is something that came up that really baffled 
us, I guess. When Clay was transitioning or moving to Houston 
and starting to go the VA in Houston, his records apparently 
from what I was told, those records were not seamlessly 
electronically sent. They did not have his records from L.A., 
and that is where the bulk of his time was once he had gotten 
out of the Marines. So as I looked back through those medical 
records, as I said there were at least two or three times in 
there that it is talked about, and he talks and admits to 
having had suicidal thoughts. So I assume that he was flagged, 
would have been flagged, as a high risk. I mean, it says on the 
medical record high risk highlighted. When he comes to Houston 
VA, nobody knows he is a high risk. The psychiatrist did not 
have anything other than Clay saying this is what my past 
history has been and this is the medication I have been on. So 
that is a great point as to when are they flagged as a high 
risk? Do any family members know that? The only way I ever knew 
that anybody called him a high risk was when I got his medical 
records and poured over them after he had died.
    Mr. Runyan. Thank you. Chairman, I yield back.
    The Chairman. Ms. Brownley, you are recognized for five 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And I want to join 
my colleagues in thanking all of you for being here and sharing 
your stories and certainly through your stories about your 
sons, it certainly to me I feel their patriotism through your 
stories, and their overall most sincerest commitment and 
service to our country. So thank you for being here.
    I wanted to ask Sergeant Renschler a question. And so in 
your service when you were in theater, was there any support 
system in place for you to go to get any kind of, you know, 
mental health support while you were there? Hearing Brian's 
story, it was very gut wrenching to hear it. And, you know, 
just to wonder if Brian had a place to go to while he was in 
theater, how helpful that might have been in terms of his time 
there and his transition coming home?
    Sergeant Renschler. Ma'am, thank you. When I deployed was 
2003. It was right after the initial surge. It was a completely 
different war theater. We really did not have anything set and 
established at that time. So to answer the question, no there 
was not anything. However, again, I work with many, many 
veterans currently and active duty members. And I have been 
told in recent deployments in Afghanistan that after major 
events take place there is sometimes availability to have a 
type of a crisis debrief. It is somewhat available. It is not 
streamlined, it is not across the board, but it has been 
implemented on some level.
    Dr. Somers. If I may? The problem is that we know that 
there is an effort in the DoD to destigmatize mental health 
issues. But if you are in theater, I would venture to guess 
that it is going to be incredibly rare for somebody to take 
advantage of that, because all of a sudden they are going to be 
taken off duty. And the whole idea to destigmatize it is to 
say, okay, you come in for treatment, but then once you are 
better then you will be able to rejoin your unit or you will be 
able to regain your security clearance. But while you are under 
treatment you are not with your unit and you have lost your 
security clearance. So I mean, the issue is a huge issue. And 
we know from people that we have spoken to that the people at 
the top are aware of this and they are trying to deal with it. 
But there is just so much you can do on a boots on the ground 
level.
    Sergeant Renschler. Well, if I may? So there is two 
separate levels here. There is a crisis response, much like a 
CISM team that can go out and basically say, hey, this is what 
happened, these are the normal reactions to this type of a 
situation, if you experience this find somebody to talk to. So 
more of an education, immediate response. And that effort has 
been available. As he stated, most military servicemembers and 
veterans, as I stated earlier in my testimony, are not going to 
go and say, gee, that was a horrible experience, I think I 
should talk to somebody before I have issues. They are going to 
wait until it becomes a crisis point in their life and 
debilitating in nature before they seek treatment.
    Ms. Brownley. I just feel like if it was part of the 
culture being in theater that there is kind of constant 
dialogue that is going on. That that would have to be helpful 
to the men and women who are there. But----
    Ms. Portwine. Brian did tell me one time when they were on 
the 15-month tour there was one time that they lost four people 
in one mission. And when he was out there the morale was very 
low after that, because these were people that were high up, 
First Sergeants, and the Lieutenant and that. So they sent 
someone in and when the soldiers would go in and talk with 
them, he asked the same question. Well, was it sort of like a 
movie? And that just insulted them almost. As just like, why 
would you ask such a silly question? So they all shut down. And 
I think by not processing those thoughts then you are going to 
internalize them so they are never dealt with. I think even 
before they are in theater, I think in basic training, they 
should be taught PTSD and while they are deployed, and to 
report on each other for their own good, and in transitioning 
home. I do not think we can say it enough. That is my opinion 
on it.
    Ms. Brownley. Yes, thank you, thank you. I think it just 
confirms that, you know, we prepare our men and women to go and 
serve, and to go to War. We do not prepare them very well to 
transition back.
    Dr. Somers, you talked about HIPAA and the barriers to 
HIPAA, and we have talked about the family involvement piece. 
You mentioned also modern technology--am I . . .? I yield back. 
I apologize.
    The Chairman. Thank you very much. Dr. Huelskamp, you are 
recognized for five minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman. I just want to say 
thanks to the moms and dads and the Sergeant for your riveting 
testimony. I look forward to asking the VA some follow-up 
questions, and I yield back, Mr. Chairman.
    The Chairman. Thank you very much. Ms. Kuster, you are 
recognized for five minutes.
    Ms.  Kuster. Thank you, Mr. Chairman. And thank you to all 
the families for being with us today. I think for many of us 
sitting here today the pain is to recognize your commitment to 
give meaning to your sons' lives. I am a mother of two sons, 22 
and 25. I cannot fathom what you are going through. But I want 
you to know that we will do our part to give meaning to their 
lives. And it just makes me feel that personally I am becoming 
more and more anti-war, pro-veteran. And I think our country 
has had those priorities misplaced, getting us into conflict 
but not being focused on the cost, society costs to our country 
and to the population. These extraordinary young men and the 
promise that they held, going to Haiti, and making a difference 
right here.
    So I am going to focus in, because I think from your 
experience you can really help the VA and the DoD to understand 
what could make a difference, and I want to commend you all for 
the specificity of your recommendations. But in particular I 
have been trying to understand best practices and whether there 
is any effort within the VA where there are practices that are 
known, ground therapy for example, or the types of medications 
that are helpful. Have any of you in any of your discussions, 
whether within the VA or since then, the experience that you 
have had meeting with people, have any of you come across any 
effort to share best practices with the transition, 
particularly around PTS and TBI, and just the trauma. How we 
can help people coming back from this level of trauma. And I do 
not know, maybe we could start with the Sergeant. If you are 
aware of any types of programs that are effective?
    Sergeant Renschler. Thank you, ma'am. There are great 
things that are effective. But the problem is--even though we 
can group veterans together in a large sum, and combat 
veterans, and another category, it is hard to label one program 
as effective for all. So many find group therapy programming 
very successful. Many find combat veteran support groups very 
helpful. Some find one-on-one peer mentoring very effective and 
helpful. This is why when we are talking about evidence-based 
therapies, best practices of the VA, pushing CBT, CPT, these 
things can be deemed as best practices. But many veterans are 
not ready to go through such intensive therapy. They would 
rather pace themselves. And so while it can be very effective 
at squashing the problem, I cannot really say that there is one 
thing that is straight across the board going to work for 
everybody. And that is why I stress the importance of a team 
that works together to bring together what is best for each 
individual veteran in a veteran centered care rather than a 
systematic care that the veteran has to adhere to.
    Ms. Kuster. So you are looking at a more individualized 
approach, but a team approach. And I think, Ms. Portwine, you 
mentioned that others on the team may see something in the 
care.
    Sergeant Renschler. Yes, ma'am.
    Ms. Kuster. I also want to visit this issue of HIPAA. 
Because I am an attorney. I have worked 25 years in health 
care. There is definitely a waiver process. And this happens in 
private sector medicine. Do you, are any of you aware of, and 
through your review of the records after the fact, or have any 
of you experienced the VA asking the patient at any point in 
their service for a waiver to identify people that they would 
be willing to have their medical records shared with?
    Mrs. Somers. I know we had specific--Daniel ended up going 
outside the VA because his psychiatrist retired and they said 
we do not have anybody for you to see. And at the time he was 
having suicidal ideation so his mother-in-law, who is a private 
sector psychiatrist, referred him to somebody that she knew in 
the community. As he was seeing that person we actually asked 
him can we be a part of what is happening, he said he would ask 
her, but my guess is that he never asked her. And we never got 
the feedback. It was just embarrassing, is probably the closest 
word we could come to for him to have to share that 
information.
    Ms. Kuster. Sure, I understand.
    Mrs. Selke. I can speak to that a little bit as well. Going 
through Clay's medical records from Houston, from the VA, there 
was a form in that assessment and there is a question that says 
do you want us to or will you allow us to, I think it just said 
do you want your family to be contacted regarding your care, 
and he had checked no. And as difficult as that was to read, I 
know, you know, I know him. And it is, I cannot even imagine, 
and I really, I just cannot even imagine. These people are so 
strong in the first place to raise their hands and say I will 
go, and they go to war. And they have these injuries. And 
especially with the mental injuries, it is so difficult to feel 
that you are a burden on other people. And I know Clay felt 
that even though he knew how much he was loved, 
unconditionally. Any of us would do anything to help him. But 
he was 28 years old. He had been a Marine scout sniper. He, you 
know, it was, you just want to be able to take care of 
yourself. And get the medical care you need. So it did not 
surprise me to see that. But there was a question of would you 
allow your family.
    Ms.  Kuster. Thank you. My time is up. So I am sorry to 
interrupt you. Thank you, Mr. Chair. I yield back.
    The Chairman. Thank you. Mr. Coffman, you are recognized 
for five minutes.
    Mr. Coffman. Thank you, Mr. Chairman. And I think, first of 
all thank you so much for the service of your sons, and 
Sergeant, in your case, your own service. And my heart goes out 
to you for your losses as a veteran myself.
    A question that I have is, do you think, certainly Sergeant 
in your case, and then for the parents, in the cases of your 
sons, was VA overmedicating them in lieu of giving them 
therapy? Sergeant, why don't I start with you? And then I will 
work this way.
    Sergeant Renschler. Sir, thank you for that question. This 
is really a culture that begins with DoD and extends into the 
VA. It is an issue that we battle with on a daily basis as we 
provide support and service to veterans and active duty members 
where I am at in my local area. Part of what I do through the 
ministry that I am in is providing support groups through the 
chaplain's channels. So I deal with this very closely on both 
sides. Medication is no longer being used as a tool to subdue 
the symptoms, but we work on the deeper issues.
    Mr. Coffman. No, what does the VA do?
    Sergeant Renschler. The VA specifically utilizes 
medication----
    Mr. Coffman. Okay, that is my question.
    Sergeant Renschler [continuing]. To control it and keep 
them, suppress the symptoms----
    Mr. Coffman. Okay.
    Sergeant Renschler [continuing]. Without working on the 
deeper issues, sir.
    Mr. Coffman. Thank you. Please.
    Ms. Portwine. Brian was never put on any medication, only 
for his back when he had that problem.
    Mr. Coffman. Okay. Okay, yes.
    Mrs. Selke. Yes, Clay was on quite a bit of medication. And 
as I said, he termed that he felt like a guinea pig, just 
constantly being given something different.
    Mr. Coffman. Do you think that they chose medications then 
in lieu of----
    Mrs. Selke. Sure.
    Mr. Coffman [continuing]. Therapy? One on one therapy?
    Mrs. Selke. Yes. The only one on one therapy that he spoke 
of that seemed to be effective, at a certain point in L.A. he 
went to a Vet Center and had a counselor there that he really 
liked, and felt that he finally found somebody he could talk 
with.
    Mr. Coffman. Okay.
    Mrs. Somers. From Daniel's point of view, I think part of 
his problem was that he also had Gulf War Syndrome, which 
manifested with so many physical symptoms. So yes, he had a 24-
inch by 24-inch drawer full of pill bottles, but I think it was 
because he was having such incredible interactions between the 
different drugs that he was taking for PTS and the Gulf War 
Syndrome.
    Dr. Somers. And Daniel was not being seen by----
    Mrs. Somers. VA----
    Dr. Somers [continuing]. VA psychiatrist after six months 
after he was home, just because he never got the postcard that 
he was supposed to get to assign him another provider.
    Mr. Coffman. How much of the stress or the factors leading 
to suicide do you think might have been related to the fact 
that, I mean, I can tell you having been to Iraq, I mean, first 
Iraq War, and then the second, that when you come home there is 
a huge sort of, I guess maybe separation anxiety. That you were 
with, that you develop these interdependent bonds and this team 
around you, and all of a sudden it is just gone. It is just 
gone. And people fall into very dark and deep depressions 
sometimes. And I think it is easier for those that come back 
and then they have a long period of active duty with the same 
people that they served with. And I am wondering if you might 
comment? We will start with this side of the table.
    Mrs. Somers. This is a problem certainly with National 
Guard. Daniel was a member of California National Guard with 
the military intelligence.
    Mr. Coffman. Mm-hmm.
    Mrs. Somers. They are routinely separated from their main 
unit and assigned to other units. Daniel went to Iraq with an 
M.P. unit out of Texas, so he was already not with the unit 
that he trained with. He went to Iraq. When he came back his 
wife had moved to Arizona to be with her parents, so he is 
California National Guard, deployed through Texas, and then 
ended up in Arizona. So he had no support group whatsoever 
close by. It would have been phone call and email.
    Mr. Coffman. Yes.
    Dr. Somers. And this is a known issue. I mean, Reserves and 
National Guard, it is a huge issue. And not to take away, of 
course, from regular servicemembers, and in all branches of the 
service. But it is a much bigger issue for those who do not 
have the opportunity to come back to a defined facility and 
spend time like you said with the people they were deployed 
with.
    Mr. Selke. Great question. The bonds that these men and 
women form in combat are just incredible. And so it is very 
difficult for them to leave service and come back to their 
communities. Clay probably stayed in, he really struggled about 
going home to Texas or staying in California. I think the 
reason, one of the reasons he stayed there for a while was 
because his close friends, Marines, were staying there, and 
continuing in his life.
    One of the tragedies in Clay was he moved back to Texas and 
he really wanted to consider going into working for the fire 
department, a paramedic, that sort of thing, and was having 
some struggles with that. After he died we found out that I 
think three, three of his group were actually in the greater 
Houston area. And one of them particularly had actually gone 
through all the steps, he was like a year ahead of him, going 
into the fire department. And it really could have helped. Just 
the knowledge that those people are there would have helped. So 
there is a big break there in leaving service and going back 
into the community.
    Ms. Portwine. When Brian went first he was with 1st Cav, 
and that was a deployment that was supposed to be 12 months, 
and then they extended it to 15. Of course he was very, very 
tight with all those brothers, and they still are very, very 
connected online and text and everything. When he was in 
college then for the year, then when he was called back the 
second time his unit was already home for the year. So he was 
put with Louisiana National Guard. And he had no idea, those 
were completely new people. So you can imagine then when you 
are already damaged, and you wake up screaming three times a 
night, and have anxiety and panic attacks, that, you know, very 
difficult. I think he did bond with the people, he was very 
social. But it was not the same type of fun he had with the 
first group.
    Sergeant Renschler. I think it has been stated well. And 
just to highlight on that, the Battle Buddies system is so 
culturally ingrained in the military community and you really 
become a family unit with those around you that you serve with. 
And separating from that, and especially our wounded as they 
are shuffled from their units into a warrior transition 
battalion they are separated from that family unit. Even though 
they are with other servicemembers, it is different. And then 
they transition out and they lose connection all together for 
the most part and begin to isolate themselves after that loss. 
And that is a very difficult thing. And I think that is why 
programs such as the VA's Peer Mentor Navigator Program are so 
essential, is we should look at that and look at the way it is 
being implemented, and improve upon that. Because 
servicemembers and veterans connect best with other veterans, 
especially those who have shared experiences and that can help 
each other navigate through the difficulties that they 
experience within the system.
    Mr. Coffman. Thank you, Mr. Chairman.
    The Chairman. Mr. O'Rourke for five minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman. And I would like to 
join my colleagues in thanking you, and just telling you that 
what you have shared with us today is so powerful. Sergeant 
Renschler, your story, the story of Brian and Clay and Daniel, 
I hope will force us and the administration and this country to 
treat this issue with the respect that it deserves, with the 
attention that it deserves. And to get the results that our 
veterans deserve. And beyond the power of the stories, which 
are just, it is just hard to put into words the effect that 
they are having on me and I think my colleagues on this 
committee, you have also come to the table with solutions and 
proposals to improve the system.
    I love the idea that we think about the VA restricting its 
responsibilities to becoming a center of excellence for war 
related injuries. I have not thought about that before. And I 
do not know what the effect would be. And I would love to hear 
from other veterans and veteran service organizations. But I 
love that you are thinking about a big idea to transform a 
system that is obviously not working today but has not worked 
for a very long time, from everything that I have learned so 
far. This idea of an interdisciplinary approach to taking care 
of veterans when they return, I would like to know more about 
that. And I think it makes a lot of sense given your earlier 
testimony. The buddy to buddy system that you brought up, 
identifying a support network when these servicemembers are 
still enlisted, are all excellent ideas.
    So what I would like to ask you is, I have received so much 
more value from this testimony today than I ever have from a 
representative of the VA, including the reasons why we should 
be focused on this, the ideas and suggestions on how to fix it. 
So I would like to ask each of you, if there was some formal 
process to involve you in fixing the VA, would you like to 
participate? And then secondly if you have any other ideas, 
because there have been so many good ones that have come 
through so far that we have not raised today. I would love to 
give you an opportunity to share that. And maybe we can start 
with Dr. Somers and work down.
    Dr. Somers. Well you know we want to be part of, if we can, 
whatever efforts. And we submitted as part of our testimony 15 
pages of problems and potential solutions. So there are a lot 
of really good people who can be very beneficial to try to help 
the system. You know, we just do not have the time to get into 
specifics right now. But to answer your question, for sure we 
would like to be involved if at all possible.
    Mr. O'Rourke. Thank you.
    Mrs. Selke. Absolutely. We would be happy to do whatever we 
can to help. I want to kind of shift the focus a little bit off 
of us as parents who have lost sons and lost children. Words 
cannot describe that. But I sit here and look at Sergeant 
Renschler and listen to his story and we are surrounded by 
veterans behind us, a lot of them from the IAVA group. If there 
is any blessing or silver lining in Clay's death, we have 
become friends with so many of these young veterans that have 
enriched our lives. I do not know where I would be without 
them. I mean that sincerely. They just have enriched our lives 
so much. So whatever we can do. We cannot do anything to bring 
back Clay or Brian or Daniel. But what we can do is do 
something, whatever it is, to make life better for Sergeant 
Renschler and for all these veterans behind us and all of them 
all across the country. All veterans, not just the Iraq and 
Afghanistan, but all of them. We should not have to be reminded 
of that. And yet we seem to have to be reminded that we need to 
do a better job. So we are happy to do whatever we can to help.
    Mr. O'Rourke. Thank you.
    Mr. Selke. Anytime, anyplace, we are available. Part of the 
process for us to heal and I think for everybody at this table 
is to have the opportunity to go beyond our personal losses and 
to address the veteran community as a whole. And to do whatever 
we can to take care of those fine men and women. And so that, 
the opportunity to be in this community here, and be able to 
talk, and be able to be heard by people who hopefully have the, 
I believe certainly have the heart and hopefully have the 
ability to make some things happen.
    The VA is very, very complicated. It is a huge animal. I 
know there is a lot of things that need to be dealt with. There 
is a lot of really, really good stuff, and there are some big 
problems. I think if we can just focus on the individuals, just 
focus on them as people in need, as patients, on their care. 
What do they need today? And then build the system and modify 
the system, do whatever based on that. I think that will take 
us a long way. The focus needs to be these veterans, totally.
    Mr. O'Rourke Thank you. My time is expired, but Ms. 
Portwine and Sergeant Renschler, would you like to just briefly 
indicate whether you would like to continue to be involved and 
perhaps in a more formal way to include your ideas and 
experiences in this process of reforming it?
    Ms. Portwine. It would be an honor. It would be an honor 
for me to help make a change for the veterans to be. It would 
be like paying it forward.
    Mr. O'Rourke. Thank you.
    Sergeant Renschler. Certainly I echo the anytime, anyplace. 
I not only bring my own battlefield perspective but that of all 
the veterans that I work with, and I can only offer that much. 
But thank you.
    Mr. O'Rourke. Thank you. Thank you, Mr. Chair.
    The Chairman. Thank you. Mr. Cook, you are recognized for 
five minutes, sir.
    Mr. Cook. Thank you, Mr. Chair. I want to thank the group 
for being here. I know this is really, really tough. Sergeant, 
for your input, this is tough to listen to. And it is even 
tougher for you guys.
    The comment about the parents not knowing. I am not 
surprised. A lot of people the worst thing in the world, when, 
after my second Purple Heart I did not want my parents to know 
what was going on. And this is going to be the problem that I 
think all of you are sharing, that common denominator. You 
know, everybody that goes through these experiences are going 
to have huge psychological problems. But who are they going to 
share it with? Are they going to share with a psychiatrist or a 
psychologist that does not understand the military culture, the 
veteran culture? They are not going to open up. You know, you 
need that connection. I think the Sergeant made a great point. 
And your comments about the Wounded Warrior Program, where they 
have that. The actual battalion where when somebody has got a 
problem they go into that system there. And I just want to get 
your feelings. And maybe I am going down the wrong road. 
Because I think they need it, as somebody that has a problem 
they need an ombudsman. Somebody that is going to look out for 
their interests. That if they are at a particular hospital, 
they can go to the administrator. They can go to anybody and 
say, hey, wait a minute, this is an immediate situation. This 
is general quarters and we have to have a meeting right now or 
somebody is going to die on your watch. And can you comment a 
little bit more on that? It is pretty much what you were 
talking about, Buddy to Buddy, the same things over and over 
and over again. But to cut through the red tape right then and 
there with individuals that understand the severity of the 
problem.
    Sergeant Renschler. Yes, sir. This is a crucial element, is 
to have somebody to come alongside of the severely injured, cut 
through that red tape, and get treatment now. This is something 
that we have experienced first hand. I have experienced, I 
shared it with some of the folks from the Wounded Warrior 
Project recently. I had a veteran that we did a crisis 
intervention on attempted suicide, and we had to remove him 
from his primary residence. We got him to a position of 
stability and I found out that he had never accessed care at 
the VA facility. So I told him that that is the next step. He 
went down and he was actually denied treatment and told that he 
would be able to be seen in three months after telling somebody 
he had attempted suicide the night before. And I went down 
there and met with that veteran and we walked in, and I said 
this is an unacceptable answer. And we got the department head 
to come out and say I will intake him today. We have a program 
we can start him in next week. And that saved that veteran's 
life that day. But there are thousands more a day that are 
getting the no and not getting that extra answer because they 
do not have somebody to advocate for them. And I am not saying 
that to toot my own horn. I am saying that if we had more 
people out there advocating for these veterans we would be able 
to save a lot of lives and get better care.
    Mr. Cook. Yes. I just got back from, I went down to Camp 
Lejeune, where I was, I spent a lot of time down there. And I 
saw some of the folks, including my platoon sergeant, who was 
my platoon sergeant 47 years ago. And we talked about the 
infantry unit, and you never forget the Marines that you lost. 
13 May, 1967, horrible, horrible day. You never forget their 
names, the occasion. Just like you are never going to forget 
this. But what you have to do is try and make the system 
better. And right now I think it is broken in terms of not 
capturing those individuals and those thoughts, their morale is 
just down to the point where they are going to do something 
bad. And if we do not correct it now, it is our fault. So----
    Dr. Somers. Yes, it is a systems issue within the VA. And 
our feeling that everybody who works in the VA should have only 
one purpose in mind, and that is to advocate for the veteran. 
And it is the person who sits in the corporate office to the 
person who cleans and empties the wastebaskets at night. That 
is the only, only thought that they should ever have.
    Mr. Cook. Doctor, that concept of the ombudsman, or for 
lack of a better term, somebody that is ultimately responsible 
or somebody that is that advocate for that person in trouble--
--
    Dr. Somers. And we agree that there needs to be an 
ombudsman. We know about the Navigator program and that is a 
great program. We know that they are doing a much better job of 
that out in San Diego. But it is not only the ombudsman, it is 
not only the Navigator, it is every single person----
    Mr. Cook. But it should be an SOP, totally----
    Dr. Somers [continuing]. Totally, totally, totally----
    Mr. Cook. Standard operating procedure for every hospital. 
I yield back.
    The Chairman. Thank you, Colonel. Ms. Brown for five 
minutes.
    Ms. Brown. Thank you, Mr. Chairman. First of all, let me 
thank each and every one of you. Let me just tell you recently 
I did some work with the Marines and they would just be very 
proud of you, your sons. So thank you very much for your 
service.
    You know, I have to say that we are talking about the VA, 
but this is not just the VA. It is DoD. And this hearing should 
be VA/DoD. Because it is DoD that sends people over and over 
and over again to combat, and there is no transition as far as 
when they come back. So it is a bigger problem. And to sit here 
and just say, well it is the VA. That is just not true. It is 
just not true. And we need to deal with the problem.
    The fact is we have been fighting a War with the reservists 
and we have sent them over and over again, and they did not 
have the support that they need. I have gone out when they are 
deployed and they just, they do not have all of the other 
resources that the other military branches have. So we are not 
doing the Wars the way that we need to, and the system is 
fragmented. And so as we develop a comprehensive system, let us 
get everybody in the room. Let us deal with the system the way 
we need to deal with it.
    Now you mentioned the formulary. Now the VA and DoD, we 
insist that they negotiate the prices of the drugs to keep the 
costs down. Now what is wrong with the way we are doing that? 
Because in the regular market it is illegal for the Secretary 
to negotiate the price of the drugs, which I think is dumb.
    Dr. Somers. Well there is no problem negotiating the price 
of the drugs. The problem is the drugs are not the same. So 
that for example Lexapro, which is, you would definitely want 
the DoD formulary as opposed to the VA formulary.
    Ms. Brown. Mm-hmm.
    Dr. Somers. No doubt about it. And I know firsthand that 
you can basically get anything you need with relatively little 
hassle through----
    Ms. Brown. But I thought the VA was the one that was doing 
a lot of the research, not the DoD----
    Dr. Somers. The research has nothing to do with anything. 
The only thing that has to do with it is the actual drug that 
you are being prescribed by your provider. You can do research, 
and actually that was one of Daniel's issues, is that there is 
a problem doing research because of the fear of the FDA and the 
DEA and Schedule 1 medications and things like that. So that is 
a totally different issue. The problem is the formularies are 
not the same. And as I said, you have got patients, not only 
veterans who are being discharged, but you have retired 
military who are being seen at a DoD hospital and at a VA 
medical center, and they are eligible to seen at both.
    Ms. Brown. Mm-hmm.
    Dr. Somers. And they are under medication restrictions 
because the formularies are different. So that is the big 
issue. We need to make it a single formulary, bottom line.
    Ms. Brown. Okay----
    Mrs. Somers. Excuse me, and just in addition to that----
    Ms. Brown. Mm-hmm.
    Mrs. Somers [continuing]. It is like if a person is doing 
really, really well on a drug, they should be able to stay on 
that drug.
    Ms. Brown. And the doctor can override that.
    Mrs. Somers. Just because you can get it for ten cents 
cheaper, and it can have major effects on their body.
    Ms. Brown. Absolutely. But the doctor can override that.
    Mrs. Somers. Right, and----
    Dr. Somers. Ma'am, not, no but what Jean is saying is 
different. It is still a generic, but as I said before it is a 
different formulation of the generic.
    Ms. Brown. Right, but----
    Dr. Somers. So and especially as was said, I mean that is 
what is so important to have these groups of the multispecialty 
groups that are, the interdisciplinary committees, or whatever 
they are, that are going to community amongst themselves.
    Ms.  Brown. Well I definitely think that is something we 
could work on. Ms. Portwine, I think you made a very important 
point. Your son you realized was having serious problems, and 
yet he was redeployed.
    Ms. Portwine. yes.
    Ms. Brown. And he was not given the medication. I mean, it 
should have been a time out at that point.
    Ms. Portwine. Well even on the form you can see it said no 
go, that was crossed through, and somebody stamped, the 
coordinator that sends the people, I forget what they call 
them, put go.
    Ms. Brown. Well, now that is DoD.
    Ms. Portwine. So that tells me they had hesitation in 
sending him to begin with.
    Ms. Brown. That was DoD.
    Ms. Portwine. That was DoD.
    Ms. Brown. Yes, ma'am. Well thank you very much.
    Ms. Portwine. You are welcome.
    Ms. Brown. And what I am saying is it is a lot of work that 
needs to go on, and it is not just VA. Thank you again for your 
service.
    The Chairman. Thank you very much. Ms. Walorski for five 
minutes.
    Mrs. Walorski. Thank you, Mr. Chairman. And thank you to 
the panel for being here. I can assure you that this is how 
things change in this country, it is when brave men and women 
step forward and say to a concerned body like this of 
Republicans and Democrats, sitting here listening to your 
story, I cannot even imagine, I cannot pretend to imagine how 
tough it is to sit here and relive this. And I think I can, I 
think I can safely say that we are committed to bringing right 
to all of this wrong. And every one of you have hit the nail on 
the head by saying, every one of you have said the story is 
about the individual veteran. And you know, I have only been on 
this committee for 18 months but the last three months the 
chairman and the ranking member have led an intense 
investigation into what the heck happened to the VA. From the 
day that it started to the mission today. And every layer of 
this onion that we have peeled back comes down to the same core 
issue: nobody is advocating for the veteran. And the culture 
itself, and when we talk about systemic problems and the 
culture itself and we, and the Secretary is removed, and a 
bunch of people are removed, and we are sitting here trying to 
be able to help America reset a button. Because Americans 
believe in our veterans. They sent us here to fight for our 
veterans. And I want to just applaud your effort.
    You have made such a huge difference here today. This is 
how laws change. This is how policy becomes correct, and this 
is how we move forward in this country. We do it together. 
Unfortunately sometimes it takes the disaster that we have had 
in a bureaucratic system of the VA. But you know, the 
frustrating thing for me is I have 54,000 veterans in my 
district and every time I describe my veterans I talk about I 
have 54,000 veterans and their families in my district. And I 
want to applaud your effort on two huge issues that I think 
that we can address in this Congress and we can help move 
forward on this issue of mental health. The one is the support 
network. I cannot even tell you, and I know you know, how many 
constituents have called our office in Indiana, and the wife or 
the husband is in tears, and they are begging and they are 
advocating for the spouse that the VA says HIPAA prohibits me 
from allowing you to get involved in this. I have gotten 
personally involved in some of these mental health cases in my 
district, calling the directors and regional directors, and 
trying to advocate for my constituent on behalf of a spouse. 
And the answer is still no, HIPAA overrides. And I even asked 
the question, do you have a different law of HIPAA? Do you 
subscribe to a different definition than we do? And the answer 
was no. HIPAA overrides. And so just having a support network. 
To be able to come in and be that bridge between somebody who 
is dying and the system. And I applaud that effort. And I 
think, I mean, I am going to make sure that we do everything we 
can to get that part of the law changed. Because we can bring 
advocates into the lives of these struggling men and women. And 
for the spouses that are trying to hold the families together, 
we can do that, too.
    And I want to just thank you for your commitment as well on 
the issue of keeping this focus where it belongs. And, you 
know, I think someday, I do not think this is a quick 
turnaround. But I think you have brought light, transparency, 
and accountability to another layer of what America needed to 
hear. And while you are sitting here today talking to us, and 
while we are trying to relate and share your brief, and we are 
trying to find solutions to move forward, you have had an 
opportunity to talk to the American people today. And I 
guarantee you that every single person that you are an 
influence to, that has followed your story in the states that 
you are from, I am going to hear from my constituents today and 
say I am just, I relate to that mom and I relate to that father 
and I relate to my fellow serviceman. And I just think it is a 
tribute today. This is how government works. And we have a 
commitment to make sure we restore not your sons, but certainly 
the America that they have been fighting for. Certainly our 
trust and their trust in us as a government who asks them to go 
fight for freedom and fight for liberty, our finest heroes in 
this nation, and to be able to reinstitute to them by 
continuing to root out the bad actors and the bad policy in the 
VA, and together set a reset button.
    So I just want to applaud your efforts and thank you so 
very much for helping us reset an organization that started out 
as a great noble effort and really has run into a bureaucracy 
that has just run amok. But you have our commitment today and 
my commitment certainly that none of what you have experienced 
will be in vain. So thank you so much for being here. I 
appreciate it. I yield back my time. The Chairman Thank you. 
Mr. Walz, for five minutes. Mr. Walz I would like to yield the 
first minute to my colleague Mr. Peters, who represents the 
Somers.
    The Chairman. One minute to Mr. Peters.
    Mr. Peters. Thank you very much. Thank you, Mr. Walz. I 
want to start by thanking the chairman and the committee for 
allowing me to be a guest. We are not members of this 
committee, Ms. Sinema and I, but I do not think there is 
anyplace we would rather be this morning.
    It takes a lot of courage to do what you are doing, and I 
just want to say thank you for that. And also to let you know 
beyond the power of your stories it is the education you 
provide that only you can provide. These are insights that only 
you have and so it has been very valuable to us. And while we 
are new here I can tell you that from time to time you see 
testimony that is going to make a difference, and that is 
certainly what has happened today. I think you can feel very 
confident that those brothers that you talked about, and 
sisters, will be heavily affected and helped by the time you 
put in and the effort you put in today.
    And I also just wanted to thank in particular Howard and 
Jean Somers for your leadership, for the time you put in on 
behalf of Daniel, and for the education you have given me. I 
look forward to continuing to work with you to make these 
issues, to resolve these issues and to make things right with 
the veterans that the VA sees. Thank you.
    Mrs. Somers. Thank you.
    Mr. Peters. Thank you, Mr. Chairman.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Chairman. And again, thank you all for 
being here. I am sorry I never got the chance to know Daniel or 
Brian. I did have the privilege and the honor to know Clay, and 
not only know him, to work with him on veterans issues. And the 
profound loss is felt by everyone who came in contact with him. 
And it shook me to the core because of someone so strong and to 
your point on we do not, you are not going to notice it, you 
are not going to see it. And these are very special 
individuals. And Josh, you and I have become friends over the 
years. We were in St. Paul a few weeks ago working with the 
Wounded Warrior Project. So I do, too, applaud you. It is, you 
hear it from the colleagues. And this is a committee of 
heartfelt folks that want to get this right.
    I would just mention, and I think all of you get this, at 
this point, and I think the frustration we all feel, solutions 
and results are all that matter. I am done with it as you all 
are. I am done with the talk. I am done with the pilot 
programs, if you will. I understand we need to do some of that, 
but there are suggestions that are concrete that can be put 
into this. But I want to read you something.
    I came here on the 3rd of January of `07, the honor of 
being elected to Congress. On the 9th of January I started 
working on a bill. And one of our colleagues, a Vietnam Veteran 
pilot Leonard Boswell put in, it was the Joshua Omvig Suicide 
Prevention Act. And here is a couple of things that it said. 
The Secretary of Veterans Affairs should develop and carry out 
a comprehensive program designed to reduce the incidences of 
suicide among veterans. The program shall incorporate the 
components shown below. Staff educations for compassion amongst 
and recognizing risk factors, proper protocols for responding 
to crisis situations, best practices, screening of veterans 
receiving medical care, tracking of veterans in a timely 
manner, counseling and treatment of veterans, and designation 
of suicide prevention counselors throughout that, and on, and 
on, and on.
    They did not do it. It was in law. We passed it. We gave 
the speeches. We had the signing ceremonies. And we went back 
home and said, gee, we made a difference. And it is the very 
same things. And here you sit, just like Joshua Omvig's parents 
sat, come up from Iowa to testify on this.
    So I guess the thing I would ask of all of you is that this 
is the second, the VA is the second largest government agency, 
behind DoD. Yet we have one of the smallest committees. We have 
committees that I do not even know what they do, they have got 
like 80 staff on them, and they do it. So we can give lip 
services or we can get serious about how we are going to do it. 
We can have this. Or we can allow, if this crisis passes, and 
the American public's attention focuses elsewhere, or whatever. 
Our veterans will be coming back. There is veterans sitting 
behind you from Vietnam and others. They have seen this movie. 
They have seen it before.
    Here is what I think is different. I think there is no 
doubt in my mind, the American public wants to get this right. 
And they are entrusting us as their representatives to get this 
right. And the commitment I have seen from this chairman and 
ranking member as a member of this committee, this is 
different. It is different than the seven years that I have 
been here. It is different in how we are focusing. It is 
different amongst the advocacy, and we cannot let this pass.
    So what I would tell you, Ms. Portwine and some of you 
asked on this, you mentioned, and thank you for this, Chairman 
Miller and Representative Duckworth and myself, along with 
IAVA, Paul, VFW, a bunch of folks, are going to be out there 
this afternoon. We are going to introduce Act 2182. And here is 
what I would say is different. And this was a well-intentioned 
bill and well-written, except look to your right, these are the 
folks that helped write the bill. So Susan was in the office 
and making the suggestions. Look to your left, Josh was there. 
The Somers' suggestions are incorporated into this. And we are 
going out because what we have got here is, and this is I guess 
the silver lining. And you get tired of hearing that. There is 
no silver lining when your son is not coming home. But what you 
have done is ask for a solution. I would ask each of you as Act 
2182 starts to move and Senator Walsh does it in the Senate, 
let us together make sure it does not end up as the Joshua 
Omvig Act. The Secretary had all this authority. He had it. The 
American people through us said do this, and they did not do 
it.
    So I would only just state to each of you, as my colleague 
Mr. O'Rourke said, this is how democracy can work best. This is 
how we can incorporate people in it. And this idea of wringing 
our hands at who could have anticipated this, really? This bill 
was started in 2007. It was anticipated before and here we sit 
in 2014.
    So keep the faith, we have to. But again, I would say this. 
The cameras, the TV, the stuff that is there, whatever, none of 
it means a damn thing. If we do not get results this time then 
shame on us. Because here is the thing. I am not going to get 
to meet Daniel. I am not going to get to meet Brian. I am not 
going to see Clay again. But I dang sure want to see Josh. I 
want to see him here and forward. I want to see the rest of 
them. That is our calling.
    So you have got the right guys up here. You have go the 
right commitment from the public. You have got the right folks 
sitting behind you writing good legislation. Now it is going to 
be can we do it? With that, I yield back.
    The Chairman. Thank you. Dr. Benishek, five minutes. Dr. 
Benishek Thank you, Mr. Chairman. Well, I too would like to 
thank you for your courage to be here today. And please know 
that your efforts today will make a difference at the VA. I 
just really want to thank you.
    Mr. and Mrs. Somers, I want to thank you too for that 15-
page primer there. That had some really good ideas. And I 
really appreciate you all taking the effort to put together a 
document like that.
    Mr. and Mrs. Selke, you mentioned, and I was disturbed by 
the comments that you found that the environment of the Houston 
VA was stressful. So could you elaborate on that? What 
specifically led to that conclusion? Have you been there since? 
Has it changed? Can you tell me a little bit more about that, 
when you described----
    Mrs. Selke. I went by myself that day and have not been 
back there since. For whatever reason I just compelled to go 
and quickly get his medical records. And I wanted to see them. 
And it was just, again, for ten weeks worth of care there, so 
there were not a lot.
    You drive up to the facility. It is huge, as they all are 
huge. There were so many people milling around out front, big 
crowds, lots of people that I do not know if they were there 
waiting for appointments or if they, you know, just do not have 
anywhere else to go and hang out there. You go inside and it 
is, I likened it to an airport terminal, in a way. You go in 
and it is just a hub. Very busy, lots of people milling around, 
lines, the cashier lines look like in an airport where you 
would line up to get your tickets or something. Just, it was 
very stressful for me. And of course I was in a grief mode but 
not a Post Traumatic Stress mode. I just could not imagine. I 
could visualize Clay going in and I could understand why when 
he left that day and he called and he said, ``I cannot go back 
there.''
    No one was at the information desk. You walk in the front 
door and they were on a break or something. But no one was 
there. And I looked around and finally found somebody that 
could direct me to where the medical records are and went and 
retrieved those. Before I left I just remember standing there 
for a few minutes and just imagining----
    Dr. Benishek. Right.
    Mrs. Selke [continuing]. If I were a veteran, if this were 
Clay, how----
    Dr. Benishek. How do you negotiate this? You mentioned 
another thing and that was your son had voiced concerns about 
the care he was receiving. Was there specific concerns that he 
raised?
    Mrs. Selke. I am not sure I am remembering what you are 
referring to.
    Dr. Benishek. All right. Okay. Well let me ask Sergeant 
Renschler a question. You wrote that the combat veterans in 
particular often approach mental health care as hesitantly or 
distrustfully. How would you suggest that we change the dynamic 
to ensure that veterans who need mental health care feel more 
comfortable accessing the care?
    Sergeant Renschler. Yes, sir. Thank you. It kind of starts 
with what she was just sharing. Even at our facility we have 
two, Seattle, and then we also have American Lakes. Seattle is 
a large hospital building, not laid out very user friendly. And 
myself, I have a Traumatic Brain Injury that I have overcome 
fairly well but I get lost and confused in that place real bad 
and there is not a lot of friendly people there to direct me. I 
get better customer service at Best Buy, quite frankly. A 
little bit of care training would go a long way within the VA 
medical centers.
    My other medical center closest to me is a campus with 
many, many buildings. And the building numbers do not even make 
sense, so I will be in 81 and I am told to go to Building 3, 
which is right next door, and Building 61 is across the campus. 
And the numbers make so sense, and the facility is confusing, 
overwhelmingly packed in and not a lot of people to help guide 
and navigate a very confusing situation. So for one, just 
recognizing who the audience of a veteran is and making an 
environment that is conducive to healing would be a start.
    Another one would be as I discussed earlier and I keep 
bringing back to that interdisciplinary team, it takes rapport. 
It takes developing a relationship and rapport with the veteran 
to get him to go beyond surface level issues with a physician. 
I am going to go and I am going to triage myself. On active 
duty, especially in the infantry culture, sick call was very 
discouraged. And if we went to sick call you were a wuss, and 
you pretty much got crap for it for the rest of the day. And so 
we do not go to sick call unless something is debilitating in 
nature. And that just kind of sticks with you for the rest of 
your life. And so as I am muscling through ridiculous pain my 
wife will eventually stop and say when are you going to go see 
a chiropractor or get some help? And it is just that mentality 
of just suck it up and drive on. And that is what these guys 
are doing with mental health issues. And that is why when they 
get there it is a crisis and needs to be treated as such. And 
so there is a two-fold answer here. Number one, the VA needs to 
recognize that there is going to be a lot of crises and come 
back in three months is not acceptable, or come back in 14 days 
to intake so that you can intake in another 14 days to get 
treated in three months. Still not acceptable. But instead to 
have a team to say, hey, welcome here. This is your place. This 
is your team. These are the people caring for you. This is what 
we are going to do for you, and provide better customer service 
for one. But for two, develop a relationship with trust and 
rapport so that I can know that I can confide in these people 
to provide the quality care that I know that they should.
    Dr. Benishek. Thank you.
    Sergeant Renschler. I hope that answers it, sir.
    Dr. Benishek. Thank you very much. I am out of time.
    The Chairman. Thank you. Ms. Titus you are recognized for 
five minutes.
    Ms. Titus. Thank you, Mr. Chairman. Thank you all for being 
here. Your stories are just tragic and heart wrenching. But I 
hope you can take some comfort in knowing what powerful 
advocates you are. I mean, you have told your stories so 
eloquently, so orderly, so thoroughly, that it really, it will 
help us to move forward.
    I have just been noting down some things that we need to 
address. And I think we are at a point where we really can make 
a difference. So in addition to the things that you have 
suggested I want this committee and the people in the room, and 
I ask you for your help on this, for us to address some other 
things that I think are also related to the problem.
    First, you are obviously very loving families. You were 
there for your children. But many of your veterans do not have 
families like that. There are many homeless veterans, they are 
sleeping on the streets, they do not know where to go. They do 
not have somebody they can turn to. And so we need to figure 
out a way how we can address the problem for those veterans as 
well as for those like your children. So I want us to not 
overlook that.
    A second thing is the VSOs are there to provide services to 
veterans and when they do not have that ability to bond like 
they do while they are in the military the VSO is there. They 
cannot be there 24/7 like your band of brothers and sisters 
can, but they are there. And maybe we need to look at some ways 
that we can help them to do more outreach and better fill that 
gap for when people come out.
    Also we have heard some horror stories about the medicine 
and all the different drugs. I think we begin to hear that 
medical marijuana is a possible way to address PTSD. Let us do 
not leave that off the table as we move forward.
    Even something as simple as the notion of companion dogs. 
That is something that you hear, too, that many vets, if they 
have a pet that helps them get through some of these troubled 
times. So let us keep that on the agenda. And you mentioned 
about being a firefighter. Let us also remember that when 
veterans come back they do not just need health care, both 
mental and physical, but they need to be able to transition 
into civilian life with easy access to education so some of 
their training counts towards college credits or employment to 
retrain and have jobs so they have something to look forward to 
that takes a little of that burden off.
    So those are all things we need to look at the big picture. 
And I just thank you very much for committing to continue to go 
down this path with us. And I would ask you, too, do not leave 
anything off the table. Anything you can think of, no matter 
what it might be, now is the time for us to address it. So I do 
not know if you want to comment. I do not want to put you 
through more questions but I want you to know that that door is 
open.
    Ms. Portwine. I have one more comment. I know that the VA 
has the emergency crisis line, 1-800-273-TALK. But I work for 
an insurance company and we have what we call Nurse Line. And 
anytime a member can call 24/7, 365 days a year. Why do we have 
to wait until it is a crisis for anybody to talk? When they are 
starting to feel depressed would be a great time for a nurse to 
be able to assess and triage what care this person needs. Do 
they need to go immediately now? Can it wait until tomorrow? 
Can it wait the routine three days? What do they need? I think 
by waiting until it is a crisis line, you are more down that 
slippery slope.
    Mrs. Somers. And if I might add, we are fairly new at this 
whole political thing. But I came across something called the 
independent budget, which if I am interpreting correctly the 
VSOs actually put together for Congress. And I would ask that 
next time that comes to you, that you really look at that 
really, really closely. Because these are your veterans talking 
to you. Thank you.
    Mrs. Selke. I would like to just add quickly one of the 
things that Clay said over the years that sticks with me, and 
it just is wrong. He would say over and over, ``I have to 
grovel for my benefits.'' And I just think we need to wake up 
as a country. Our veterans should not have to grovel for 
anything. And it just should not be so difficult to get the 
care they need, at all.
    Ms. Titus. Thank you very much. I yield back.
    The Chairman. Dr. Wenstrup you are recognized for five 
minutes.
    Dr. Wenstrup Thank you, Mr. Chairman. And I cannot thank 
you enough for being here today, and the sacrifices that you 
have made. And I pray that the sacrifices that you and your 
entire family have made will make us a better nation at the end 
of the day. I think most that sign up to serve have that 
intention, that they will make this a better nation at the end 
of the day.
    I am a physician and also a Reservist, and I served in Iraq 
for a year. That has led me to want to be here today. And one 
of the things that I know as a doctor, and I am sure Dr. Somers 
you can relate, that when you have patients with, and 
regardless of their problems, there is a level of anxiety 
because they have something wrong. Whether it is 
musculoskeletal or mental, it does not really matter. Something 
is wrong and there is anxiety. And it makes it even more 
difficult and it heightens the anxiety when you have all these 
administrative problems. And I know you started to deal with 
that in private practice, more so maybe than when you first 
started, where you, the prescription you think is best they are 
not allowed to have, those types of things just increase the 
patient problem and actually trying to take care of the 
patient. And we really are here, I will say on this committee, 
not just to complain but to come up with solutions. And so your 
input today is extremely valuable.
    And one of the things I see is if a doctor is credentialed 
at one VA, he should be credentialed at every VA. That allows 
him to go from one VA to the other if there is a deficit 
sometime. And if your prescription is good at one VA it should 
be good at another VA. You can do that if your patient is out 
of town. You can call another state and get the prescription 
filled. And when you cannot, think of the anxiety that comes 
with that. These are things that we can fix, and these are 
things we have got to fix.
    And I will also contend that it is a big difference, too, 
being in uniform and out of uniform as far as care. As a 
Reservist, you know, I can just remember, you know, being with 
that family for 15 months. And then all of a sudden I am the 
last one left at the airport and going home. And when I get 
home they say, well, you have got 90 days to go back to work. 
Well, I said, that is not going to work. I am going back in two 
weeks. You know, I am getting my house in order and go back to 
work because you have to have something to go to. And so when 
you are just wallowing out there, and I think we need to 
engage, now this is the DoD side, engage on what you are doing 
when you go home. And have the VA be part of that as well. And 
we have got to blend these two systems together. We have to 
engage in the post-deployment activity. And so when I have been 
in uniform I have had the opportunity to serve in preventative 
medicine, and particular suicide prevention. And you know, we 
learn a lot, and we get a lot of training, I think, in uniform 
of what to look for, and have that battle buddy, and the types 
of symptoms you are looking for. And sometimes when the 
decision is made that you are going to take your life that 
there is a calmness. And you look for somebody giving away 
their stamp collection or coin collection because they have 
made up their mind. And they spend more time with family 
because they have made this decision that their problems are 
going away.
    Those are the types of things we get. We get those in 
uniform but we do not get them afterwards. And for Guard and 
Reserve in particular, you just go home. And I did see, I have 
seen at Fort Lewis, for example, families being engaged with 
programs but that does not happen the same way with Guard and 
Reserve, and it is a different animal.
    But I guess more than anything else what I want to do, when 
you want to talk about solutions, we can all be trained to look 
for symptoms and look for signs, but how do we go about 
preventing the very ideation of taking one's life? What are we 
doing that creates a situation where someone comes up with that 
ideation, that this is the best way to go? And that is the type 
of input we need. And that to me is really preventative 
medicine more than anything else. And I hope that through this 
we find our way. Because our suicide rate is going up in our 
civilian population as well. So we have a national problem 
here, not just a military problem.
    Again, I applaud all your input. It is extremely helpful to 
us. And as you have seen, this is a determined group here that 
wants to make a difference in the history of our nation as we 
move forward. And we are glad to have you as a part of it. So 
your input is always welcome, and thank you for commitment. And 
I yield back.
    The Chairman. Thank you, doctor. Ms. Sinema you are 
recognized for five minutes. Check your microphone, there you 
go.
    Ms. Sinema. Thank you, Mr. Miller and Mr. Michaud, for 
allowing me to participate in today's hearing. And a special 
thanks to my colleague from Arizona, Ms. Kirkpatrick, who 
represents our state's veterans so well on this committee.
    I want to thank all of today's panelists for joining us. In 
particular, thank you to Daniel's parents, Howard and Jean for 
being here. We worked together quite closely since learning of 
Daniel's suicide and it is an honor and a privilege to be here 
with you again today.
    Unfortunately Daniel's story and the story of the other 
young men who committed suicide is just all too familiar in our 
country, and 22 veterans a day are still committing suicide 
even after we have heard the tragedies of the young men who 
lost their lives here, and their brothers all across this 
country. And as we heard from Mr. Walz, Congress has addressed 
this issue before, has passed legislation before, has said they 
were going to fix it before. And yet the problem has not only 
not gotten better, it has gotten worse.
    I have heard a lot of testimony today about ideas to 
actually reform the system and make it better. The HIPAA issue 
I think is one that the committee would agree needs to be 
addressed. I am particularly interested in the pilot program 
that Sergeant Renschler participated in. And my question to Dr. 
and Jean Somers would be about Daniel. Daniel's experience at 
the Phoenix VA, like many, many veterans' experience at the 
Phoenix VA, was one of lack of concern, lack of care, lack of 
follow through, and a discombobulated system that did not allow 
veterans to get the care they needed. In particular one of the 
struggles Daniel faced was as an individual who had served in 
classified service, he was unable to participate in group 
therapy because he was not able to share the experiences he 
experienced while in service. And yet at the Phoenix VA he was 
unceremoniously put into group therapy. And when requested 
private therapy was not able to get that care. And of course, 
as we know, he took his own life as a result of being unable to 
get that care.
    The medical home model I believe in the private community 
has provided an opportunity to create patient centered care and 
allow civilians to get the care they need in one home, easily, 
that is centered directly on their needs. While the pilot 
program in Washington was ended because of, well I do not 
understand why. They said they did not have enough money for 
it, which I think is outrageous and a horrible, horrible reason 
to stop providing care that we know is effective and 
appropriate. My question for Dr. and Jean Somers is whether you 
believe a medical home model would work or could be helpful to 
veterans like Daniel? We know that many of our Post-9/11 
veterans face co-occurring disorders, PTS, TBI, anxiety, 
depression, physical maladies. Would a medical home model have 
been a model that may have worked better for Daniel than what 
he faced?
    Mrs. Somers. Absolutely. As Daniel's irritable bowel 
syndrome worsened, he did not feel he could physically leave 
the house. I cannot imagine that embarrassment. And then as 
Howard mentioned at the time Phoenix has the speed traps set up 
on the major highway to get from his home to the Phoenix VA so 
he actually had to find a way to get off of the highway so that 
the flashing lights would not affect him. So absolutely. I can 
see that it would have been very helpful to him just to have 
the privacy capability.
    Dr. Somers. I completely agree. I think not only the 
medical home model but what we talked about, the ability within 
the facility for the different people. Because of his IBS and 
his TBI and his PTSD, you are being treated, as we learned 
here, the term being in silos. And what you have to do is you 
have to get out of the silos and you have to combine resources, 
combine knowledge. And we have heard of programs such as was 
mentioned that are very successful where people can have 
problems and for whatever reason have an optometrist or an 
ophthalmologist in there. And they say, well, you know, it 
sounds like it is not this, but it is this, and something that 
you might not have thought of. So the medical home model, the 
ability to create these panels of care, I think anything like 
that would be overwhelmingly positive.
    Ms.  Sinema. Thank you. And Mr. Chair, while Dr. Benishek 
has already left I do want to take a moment just to thank him 
for cosponsoring legislation that we drafted with the Somers 
specifically to address the issue of servicemembers who served 
in classified settings and who need appropriate care when they 
return to the VA. And I want to thank the subcommittee and the 
committee for supporting just a part of the solution to this 
issue. Thank you. I yield back my time.
    The Chairman. Thank you very much. Mr. Bilirakis, you are 
recognized for five minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I really appreciate 
it. And I appreciate the panel testifying, and I appreciate 
your courage.
    I want to ask about alternatives to medication and I want 
to ask the entire panel. Which alternatives do you believe the 
VA could consider in addressing the mental health issue? I 
realize that you have to have some medication in most cases 
prescribed, but I am familiar with the recreational therapy. 
The chairman and myself participated in a field hearing not too 
long ago on recreational therapy, the equine therapy. In my 
district they have Quantum Leap Farms, I know they are all 
over, they travel from all over the country to go to Quantum 
Leaps. The service dogs do wonders, I understand, from talking 
to veterans, just to name a few. But can you maybe elaborate a 
little bit, whoever would like to, with regard to the 
alternatives to the medication for mental health therapy, PTSD, 
TBI, what have you? Please, thank you.
    Ms. Portwine. Yes. Brian had a brother that came back and 
he had PTSD and he had a friend that was doing some gardening. 
So he started just working in gardening with him. Pretty soon 
they realized they really liked it and their garden was pretty 
good, so they decided to make it bigger. Then they thought, 
well let us take these vegetables and take it to market and see 
if we can sell them. And so now they have this huge area and 
they do this. I have also heard of veterans going on farms, 
because there is not loud noises and flashing lights and the, 
you know, the sound issues that they have with PTSD. So those 
are two others.
    Mr. Bilirakis. Thank you. Anyone else, please?
    Sergeant Renschler. We, I mean, we could just put together 
an extensive list of what veterans use to cope with these 
things outside of medications. Motorcycle riding, bike riding, 
equine therapy, service animals. I mean, it just, the list 
could go on and one. And that is, I would rather stress the 
importance of the fact that there is no one solution. And until 
the VA can get to implementing best practices systemwide and 
tailor fitting to each individual veteran's needs, and using 
these known best practices that exist out there, until they can 
do that we are not going to be able to fix anything. I mean, we 
can put policy in place saying that you have to provide access 
to these individual treatments that exist. But it is the 
implementation of that policy that is the major issue here. And 
yes, I mean there is, the list is extensive.
    Mr. Bilirakis. Thank you very much. And definitely, one 
size does not fit all. Anyone else?
    Mrs. Somers. I would like to weigh in on that. That we hear 
a lot, a lot of the excuses that we heard at Phoenix was it has 
to be evidenced-based treatment. And how do you get innovative 
therapy if everything has to be evidence-based before they will 
use it? I think they need to open up their minds a little bit 
and think outside the box. As you have heard, not every therapy 
works for every person. Everything does have to be 
individualized. And you know, I have heard of gardening before, 
too. You know, as being very therapeutic for people. I think it 
just, they need to get out of the mentality that this is all we 
can do, we have these blinders on.
    Mr.  Bilirakis. Thank you very much. The bottom line is, we 
need to listen to the vets, just like you said. Anyone else, 
please?
    Mr. Selke. I think it is, again to use the word holistic, 
it is a community, it is a lifestyle sort of approach. I mean, 
the VA needs to do what the VA needs to do the best way the VA 
can do it, but the VA cannot do everything. So there is a lot 
of, I mean, Clay kind of put together his own kind of therapy 
program. He got involved in service. That was helping him. He 
got involved with IAVA, you know, Storming the Hill, and their 
community. He got involved with Team Rubicon doing disaster 
relief programs. He got involved with Ride to Recovery riding 
bikes, and that was great for him to be able to heal but it was 
also great for him to be there to help his brothers and sisters 
heal. The problem, you know, for whatever reason when a person 
decides to take their life, they have given up hope. So what do 
you do about that? And Clay could do everything. He could go on 
these, you know, on these missions, and he could do one-week 
bike rides. But what got him was being alone, in his apartment, 
by himself, hopeless. And there is questions and matters of 
faith there, but it is a community approach. People need to 
come to government and volunteer organizations. Partner. No one 
organization, not even the government, can do it all. And 
everybody needs to realize that and come together and take care 
of these folks.
    Mr. Bilirakis. Thank you so very much. I yield back, Mr. 
Chairman.
    The Chairman. Mr. Jolly, you are recognized for five 
minutes.
    Mr. Jolly. Thank you, Mr. Chairman. I want to associate 
myself with the comments of Mr. Bilirakis and Ms. Titus about 
alternative therapies. I think we know they work. Clearly they 
do. And Mrs. Somers, I appreciate your comment about evidence-
based. I am not a doctor but I have seen evidence that non-drug 
therapies work. And to me that is good enough, and if it is 
good enough for the veteran, it should be good enough for the 
VA.
    I want to talk a little bit about the VA acknowledgment of 
non-drug therapies and your experience with that, understanding 
every case is going to be different. I hosted a VA intake day 
recently. We had about 300 people come through my congressional 
office in the district. One man brought a backpack that he 
turned upside down on my desk and he dumped out surplus 
medications, dozens and dozens and dozens of bottles of them. 
Sergeant, you referred to your cocktail going from 11 drugs to 
14. Mrs. Selke, I think you expressed some concerns about 
Ambien. The Somers have expressed concerns about the use of 
generics and otherwise. Just on its face, do you lack 
confidence in the way that VA administers pharmaceuticals? Not 
on the merits of pharmaceuticals, but in the experience of 
pharmaceutical use as administered and directed by the VA?
    Mrs. Selke. I mean, I will speak to that. I spoke earlier 
about the difficulty of Clay getting a prescription refilled. 
But what has been said before, in the private world if I go to 
a doctor and they determine I need Synthroid for my low thyroid 
issue, I got and I get Synthroid and I stay on Synthroid as 
long as I am retested and that is shown to be effective. I do 
not understand why the DoD and the VA have two different 
pharmaceutical programs and the veteran has to suffer the 
consequences when you separate from the service and move to VA, 
especially on mental health drugs. You cannot swap them out and 
stop cold and all of that. Or even on anything physical. It 
makes no sense to me. I do not understand why one system would 
not work for both. Why not whatever works for DoD as far as 
pharmaceutical medications or anything, why does the VA have to 
be different? It sounds to me like it is a cost factor.
    Mr. Jolly. And I----
    Mrs. Selke. We have to shift to the cheaper route. Well we 
have people dying everyday because we have switched to the 
cheaper route.
    Mr. Jolly. And I ask, and I realize very much this is just 
a matter of personal impression and not clinical. But my 
concern having heard each of your stories is that simply 
because of the volume of patients, that million-plus volume of 
mental health patients, the 21,000 employees, you have raised 
concern about personalized care. And it would seem to me there 
is, that is clearly lacking. I do not know what your 
impressions would be? If you could speak to that? And also, 
simply whether or not alternative therapies have ever, did your 
sons have that discussed perhaps? Or Sergeant, in your 
counseling the ability to get alternative therapy? And I say 
that based on a personal experience as well. At VA intake day I 
had a man in my office who said, ``Equine therapy works.'' Well 
that was good enough for me. But it was not good enough for the 
VA. So can you speak to any discussions about alternative 
therapies, availability of, your opinions to that?
    Sergeant Renschler. Yes, sir. So again within the VA 
medical center they had at one point in time available to 
polytrauma patients or those who suffered from comorbid 
conditions, we were able to access recreational therapy and I 
was put on a six-month waiting list. And when the six months 
came up they lost the recreational therapist, so that was my 
only experience there. I never had a chance to engage in that 
because I was downgraded from polytrauma care when the VA 
determined that my Traumatic Brain Injury had reached a plateau 
of recovery and it probably would get better. That is a 
completely separate hearing day. But as far as the efficacy of 
alternative therapies, I mean we could, again, it is, it really 
helps. And the VA currently----
    Mr. Jolly. The availability?
    Sergeant Renschler. The availability is not there through 
VA channels. It is private community, is where you have to go.
    Mr. Jolly. All right. Dr. and Mrs. Somers., do you----
    Mrs. Somers. Yes, I would agree with that, that it is. 
Daniel himself was a musician so it was easy for him. He got a 
piano and a guitar and that was his therapy. But I would 
totally agree with that. At the San Diego VA I know they have 
pottery classes, which we were thrilled to hear about, and a 
guitar program.
    Dr. Somers. And when you talk about evidence-based it is 
certainly not just medications. I mean, there are these 
psychological treatments that are out there but they are only 
using two of them at this time when there are so many other 
potentials out there. And the other thing that we had mentioned 
was the MDMA ecstasy and LSD for pain, the MDMA for PTSD and 
LSD for pain. And because of our national phobias against these 
particular chemicals, we are making it very difficult to do 
trials with these potential, potential benefits.
    Mr. Jolly. All right. Thank you very much. Thank you to 
each of you. Mr. Chairman, I yield back.
    The Chairman. Thank you very much, members. We thank the 
witnesses for participating. Whether or not you know it, you 
have been at that table for three hours. And we are very 
thankful that you have been willing to share your stories with 
us. So with that, thank you very much, and you are excused.
    Members, what we have done is we have asked the second and 
third panels to combine together. So we will have them appear 
at the witness table together instead of having a second and 
third separate panel. So I would like to invite the witnesses 
to please come forward.
    Joining us at the table will be from VA Dr. Maureen 
McCarthy, Deputy Chief Patient Care Service Officer. She will 
have Dr. David Carroll, the Acting Deputy Chief Consultant for 
Specialty Mental Health with her at the table. Our third panel 
includes Alex Nicholson, the Legislative Director for the Iraq 
and Afghanistan Veterans of America; Lieutenant General Martin 
Steele, the Associate Vice President for the Veterans Research, 
the Executive Director of Military Partnerships and the Co-
Chair of the Veterans Reintegration Steering Committee for the 
University of South Florida; also Warren Goldstein, the 
Assistant Director for TBI and PTSD programs for the American 
Legion's National Veterans Affairs and Rehabilitation 
Commission; and Dr. Jonathan Sherin, the Chief Executive 
Officer and Executive Vice President for Military Communities 
for Volunteers of America. Thank you all for being here. And 
Dr. McCarthy, you are recognized for your opening statement.

               STATEMENT OF DR. MAUREEN MCCARTHY

    Dr. McCarthy. Thank you. Good morning, Chairman Miller, 
Ranking Member Michaud, and members of the committee. I 
appreciate the opportunity to discuss the Department of 
Veterans Affairs mental health care and services for our 
nation's veterans. I am accompanied today by Dr. David Carroll, 
Acting Deputy Chief Consultant, as you mentioned; and Dr. 
Harold Kudler, our Acting Chief Consultant for Mental Health; 
and Mr. Michael Fisher, from the Readjustment Counseling 
Services have joined us as well.
    Let me begin by expressing my sorrow and regret to the 
families of Daniel, Clay and Brian. I want to thank you for 
coming forward and telling your story and their stories. We 
truly believe that one death by suicide is one too many. Thank 
you, Joshua, as well for sharing your experiences. Veterans who 
reach out for help deserve to receive that help. A veteran in 
emotional distress deserves to find there are no wrong doors in 
seeking help. In VA we must ensure those doors are swiftly 
opened, calls are returned, messages are responded to promptly, 
efficiently, and compassionately.
    Over one million veterans, servicemembers, and their family 
members have called our crisis line and received help. Suicide 
rates among those who are VA users who have a mental health 
diagnosis have decreased. The rates of suicide following a 
suicide attempt have likewise decreased. We invite veterans to 
entrust their care to us and we want to ensure them that we can 
provide them the care they need or connect them with someone 
else who can.
    Tragically it is true that about 22 veterans per day die of 
suicide. But another tragedy is five of those 22 veterans are 
veterans who have been in our care. We acknowledge that we have 
more work to do and we are fully committed to fixing the 
problems we face in order to better serve veterans.
    Our actions include the deployment of mobile Vet Centers 
with locations with the greatest challenges in providing timely 
mental health care. Examples include El Paso and Phoenix. We 
have begun a program to ensure veterans waiting more than 30 
days for care may receive mental health care in the community 
from providers who are not VA employees. We have removed access 
measures but not expectations about access and are focusing on 
veteran satisfaction with the timeliness of care they have 
received. We have initiated Operation SAVE, a training program 
for suicide prevention delivered by our suicide prevention 
coordinators to VHA and VBA staff. We have provided suicide 
risk management training to clinicians. This is a VA-mandated 
training for all VA clinical staff which teaches about 
assessment, warning signs, risks, means restriction, and safety 
plans. And we have developed a web based training for 
clinicians specifically focusing on women veterans who are 
struggling with suicidal thoughts about how to recognize their 
distress and bring them into treatment.
    Our actions taken to meet the increasing demands for mental 
health care include the addition of over 2,400 mental health 
professionals and 915 peer support providers since March of 
2012. We have expanded the Veteran Crisis Line services, 
renamed it from a suicide line to a crisis line to reach out 
specifically to those in crisis or not quite yet in crisis, and 
offer both text messaging and an online chat service in 
addition to receiving phone calls. We have partnered with the 
Vet Center Combat Call Center to respond to veterans in 
distress. We have greatly expanded opportunities to access 
mental health, including in rural areas, by telemedicine. We 
have developed mobile apps to assist veterans with their 
symptoms. We have developed an addition focus on improving and 
coordinating with care in the community for those who may not 
seek our help. We have trained community providers on military 
culture and partnered in community engagement. We have 
partnered with the Department of Defense in developing clinical 
practice guidelines for suicide risk assessments and 
intervention, and for the care of PTSD, depression, and 
substance abuse. We also reach out to Guard and Reserves at 
demobilization events to bridge the gaps in understanding about 
benefits and services. We have greatly expanded the provision 
of evidence-based treatments, including psychotherapies for 
mental health conditions. VA is committed to working with 
families and friends of veterans.
    We know mental health outcomes improve when families are 
involved in care. We now have a family services continuum that 
includes family education, consultation, psychoeducation and 
marriage and family counseling, and research remains underway 
to address improvement of mental health care and prevention of 
suicide. To maximize what we can provide, we have developed 
measures of provider productivity, integrated mental health 
care into primary care settings and initiated several campaigns 
to break down any barriers or stigmas that may be associated 
with seeking help.
    We have developed a program on college campuses where 
student veterans may receive needed mental health care without 
leaving the campus.
    Mr. Chairman, we are fully committed to ensuring accessible 
mental health care of the highest quality for our 
servicemembers and veterans who have sacrificed so much on our 
behalf. We are committed in our efforts to decrease suicide by 
decreasing risks we can identify and focusing meanwhile on 
improving the quality of life for these veterans. VA will 
continue to provide care in a veteran-centered manner, 
expanding access and breaking down barriers associated with 
seeking help. We are compassionately committed to serve who 
have served making it easier for them to ask for and receive 
the help they need.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to answer your questions as the panel 
proceeds.

    [The prepared statement of Dr. Maureen McCarthy appears in 
the Appendix]

    The Chairman. Mr. Nicholson, you are recognized.

                  STATEMENT OF ALEX NICHOLSON

    Mr. Nicholson. Thank you, Mr. Chairman, Ranking Member 
Michaud, and Members of the Committee. On behalf of the Iraq 
and Afghanistan Veterans of America, we really appreciate the 
opportunity to share with you our views and recommendations 
recommending mental health access at the VA and suicide 
prevention efforts.
    Combatting veteran suicide is IAVA's top priority for 2014 
and it is a critically important issue that affects the lives 
of tens of thousands of servicemembers and veterans, especially 
of the wars of Iraq and Afghanistan. In IAVA's 2014 member 
survey, our members listed suicide prevention and mental health 
care as the number one issue facing our generation of veterans. 
In that same survey that was just conducted in February and 
March of this year, 47 percent of respondents reported that 
they knew an Iraq or Afghanistan veteran who had attempted 
suicide and over 40 percent knew and Iraq and Afghanistan 
veteran who had died by suicide. We have over 270,000 members. 
Forty percent of them know someone who is a fellow veteran of 
Iraq and Afghanistan who has died already by suicide.
    In response to the overwhelming need for action, IAVA 
launched the campaign to combat suicide this year which 
includes a call to pass comprehensive legislation that can 
serve as a cornerstone for additional efforts across government 
and across the country. In addition to legislation, IAVA is 
calling on President Obama to issue an Executive Order to 
address additional aspects of suicide prevention efforts and 
IAVA is working to connect more than one million veterans this 
year with mental health services across the country.
    The need to examine mental health services and suicide 
prevention efforts provided to veterans is even more critical 
in light of the recent VA scheduling crisis. In addition to the 
general delayed access to care that veterans are experiencing, 
as I am sure all of you know, investigations have also 
uncovered cases of significantly delayed access specifically to 
mental health care. While no veteran should have to wait months 
for a medical appointment of any kind, veterans utilizing 
mental health care services and especially those who are in 
crisis should never had to wait an unreasonable amount of time 
to be seen by a mental health care provider. Providing timely 
and efficient mental health care must be a much greater 
priority for the VA moving forward.
    Increasing the accessibility of mental health services must 
also be coupled with increasing access to care for vulnerable 
populations of veterans currently excluded from VA care. 
Between 2001 and 2011, an estimated 30,000 servicemembers may 
have received a downgraded discharge characterization due to a 
misdiagnosis of personality disorder. Even more troubling, an 
unknown number of servicemembers were punitively discharged for 
disciplinary actions that may have been connected to an 
undiagnosed mental health injury. It is imperative that the 
thousands of individuals with such experiences are identified 
and their records are properly re-evaluated and rectified in 
order to provide access to earned VA mental health services and 
benefits.
    Examining access to care should also include a review of 
the current five-year special combat eligibility for VA health 
care provided to recently transitioned veterans. The five-year 
time period may not be enough time for veterans who present 
with mental health injuries symptoms later or who might delay 
care due to concerns with stigma of seeking care. Extending 
special combat eligibility, though it may be costly, will 
provide access to care for veterans when they are ready to seek 
it. It is important to recognize the efforts the VA has put 
into mental health services and suicide prevention programs in 
recent years, and especially, as has been mentioned already, 
the Veterans Crisis Line has been an enormous resource for our 
community and the VA has done a terrific job of promoting that 
and we have been happy to partner with them in helping them 
promote that, disseminate that, and we refer veterans in crisis 
to the Veterans Crisis Line through our Rapid Response Referral 
Program every single day. It has been a fantastic resource, but 
more, of course, needs to be done. Increasing access to care, 
meeting the demand of that care, and providing high-quality 
care with continuity and responding to veterans in crisis 
requires a comprehensive approach, and while there is no 
illusion that veteran suicide will be completely eradicated, 
implementing better approaches to mental health care and 
suicide prevention can and does save lives.
    Again, we appreciate the opportunity to share our views on 
this topic and we look forward to continuing to work with each 
of you and your staff and the Committee to improve the lives of 
veterans and their families. Thank you.

    [The prepared statement of Alex Nicholson appears in the 
Appendix]

    The Chairman. Thank you, Mr. Nicholson.
    Now, General Steele, who is the co-chair of the Veterans 
Reintegration Steering Committee at the University of South 
Florida, you are now recognized for five minutes.

             STATEMENT OF GENERAL MARTIN R. STEELE

    Lieutenant General Steele. Thank you, sir.
    Chairman Miller, Ranking Member Michaud, distinguished 
Members of the Committee, on behalf of the University of South 
Florida, thank you for holding today's oversight hearing. By 
way of a brief background, the University of South Florida is a 
global research university with over 47,000 students, including 
over 2,200 veterans and their families. Military Times EDGE 
magazine recently ranked USF the fifth best college for being 
veteran-friendly in the United States out of 4,000 colleges and 
universities.
    Under the leadership of our president, Dr. Judy Genshaft 
and our Senior Vice President for Research and Innovation, Dr. 
Paul Sandberg, numerous USF researchers are currently involved 
in funded studies related to such topics as: suicide 
prevention, traumatic brain injury, post-traumatic stress, 
robotics and prosthetics, speech pathology and audiology, gait 
and balance, and age-related disorders. We have numerous 
research and health care partnerships through affiliation 
agreements to include the James A. Haley Veterans Hospital, the 
largest polytrauma center in the VA system, along with the C.W. 
Bill Young VA Medical Center, number four in the system, 
located in St. Petersburg. We have memorandums of understanding 
with United States Central Command, U.S. Special Operations 
Command, and work closely with MacDill Air Force Base and the 
Pentagon.
    Our Veterans Research Reintegration Steering Committee 
consists of scientists from throughout USF's faculty, staff, 
and students who work with veterans, along with representatives 
from the Veterans Administration, the Care Coalition of Special 
Operations Command and Draper Laboratories. We have a holistic 
approach in regards to education to provide services to our 
veterans and their families.
    In order to address the mental health needs of our veterans 
and our diverse population of at-risk students, we have 
embarked on a Collaborative Suicide Prevention Project. This is 
a three-year initiative funded by a $306,000 grant from the 
Substance Abuse and Mental Health Services Administration, 
SAMHSA. Some of the goals and measurable objectives of this 
project are to increase the number of persons involved in 
suicide-prevention efforts, reduce the stigma associated with 
it and the barriers, and increase family involvement in suicide 
prevention.
    As you are aware, the Blue Ribbon Panel of the VA Mecical 
School Affiliations was established in 2006 to look at quote, 
``A comprehensive philosophical framework to enhance VA's 
partnerships with medical schools and affiliated 
institutions,'' unquote. The panel believed that the crisis in 
the U.S. Health Care System offered a unique opportunity to 
explore fundamentally new and better models of patient care, 
education and research. As the panel revealed, currently 
available mechanisms for meaningful dialogue between the VA and 
academic community were inadequate. Some of the major 
challenges include credentialing, as was mentioned earlier, 
which requires considerable time, along with the research 
approval process, which is cumbersome, very time-consuming for 
both parties. The process takes months, and in some cases can 
take over a year just for approval.
    There are also many barriers to innovation. One of our 
professors, has an innovative approach for the treatment of 
post-traumatic stress and is highly unlikely, we believe, to 
receive approval by the VA health care facility. The protocol 
known as Accelerated Resolution Therapy, or ART for post-
traumatic stress, has been shown to be effective in published 
research from the University of South Florida, yet the VA has 
not accepted invitations to collaborate on a pilot study for 
patients diagnosed with PTS. We do work with the Department of 
Defense. I have been at Fort Belvoir in Virginia and Fort 
Benning in Georgia and also Special Operations Command in Tampa 
to work with this protocol which has been proven very 
successful.
    We recommend streamlining the credential process and 
creating fast track approvals for collaborative pilot studies 
between VA and University research studies that involve minimal 
risk to the patients, but could provide significant benefits to 
treatment of mental disorders. We also are recommending 
developing agreements between the VA system at the national 
level and academic communities throughout the country. We also 
believe the very definition of academic affiliates needs to be 
re-examined to move beyond the limited focus on health care to 
a much more encompassing venue which would include employment, 
education, business development, enhanced use/lease 
relationships, and increased researched funding.
    In 2012, a VA research scientist from USF, along with a 
research scientist from the medical research service at James 
Haley, conducted a pre-clinical animal research linking post-
traumatic stress, mild TBI, and the potential for suicides in 
the military. We believe their research needs to be extended to 
learn more about how the brain is affected by physical and 
emotional trauma. More importantly, we believe this type of 
animal research will lead to more effective treatments for 
post-traumatic stress and TBI, which will potentially reduce 
the risk of suicide in our military and veteran population and 
could be influential in alternative drug protocols.
    The 2006 blue ribbon panel also noted, with concern, the 
aging VA's research infrastructure. The panel recommended that 
VA enhance its research facilities by fully exploiting 
opportunities to share core resources with its academic 
affiliates. To that end, the University of South Florida 
recommends strong consideration of the development of a 
singular, unique, one-of-a-kind research and clinical 
outpatient treatment facility. This initiative is intended to 
be a collaborative venture between the Department of Defense, 
the Veterans Administration and USF in order to meet the health 
and welfare needs of our veterans and their families.
    USF remains committed to providing the nexus to foster 
research collaborations in pursuit of excellence in the 
rehabilitation, adjustment, resilience, and reintegration of 
wounded warriors and their families into civilian life. Our 
nation's dedicated heroes, from all wars, deserve to have the 
benefit of the best research and services available in order to 
return to productive lives and members of our society with jobs 
and homes for the sacrifices that they and their families have 
made for our country.
    Thank you, again, for holding this hearing and the 
opportunity that I have to submit this testimony, sir.

    [The prepared statement of General Martin R. Steele appears 
in the Appendix]

    The Chairman. Thank you, General.
    Mr. Goldstein, you are recognized for five minutes.

                 STATEMENT OF WARREN GOLDSTEIN

    Mr. Goldstein. Thank you, Mr. Chairman.
    Every day in America 82 people take their own life. That is 
one every 17 and a half minutes. Since this hearing began over 
three hours ago, statistically, 12 people have chosen to end 
their life with suicide. One in four suicides is a veteran. 
Twenty-six percent of suicides are veterans and veterans only 
make up seven percent of the population.
    The stakes could not be higher. We must find a solution to 
this problem. Chairman Miller, Ranking Member Michaud, and 
Members of the Committee, on behalf of our National Commander, 
Dan Dellinger, and the 2.4 million members of The American 
Legion, I thank you for taking one of the most serious 
challenges facing America's veterans: finding solutions for 
this mental health crisis.
    The mental health of veterans is something that The 
American Legion takes very seriously. The American Legion 
established a committee on TBI and PTSD in 2010 because of 
growing concerns of the unprecedented numbers of veterans 
returning home with what has come to be called the signature 
wounds of the war on terror. Since then, Legion staff, alone 
with senior leadership has met regularly with academia, medical 
consultants, experts in the field of mental health and brain 
science. We published the findings of our comprehensive three-
year study of veterans, their treatments and therapies, in a 
report called The War Within, which is also available on our 
American Legion website.
    Following up on that report, we recently conducted an on 
line survey to evaluate the efficacy and availability of 
treatments and what we found was somewhat disturbing. The 
result of the survey, conducted in coordination with the Data 
Recognition Corporation, showed that nearly a third of veterans 
surveyed had terminated their treatment plans before completion 
and that almost 60 percent of veterans reported no improvement 
or feeling worse after having undergone treatment.
    Clearly, there are problems with the current practice in 
place. The American Legion convened a symposium last month to 
discuss these findings and highlight other areas where 
complimentary and alternative treatments could prove helpful. 
We listened and saw firsthand the encouraging results for 
veterans who had benefitted from animal therapies with service 
dogs, art therapies, acupuncture, and a host of other non-
traditional treatments. The American Legion believes that by 
exploring options such as these, we can all work together to 
help veterans get the effective treatments they need.
    It is devastating when a veteran cannot get timely 
appointments, but 60 percent of veterans reporting no change or 
worsening symptoms after treatment means that what care they 
are getting is just as important as whether or not they can 
access the care in the first place. This is not to say that 
access does not matter. Indeed, over the past several months. 
The difficulties veterans face, access to care, have been front 
page news and have been a major focus for this committee.
    For The American Legion, it wasn't enough to sit and watch 
idly as veterans struggled to get help; we had to go do 
something about it. That is why The American Legion developed 
Veterans Crisis Command Centers that have been deployed across 
the country, and specifically where it had been reported that 
veterans were being stonewalled while trying to seek care. By 
utilizing American Legion posts already located in every 
community in America, The American Legion has combined town 
hall meetings and coordination of care for veterans so they can 
get the immediate counseling and medical help they have earned 
and desperately need without getting in the way of VA's on-
going efforts.
    We are there to assist VA's efforts and to be a force 
multiplier. So far, Phoenix, Arizona; El Paso, Texas; and 
Fayetteville, North Carolina, we have been able to reach nearly 
2,000 veterans and next week we will expand operations to two 
new locations in St. Louis, Missouri and Fort Collins, 
Colorado, with more locations to follow as we try to get help 
to veterans.
    Yes, there are things VA should be doing to ensure veterans 
in crisis get the help they need, but we now see that our 
veterans can't just depend on VA to fix the problem, that is 
why The American Legion has full-time staff and a leadership 
committee dedicated to studying the challenges of mental health 
treatments to ensure the way America treats veterans is a way 
that will bring real improvements to their lives. And that is 
why legionnaires, veterans, VA, and local businesses across the 
country are supporting our Veterans Crisis Command Centers and 
donating their time and efforts to link the veterans with the 
resources they need.
    By the time this panel finishes our opening remarks, 
America will have lost another person to suicide. That is a 
terrible tragedy. We all have to work together to ensure that 
this rate cannot and will not continue. Thank you.

    [The prepared statement of Warren Goldstein appears in the 
Appendix]

    The Chairman. Thank you.
    Dr. Sherin, you are recognized.

                STATEMENT OF DR. JONATHAN SHERIN

    Dr. Sherin. Thank you. Thank you Chairman Miller, thank you 
Mr. Michaud, and Committee for convening today and for inviting 
me to today.
    My name is John Sherin. I am a psychiatrist and 
neurobiologist by trade and currently serve as the executive 
vice president for military communities and chief medical 
officer at Volunteers of America. While I am not a veteran, my 
life's calling has been to serve veterans. Having worked for a 
decade at VA as a psychiatrist and chief of mental health prior 
to joining VOA, I have been able to observe the VA from both 
the inside and out. This experience has given me a unique 
perspective as to the nature of access problems facing veterans 
and possible solutions.
    In general, I contend that the most immediate solutions 
reside in growing capacity through more robust partnerships 
between VA and local communities. Working alongside VA last 
year, VOA supported and housed more than 10,000 homeless 
veterans, a number that will increase this year. Though 
significant, the opportunity for impact in partnership with VA 
is much larger and can include helping veterans at risk of 
watching their unmet needs become urgent problems that evolve 
into health crises due to inadequate access. The VA has a 
golden opportunity to lead this effort right now by leveraging 
organizations like VOA to grow capacity and improve access.
    In contemplating partnership strategies, it is important to 
recognize that access barriers go way beyond wait times. Red 
flags in isolation and inadequate knowledge of available 
resources and unwillingness to engage in the help-seeking 
process, difficulty navigating complex systems and lack of care 
coordination all impact access. Recognizing this array of 
access barriers, VOA has developed the Battle-Buddy-Bridge 
program, a program rooted in trust and designed to mitigate 
access barriers through real time, peer-to-peer engagement and 
local resource navigation.
    Peer approaches, which are used by other organizations, 
including the Augusta Warrior Project, Team Red, White & Blue, 
IAVA, The Mission Continues, Team Rubicon, and others, 
transform the access dynamic in many cases. As such, it is my 
first recommendation that community-based peer-engagement and 
navigation programs be brought to scale with federal support as 
part of all out assault on access barriers at the VA and 
beyond. Leveraging this model further, my second recommendation 
is for the VA and the private sector to set up rally points in 
communities, as well as on VA campuses that are endowed with 
trained peers, vehicles, resource maps, and tightly linked to 
VA's Suicide Prevention Program, the national crisis hotline, 
2-1-1 exchanges, tech-based veteran community portals such as 
POS REP, and any other referral sources of relevance. Rally 
point networks could have a profound impact on access in any 
geography.
    As a final point, I want to highlight a major partnership 
success story, the Supportive Services for Veteran Families 
Program of the VA. This program administered by VA's National 
Center for Homelessness Among Veterans has fostered 
relationships between VA and communities that are 
unprecedented. In the opinion of many experts in both the 
community and the VA, the streamlined structure of SSVF offers 
the best means for managing partnerships going forward.
    As such, my third and final recommendation for resolving 
mental health access issues and improving suicide prevention 
going forward is for the VA to adopt an SSVF-like mechanism as 
the basic template for VA to use in developing more robust 
relationships. By using this mechanism, VA can most effectively 
leverage partners to create community-driven programs that 
improve access to the vast array of resources which address 
mental health conditions.
    To close, more robust partnership between the VA and 
community will not only help veterans enrolled in VA to get 
better access, it may also help veterans--it may also help 
provide access to veterans who refuse to enroll in the VA, as 
well as veterans who are located in remote areas. Let's all 
take advantage of recent findings at VA and recognize that 
while inadequate access to care in the veteran population 
reflects the shortcomings of a federal agency, it also reflects 
the fundamental failure of the American community and process.
    It is time to roll out a new era of public, private 
partnership that grows capacity and ensures veterans have 
access to the resources they need for successful community 
reintegration.

    [The prepared statement of Dr. Jonathan Sherin appears in 
the Appendix]

    The Chairman. Thank you very much, Doctor.
    Dr. McCarthy., On Tuesday evening this committee heard from 
a whistleblower that was a former chief of psychiatry at the 
St. Louis VA Medical Center. Are you aware of his testimony?
    Dr. McCarthy. I am aware of it, yes, sir.
    The Chairman. Okay. He stated he could not identify, within 
his clinic, the average number of patients that are seen by 
provider per day or the time a provider spends on direct 
patient care per day. When he asked other psychiatry chiefs to 
estimate similar data at their facilities, he received answers 
that ranged from 8 to 16 veterans per psychiatrist per day.
    When he worked with a VA database administrator and his 
outpatient psychiatry director, he said he was shocked to find 
that outpatient psychiatrists at the St. Louis VA were only 
seeing on average six veterans within eight hours for 30 minute 
appointments. There were only three 60 minute appointments of 
those each week and he could only account for three and one 
half hours of work during an eight-hour day.
    So, as we have already heard people talk about a nationwide 
shortage of mental health providers, do you feel that the 
utilization of staff at VA is appropriate?
    Dr. McCarthy. Sir, that is why we have what is called the 
SPARQ tool. This is something that has been developed as part 
of our physician productivity model. We can look at 
psychiatrists----
    The Chairman. I am sorry, my question is: Do you think that 
utilization of staff at this level is appropriate?
    Dr. McCarthy. I do not believe that what you said is an 
appropriate way to use staff; however, I have data that 
supports that that may not be the full story.
    The Chairman. Do you know what the mental health staffing 
is and productivity requirements throughout the system?
    Dr. McCarthy. I know the model, which is in terms of the 
number of psychiatrists and given population of veterans----
    The Chairman. Whose model?
    Dr. McCarthy. It is our model, sir.
    The Chairman. VA's model?
    Dr. McCarthy. Yes, sir.
    The Chairman. Should we be using what VA wants now or 
should we be looking outside of VA?
    Dr. McCarthy. It seems like there may not be a right answer 
to your question, but I can tell you why the model developed. 
It is a team-based model of care----
    The Chairman. From VA?
    Dr. McCarthy. Yes, sir.
    The Chairman. Okay.
    Dr. McCarthy. And----
    The Chairman. Do you know what the health staffing and 
productivity requirements are throughout the system?
    Dr. McCarthy. We have a quadrant-type model which looks at 
productivity and other measures to determine if we are staffing 
appropriately.
    The Chairman. Do you know what the standard is?
    Dr. McCarthy. Okay. Help me understand.
    Are you asking how many work RVUs per physician, per day--
is that the kind of question that you would like me to answer?
    The Chairman. I guess that is good enough.
    Dr. McCarthy. Okay.
    The Chairman. Do you?
    Dr. McCarthy. I don't have the exact expectations of the--
--
    The Chairman. The other question is: Is VA meeting the 
standards?
    Dr. McCarthy. Sir, I can answer that question. If we look 
at our work value units compared to the national average for 
physicians who are psychiatrists, as well as psychologists, we 
are meeting the national average for productivity according to 
that standard.
    The Chairman. According to whose numbers? Are those numbers 
that VA establishes or----
    Dr. McCarthy. No, they are external.
    The Chairman. No, no, I am talking about internal numbers.
    Dr. McCarthy. Okay.
    The Chairman. Are your folks reporting the truthful number?
    Dr. McCarthy. Sir, what that model is based on is the 
actual encounters that occur.
    The Chairman. No, no. Are your folks telling the truth?
    Dr. McCarthy. Yes, sir.
    The Chairman. Everywhere?
    Dr. McCarthy. I can't answer a question like that, sir. But 
about the model, I can tell you that the numbers are driven 
from a system that couldn't be manipulated.
    The Chairman. Based on what we have seen over the past 
three or four months, do you trust the numbers that people are 
giving?
    Dr. McCarthy. If you ask me about access numbers, I don't, 
and I think there has been evidence before this committee that 
shows that access numbers are not reliable.
    The Chairman. And so--but you think the other numbers are 
reliable?
    Dr. McCarthy. There are some numbers that are reliable, 
yes, sir. I have been looking for numbers that we can try and 
understand measures of our access and timeliness of care and we 
have, for instance, numbers of consults that----
    The Chairman. Let me ask you a better question: Would you 
bet your life that the numbers that people give you are 
truthful?
    Dr. McCarthy. I am sorry, sir. Are you talking about 
numbers related to productivity?
    The Chairman. I don't care what the number is. Would you 
bet your life on any number that somebody gives you as a 
truthful number because we just had a panel of witnesses who 
have lost their children. They lost their lives.
    Now I am asking you: Would you bet your life that the 
information that people are telling you is truthful?
    Dr. McCarthy. Sir, I would not. I would not bet my life----
    The Chairman. That is all I need to hear.
    Dr. McCarthy. [continuing]. That the access numbers that 
you received are truthful.
    The Chairman. That is all I need to hear. Thank you very 
much.
    Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Dr. McCarthy., we heard an earlier panel issue dealing with 
HIPAA. My question as it relates to HIPAA is in the department 
and I actually did find the OIG report and I heard that the 
Veterans Health Administration and the Veterans Benefit 
Administration could not exchange information because of HIPAA 
problems. I mean they both work for the same department, so I 
am not sure why there would be any HIPAA problems with VHA 
talking to VBA.
    My question is--is the recommendation from the OIG back in 
2011 was that the VA medical center directors and VBA directors 
will meet monthly; they meet monthly and they will discuss this 
issue--had that issue about any HIPAA problems been resolved 
between VHA and VBA, do you know what would the outcome of that 
is; if not, could you get back to the Committee?
    Dr. McCarthy. I would be happy to take that one for the 
record, sir. I can give you an example.
    For instance, if I were to do a C&P (compensation & 
pension) exam on a patient, that is considered--it is not 
considered a VHA document; it is concerned owned by the veteran 
or by the VBA, so that is not something that VHA releases. 
There are some separations that are aimed at protecting 
veterans.
    Mr. Michaud. But if both VBA and VHA works for the 
Department of Veterans Affairs----
    Dr. McCarthy. Yes, sir?
    Mr. Michaud [continuing]. So I am not sure why there would 
be any HIPAA problems between VBA and VHA. So, yeah, if you 
could get back on that, I would appreciate it.
    Dr. Sherin. I agree with you that VA can't do it alone. 
What has been your experience with trying to partner with the 
VA to provide the service to, you know, in the communities, and 
have there been different, you know, outcomes depending on what 
region VOA has been around the country--involved in?
    Dr. Sherin. That is a great question. I do believe there is 
variability, and getting back to my final point, I think that 
it is important that we look to the VA to develop a consistent 
mechanism that is responsive and that program that I have 
described, which I am sure you are familiar with, SSVF, is one 
that is very responsive and very effective.
    The bigger question, as I see it: What is VHA's mission? Is 
VHA's mission to deal with all reintegration problems? And I 
would say probably not, because so much is trying to stream 
through VHA to deal with reintegration issues outside of health 
care, it has created a strain on the system and has diluted its 
primary mission of providing outstanding health care, including 
mental health services.
    Mr. Michaud. Thank you.
    Getting back to the VA, as you--I noted in your opening 
remarks that VA's spending on mental health is approaching $7 
billion dollars, double the amount in 2007. What is the VA's--
what is VA using as a measure of success of this investment in 
mental health services?
    Mr. Carroll. Thank you, Congressman.
    There is no single measure that we point to that is going 
to satisfactorily answer that question and certainly what we 
have heard today, what we have heard over the past few weeks 
points to the fact that VA has a lot more to do. At the end of 
the day, what matters most is whether or not we have met the 
needs to the individual veteran who presented himself or 
herself for VA mental health care, whether we have addressed 
those needs at the time they came in today and whether they 
left better off or with a clear plan of things that they could 
do to move forward. That is the ultimate outcome of our care 
and it has to be addressed and assessed for each individual at 
each time of care.
    I think we can point to some things in our system. We know 
that over the last seven years, there have been 37,000 rescues 
or saves that have been facilitated through the Veterans Crisis 
Line. On the one hand, that is a remarkable number and on the 
other hand, it is not enough and we know that. We can look to 
veterans with serious mental illness and we can look to our 
Mental Health Intensive Case Management Program and we know 
that they are able to live in the community of their choice, to 
find employment, and to stay out of the hospital. We know that 
when veterans drop out of care with serious mental illness, we 
can successfully re-engage them in care. There are multiple 
other examples, but I think at the end of the day, it is the 
individual veteran and whether or not we have addressed their 
needs today is the ultimate test.
    Mr. Michaud. Thank you. I yield.
    The Chairman. Dr. Roe.
    Dr. Roe. Thank you, Mr. Chairman, and thank the panel for 
being here. I want to go ahead and continue along the line for 
just a moment the chairman did.
    Dr. Matthews, in the St. Louis VA, six percent of the 
veterans did not return for care and then we hear in other 
testimony today that a third of other veterans dropped out of 
care and 60 percent showed no improvement. This is difficult to 
treat and I understand that. It is a very difficult issue and 
it is very individualized with each patient that you see. But 
how can you explain that kind of drop out when these people are 
lost to follow-up and you don't know what happens to them? 
Those are the folks that may be needing a hotline or the ones 
that are committing suicide at this astounding rate. When you 
have more veterans committing suicide that are diagnose in 
combat we have a true crisis, so is it--and we have added 
several thousand more providers to the VA during the last, I 
guess, couple of three years.
    Dr. McCarthy. Yes, sir.
    Dr. Roe. So how, exactly, in the metric that he was talking 
about, productivity, I don't really agree with that, that it is 
meeting the same metric because what we found out with these 
oversight and investigation hearings is that time after time 
after time, the VA's self-analysis is not true. It turns out 
that when it is investigated by an outside party--what we have 
been hearing now--now, let me tell you how frustrating that is 
for me to sit up here.
    I expect people, when they come to that dais up there, 
whether they are sworn in or not, to tell the truth, not just 
to make themselves look good, and that is what we have done. 
And let me know what VA has done, and as a surgeon, you have to 
have a lot of trust to have a patient lie down and let you open 
them up and operate on them. The VA has lost a tremendous 
amount of credibility and trust and it is going to be very 
difficult to put that humpty dumpty back together again.
    So how can you--what can we do now? That is all in the 
rear-view mirror. How do we go forward, that is what I am 
asking.
    Dr. McCarthy. We do have a lot of work to re-build that 
trust. We absolutely do, and our department is focused on that. 
Our acting secretary has laid out clear expectations about ways 
to restore that trust. What we can tell you are things like for 
the veterans who seek our care and who have entrusted their 
mental health care to us, for those veterans who are receiving 
our services, the suicide rate is actually going down. For all 
veterans who seek VA care and are enrolled in our care, for all 
of them, not just the mental health veterans, their rate of 
suicide is going down.
    We do have some successes and I guess what I want to do is 
not discourage the veterans from reaching out to us who need 
us.
    Dr. Roe. We don't want to do that at all.
    Dr. McCarthy. We want to get----
    Dr. Roe. I don't mean to cut you off, but my time is 
limited.
    Dr. Sherin, a couple of things that have interested me is 
that there are a lot of programs around, both outside, Not 
Alone and others you have heard of in what you do, how do you 
make--how does the VA help coordinate, because you are right, 
some veterans don't want to go through and see this--go through 
this big maze of things at the VA, walk into this big building 
and wind their way around and follow a dotted line to some 
place. How do you coordinate all of that?
    Dr. Sherin. That is a great question. There are a number of 
efforts around the country. One where I live in LA, the Los 
Angeles Veterans Collaborative, which actually brings together 
roughly 250 organizations per month, including the VA, with the 
aim of developing coordinated systems.
    The idea that I share with you, recommendation number two, 
to create rally points, is to get proactive by creating 
navigation--a navigation network that is operated by veterans 
who can function as a surrogate family. We heard the families 
that were here in the first panel talk about the need for a 
support system, that special relationship between the brothers 
and sisters in the military community. We need to leverage 
that. That is a way to get information from people that are 
suffering. It is a way to introduce a process and content 
expertise into communities with navigators who engage and then 
advocate.
    Dr. Roe. One of the things that is in my local community 
that my wife is involved in is The Humane Society. We are 
finding out that veterans sometimes won't go to the hospital 
because they leave their animal, their dog at home, and they 
don't have anyone to take care of them because they are alone. 
And so The Humane Society are now taking care of those animals 
so the veterans can go to the VA. It is something that I never 
thought of. I had no idea that that was even going on, that 
people would not get care because their companion, which is 
their animal, didn't have anyone to care for them if they went 
in to seek care. So that is another thing that I think one of 
the great challenges--and I applaud your effort for doing 
that--is that there are a lot of people trying to help and 
there is no question about that, and you will see a renewed 
effort here--is how do we coordinate that?
    And with that, Mr. Chairman, I yield back.
    The Chairman. Ms. Brownley, you are recognized for five 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    So, Dr. McCarthy, I wanted to follow up on I think Dr. 
Roe's line of questioning and you were talking about some of 
the successes that you feel improvements that have been made, 
and, Dr. Roe was talking a lot about trust. I think, you know, 
one of the issues I think for me and the rest of us here is of 
what data are you working--you know, when you state these 
successes, what data are you looking at and is it, you know, we 
have heard a lot about bad information and people not telling 
the truth and so it is hard to believe that there are 
successes, if there are, because I don't know--I am not feeling 
good about the data of which you would make those conclusions.
    Dr. McCarthy. Thank you for asking that.
    We have, in the last few years, been able to obtain data 
from the states, some with the help of the members of this 
committee. We now have suicide data from 48 states that is not 
VA data that we are using to analyze rates of suicide for 
veterans, including veterans who may not be seeking our care, 
and so the data that we are using include the data that we are 
getting from the states about actual suicides. We often did not 
hear about veterans even in our care who completed suicides, 
and so now we have data about them, but also other veterans. 
That data doesn't go back to 2001, but if you start kind of 
counting in 2001 after 9/11, then that is the data that we are 
following the trends for, ma'am.
    Ms. Brownley. So do you believe that there is a crisis 
going on in the VA and certainly in terms of access to mental 
health care?
    Dr. McCarthy. Absolutely.
    Ms. Brownley. And so what are some of your--what are your 
top three things that you are planning on doing to resolve this 
crisis?
    Dr. McCarthy. Among them are extending hours, partnering 
with care in the community. There has been an increase in 
funding for what we call fee-basis care and our vet center 
partners have expanded their services and their hours to also 
provide for care. Those are the three major crisis kind of 
interventions and some of that extra hour care has included 
partnership with The American Legion and we are grateful for 
that.
    Ms. Brownley. So with partnerships, public/private 
partnerships, I mean I hear over and over and over again that 
it is very difficult to work with the VA and establish those 
partnerships with the community to expand services to our 
veterans in their communities. So what are you doing to 
alleviate some of those barriers to make it easier to create 
those partnerships?
    Dr. McCarthy. Last year we started these community summits 
which included partnerships with various--they were run locally 
and in the various medical centers. We have reached out to all 
kinds of people of goodwill in the community, people that would 
like to partner with us and they are site-specific.
    Ms. Brownley. Well, reaching out, we have done that in my 
district where I represent and that is a good first step 
because quite frankly in my area, the VA didn't even know about 
all of the services that the communities are providing for our 
veterans. I think now they do, but how are we going to 
eliminate the barriers, if you will, and just in terms of 
contracts and so forth to actually create good public/private 
partnerships to increase services to veterans?
    Dr. McCarthy. So after the summits, there are a series of 
action plans that we have engaged in to address some of the 
barriers that were identified. As far as the access to fee-
basis care, we are using models of payment for fee-basis care 
that are traditional models, but we are also expanding kind of 
contracting services that would be available. El Paso, for 
example, has reached out and formed a relationship with the 
practice that provides their inpatient mental health care to 
provide more outpatient mental health care, and that is just 
one example nationwide.
    Ms. Brownley. And what about alternative therapies? We 
talked about that earlier today. Are you looking at 
partnerships with alternative therapies? Equine therapy, I have 
a great program in my district, Reins of Hope, that is a very 
successful program. Veterans are coming from all over the 
region to utilize this program. It would be great if the VA 
could partner with programs like that.
    Dr. McCarthy. And there are programs like that that VA has 
research partnerships in and there are others where there are 
community partnerships and the veterans are engaged as part as 
the goodwill of the community involved in helping them.
    Are you asking if every VA should have equine therapy?
    Ms. Brownley. Well, I want to know how we can increase 
these partnerships. I will just use my own exactly--I am really 
watching the clock here; my time has just run out, but I will 
follow up with you on my question.
    The Chairman. I am glad that you saw that red light.
    Ms. Brownley. I am learning, Mr. Chairman.
    The Chairman. Mr. Huelskamp, you are recognized.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    A question for Dr. McCarthy, following up closely on a few 
others: What are the waiting times for access to mental health 
care?
    Dr. McCarthy. It is hard to give an actual number, given 
that both the members of this committee and I have said that we 
are not sure that we trust the actual numbers. What we now 
have, though, right on the VA Web site, very transparently, 
information about access. I printed and brought some of that 
information, but what is posted is for every VA medical center, 
what the new patient mental health average wait time is, the 
established mental health wait time, and then a running average 
over the last month for what that particular wait time has 
been.
    When we look over the last month, certainly for those, 
there are significant improvements over what they had been 
before, but----
    Dr. Huelskamp. Ma'am, are those reliable data?
    Dr. McCarthy. I believe these are reliable. I would not 
stake my life on it, as Chairman Miller has said, but to my 
knowledge----
    Dr. Huelskamp. Have they ever been audited by independent 
entities outside the VA?
    Dr. McCarthy. I do not know the answer to that question. I 
would be happy to take that for the record.
    Dr. Huelskamp. Well, yeah, I would appreciate that because 
we have heard testimony, the Office of Inspector General on 
June 9th, clearly, data has been manipulated and data has been 
falsified and actually, I think on June 23rd, the VA admitted 
that their data was not reliable and a few minutes later they 
talked about their data and what they could draw from that.
    I agree with most of my colleagues that we don't know what 
the data is. I mean the epistemological question is: What do we 
know that we know? And right now it is clear, especially the 
investigations, you know, 70 investigations going on--going 
after or investigating retaliation against folks that are 
saying that this data is falsified. In particular, I had just 
one whistleblower in one hospital and I had asked the VA what 
is the range of the workload for doctors across the nation and 
the total range--the bottom range, I found out, according to 
one whistleblower in only one hospital was lower than supposed 
the national range. And so one independent source verified that 
all the data was inaccurate there.
    So can you tell me what the VA is doing to actually assess 
and verify and authenticate the data so folks on this committee 
and the 341,000 employees at the VA can actually say, this is 
where we are heading; this is where we have been; this is how 
we have improved the system. Give me a sense of how the VA is 
going to actually answer that basic question of how we are 
going to independently assess the data.
    Dr. McCarthy. Our Acting Secretary has talked about not 
looking at the same kinds of access measures, but instead, 
looking at patient satisfaction with the timeliness of the care 
that they have received as a measure of access and timeliness. 
As far as these----
    Dr. Huelskamp. And that will all be done--internally 
handled by the VA? I mean who is coming in independently and 
saying--ma'am, I don't trust the data. You apparently don't 
trust your own data unless it serves the purpose and I am 
looking at an IG report for 2012 and said the average of 50 
days--the average is 50 days to receive a full mental health 
evaluation.
    I would say today that the Office of Inspector General 
probably says, well, we don't know; we use the data from the 
VA, and now they are telling us today that it is all made up 
and it could be falsified. And all we are going--and I am like 
many here, you are hearing from constituents is saying well, 
what you are being told, and I heard from a whistleblower who 
called my office yesterday, just wanted to say that what you 
are being told by the VA is whitewashing the situation in this 
particular vision because they are falsifying the data and 
punishing those that make that point.
    So, again, quickly, if you could tell me how you are going 
to prove to me and members of the Committee and the American 
public that this is our data and this is how we can prove that 
we are improving our performance to meet the needs of our 
veterans?
    Dr. McCarthy. Sir, I believe that there are audits planned, 
I am just not personally familiar with those particular audits, 
but I do invite you or anyone to go to the VA Web site and look 
at the data because you can see it and it is part of our effort 
at increased transparency. I think that looking at how long it 
took people in the last month to get care is----
    Dr. Huelskamp. I can't believe the data.
    Dr. McCarthy. Okay. I----
    Dr. Huelskamp. Because it is not independently verified. It 
is not authenticated. There is no one on the outside. I mean my 
district is in four different VIZNs and some reports have come 
out in the last couple days of how they double checked. 
Everything is going fine, but I don't think that they talked to 
a single veteran, and it is not matching up with what the 
whistleblowers are saying. So every time someone from the VA 
comes to our committee and says, Hey, we have got data--it 
might not be good data, but we have got data, I mean it is the 
old GIGO, garbage in/garbage out, and that is what is happening 
here and we can't trust that.
    I would suggest that you look at independent 
authentication, get an outside assessment of what is going on 
at the VA. I know that the chairman has been pushing that. I 
believe that is what needs to happen to re-establish trust, and 
more importantly, to re-establish to make certain that we are 
getting the care that we claim that we are giving to our 
veterans.
    I yield back, Mr. Chairman.
    The Chairman. Thank you.
    Ms. Kirkpatrick you are recognized for five minutes
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    I recently attended a veterans stand down in Phoenix which 
is a one-stop shop for services that our veterans need and they 
had all kinds of things going on--thousands of people there--
and off to a side was a room and I looked in and there were 
veterans sitting there with needles in their ears and maybe in 
the back of their neck and they were receiving acupuncture. So 
I was curious about it. The person delivering the acupuncture 
is actually a constituent in my district who is volunteering 
her time to be there.
    And to a person, every veteran that I talked to said that 
they benefitted from acupuncture. It helped relieve stress, 
anxiety, and asked me to advocate that it be an approved 
treatment in the VA system, so I am doing that. But my 
question--and I didn't ask them if they had a PTS diagnosis, 
but clearly some of them in the room did--every one of them 
benefitting from this treatment.
    So my first question for every panelist is simply this: Do 
you think that acupuncture should be an option within the VA 
for medical treatment for every veteran, starting with Dr. 
Sherin?
    Dr. Sherin. Yeah, I believe strongly in alternative 
approaches for mental health issues and pain and substance 
abuse. I think that acupuncture is a very powerful technique, 
so is meditation, so are many other, you know, well-established 
treatments. The question, though, that I go back to is: Is that 
something that you build into the VA or is it something that 
the VA supports in the community where there are already 
functioning systems?
    Ms. Kirkpatrick. And my question is simply: Does the VA 
cover it? Offer it as a treatment? And because I want to hear 
from everyone, I need to hear quickly.
    Dr. Sherin. Yeah.
    Ms. Kirkpatrick. Should it be a regularly offered treatment 
to veterans regardless of where it is provided?
    Dr. Sherin. I would say absolutely.
    Ms. Kirkpatrick. Thank you.
    Mr. Goldstein.
    Mr. Goldstein. Congresswoman, yes, The American Legion 
believes that all treatments should be made available. If it is 
helping veterans, then yes it should be made available for 
treatment. Thank you.
    Ms. Kirkpatrick. Lieutenant General.
    Lieutenant General Steele. I fully support it, also. I 
think alternative treatments need to be investigated. It is 
part of the cultural shift that we have been talking about and 
what this panel is all about. We have to get to alternative 
treatments. If they work for one person, just as you 
experienced, Congresswoman, hyperbaric chamber is the only 
thing that works for them. It is the same thing. It is not 
evidence-based. It is not approved right now. We have to fix 
this by bringing the opportunities in to get alternative 
therapies to take care of this population.
    I would just like to make one amplifying comment. I am a 
Vietnam era vet. I have people who are contemporaries of mine, 
just like the congressman earlier today, who are just now 
coming forward with their issues about post-traumatic stress 47 
years ago. We don't believe that this population is really 
going to come forward until the year 2030, so that is why I am 
talking about research here to be able to get this fixed so we 
don't have the same thing that has happened to the Vietnam-era 
population.
    I am going to say one other thing. Personally, again, not 
USF, my father is a prisoner of war of World War II. He 
suffered his entire life from post-traumatic stress--never 
recovered from it. He was an alcoholic. It is all part of what 
are we doing here to be able to include all of these things 
together, all of these opportunities that we have to be able to 
bring it together to make it better to take care of the 
patient? To take care of the veteran? Thank you.
    Ms. Kirkpatrick. Thank you.
    Mr. Nicholson. IAVA has been a big proponent and advocate 
for alternative and complementary medicine, so absolutely. 
Especially for the younger generation of vets who are perhaps 
more open to alternative forms of treatment, it absolutely 
would be beneficial. They are already doing it. A lot of them 
are already doing it and covering the costs out of pocket. 
Having help with that would definitely be a big deal to them, 
especially since some of them, especially the younger vets are 
still transitioning, you know, they have lower incomes as they 
are in area earlier career trajectories, so definitely.
    Ms. Kirkpatrick. Dr. McCarthy.
    Dr. McCarthy. Yes, it is part of our clinical practice 
guideline the joint DoD/VA clinical practice guideline for the 
treatment of PTSD that we have been rolling out. So we are 
hoping to have----
    Ms. Kirkpatrick. Does the VA pay for it? That is my 
question.
    Dr. McCarthy. The VA is providing it at some medical 
centers, but----
    Ms. Kirkpatrick. But not across the board?
    Dr. McCarthy. Not yet.
    Ms. Kirkpatrick. So my follow-up question is--quickly--what 
would it take for the VA to have this be part of the standard 
treatment offered to our veterans?
    Mr. Carroll. We need to ensure that there are credentialed 
providers available either on staff in the VA or in the 
community that we could partner with.
    Ms. Kirkpatrick. And just very quickly, would they be 
credentialed by the VA? Do you have a process for that?
    Mr. Carroll. If they were working for the VA, they would 
need to be credentialed for providing that service within VA, 
otherwise we would need to recognize that expertise in the 
community.
    Ms. Kirkpatrick. Thank you. My time is out, but I would 
like to explore at some point in a little more detail.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Ms. Kirkpatrick.
    Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    Dr. McCarthy., when you talked about RVUs, relative value 
units, as a measure of productivity, would it be correct that 
those RVUs are based predominately on time spent with a patient 
in mental health?
    Dr. McCarthy. Primarily.
    Dr. Wenstrup. Okay. And do you feel that that is a good 
measure of productivity?
    Dr. McCarthy. We use the WRVUs and take out the part of the 
RVU that covers malpractice and overhead costs, so it is a part 
of the RVU that we call the WRVU, and it is not ideal, but it 
is the best we have.
    Dr. Wenstrup. Okay. But it is the measure of productivity 
that you are using?
    Dr. McCarthy. For mental health.
    Dr. Wenstrup. Do you go and check to see if those RVUs 
match up with the number of patients seen? In other words, if 
somebody has RVUs that would add up to what would equal eight 
hours of patient care, are you checking to see if they really 
match that? In other words, if they have only seen three 
patients but they have RVUs that match an eight-hour day, eight 
hours of patient interaction, are you checking that?
    Dr. McCarthy. I can't say that I personally am. I can say 
that I would hope that folks are matching that up.
    Dr. Wenstrup. So formally, that is not being done at this 
point?
    Dr. McCarthy. It's a relatively new model for us and it has 
been rolled out since 2011, increasing the numbers of 
specialties per year. Mental health has just been added, so we 
just have the data, but we certainly have to refine it and make 
sure that it is validated.
    Mr. Wenstrup. Because that would authenticate things pretty 
well, which isn't being done.
    And the other thing that we found that is not really being 
done is, what is the cost per RVU within the VA system--not 
just in mental health, but in anything--what are we actually 
spending per every RVU that we put out in care? And that is a 
key number as far as productivity and efficiency, and I think 
that we really have to go that way.
    The next question is: Do our doctors in mental health claim 
responsibility for their patients? In other words, do you look 
back and say, well, Dr. X had 10 patients that attempted 
suicide and he had six that actually committed suicide.
    Do you look at those numbers? Do doctors actually have 
patients that are their responsibility?
    Dr. McCarthy. Absolutely. We have a very active peer-review 
program where cases are reviewed and typically all suicides are 
reviewed in that particular format. In addition, we go through 
what we call psychological autopsies and root cause analyses 
when those kinds of events occur, so a very thoughtful approach 
to each one so no death was in vain.
    Dr. Wenstrup. What happens if one provide had an abnormally 
high number? I mean is it bad luck or are you actually looking 
and saying, what are you doing as far as the type of care that 
you are administering or how much attention to detail are you 
paying to this patient?
    Dr. McCarthy. So a typical peer-review committee would take 
looking at the chart that the doctor--that the documentation 
and all the other factors around the patient actually 
projecting up on a screen, the peer-review committee reviews 
all of the components of the care, looks at the follow-up, 
looks at what appointments were scheduled and so forth and then 
an assessment of did the doctor do the right thing.
    Dr. Wenstrup. And then action is taken, that part you 
didn't mention.
    Dr. McCarthy. Oh, let me keep going then. People are rated 
on a peer-review scale of one, two, or three. Three is if the 
case should have been handled differently. Two if it might have 
been handled differently. One if people felt like it was--the 
standard of care.
    If a provider has a level three, the provider is counseled 
about that and if there is more than one level three, certainly 
there is an intervention program followed and there is an FPPE 
often put in place.
    Dr. Wenstrup. Any firings ever? You ever let a provider go?
    Dr. McCarthy. I can't say that I have personal experience 
with the letting of a provider who had issues with mental 
health suicides go, because I can say that there are situations 
in which we have let people go.
    Dr. Wenstrup. Just performance in general was my question.
    Dr. McCarthy. Yes, sir.
    Mr.  Wenstrup. Thank you very much.
    You know, Dr. Sherin, when I deployed, I was also concerned 
about those who received no mail during an entire year, and I 
always tried to encourage people at home to send this soldier 
something and I wondered what happened to them when they went 
home. You know, which leads me to--I just want your opinion 
real quick on the idea of when you are getting a garden reserve 
go home, you know, active duty, go back to a base or post, an 
opportunity for consultation for the garden reserve of what are 
you doing when you go home? What activity are you engaging?
    Because to me, the worst week was the first week home when 
I did nothing and then I went back and saw patients against. 
And so do you think that would be beneficial because you are 
not coming home to parades and there is not a lot of jobs?
    Dr. Sherin. Yeah. I think I may have missed the question.
    What we try to do in the community is actually to try to 
generate lots of opportunities and one of the key features of 
opportunities involves, you know, kinship, support 
relationships, community. We look at individuals in terms of 
their well-being, and in order to have well-being, yeah, you 
need to have emotional health; you need physical health; you 
need intellectual health; need family; need a community and you 
need spiritual health. Those are the targets that we look at, 
at Volunteers of America and one of the things that we are 
actually trying to push out is a lot more recreational-
occupational activities that bring people together and help 
them knit that community fabric together for the reasons that 
you are pointing out.
    Dr. Wenstrup. That answers my question. I really just was 
questioning if you see the great value in that, and I 
appreciate that. I yield back.
    The Chairman. Thank you very much.
    Mr. O'Rourke, you are recognized for five minutes
    Mr. O'Rourke. Thank you, Mr. Chairman. I would also like to 
thank all the panelists for their testimony today and their 
service to our veterans throughout the country and as I 
represent the veterans in El Paso, I would also like to thank 
Mr. Goldstein.
    The American Legion worked with the local commander, Mr. 
Briton, to set up a command center to connect veterans there 
with health services like the ones that we are talking about 
today, as well as benefits, and by every measure, most 
importantly, in talking directly with veterans, it was very 
successful, so I want to thank you.
    I want to thank Dr. McCarthy. She mentioned the mobile vet 
center and other resources that are being directed to El Paso, 
all of which should tell us that we had a problem in El Paso 
that we are now belatedly trying to correct and to fix. And 
during that time when, especially access to mental health care 
was so problematic, I had an opportunity to meet a young 
veteran named Nick D'Amico and his mom Bonnie, who came to a 
town hall meeting of mine and Nick was having a hard time 
accessing mental health care services at the El Paso VA and 
shared that with me and my team, but was also there to hear 
veterans who served as far back as Korea and Vietnam and the 
Gulf War share frustration with not being able to get into the 
VA.
    As he was driving home with his mom Bonnie from our town 
hall that night in September, he said, you know, I am having a 
hard time getting in and I am a young, new veteran. Some of 
these guys have been trying for years and can't get in and for 
our five days later, Nick D'Amico killed himself, and I have 
got to connect the lack of access, the delay in care, which 
turns into denial of care into Nick D'Amico's death. It is at 
least partially responsible.
    And yet in that time, the El Paso VHA and the national VHA 
was telling me that things were under control, and as recently 
as May 9th of this year, the director of VHA told me that there 
was zero days wait time on average for a veteran seeking mental 
health care access in El Paso, and what I take that to mean is 
that no veteran waited no more than 14 days to do that.
    The discrepancies between what we are hearing from people 
like Mr. D'Amico and the VA were so great that, as I have told 
this committee before, we initiated our own survey of mental 
health care wait times and found that the average wait time was 
71 days. Found at that like, Dr. Matthews told us earlier this 
week, more than 40 percent of veterans stopped trying to seek 
mental health care because it was too frustrating and fully 36 
percent, one-third, could not get an appointment at all.
    And so I want to ask you, if you had known that the average 
wait time was 71 days, or as your own VHA audit found last 
month, 60 days, but certainly much longer than 14 days, if you 
knew that as we know now, we are--we have the worst wait times 
in the country for access to mental health care for veterans, 
the worst as of June, what would you have done differently? You 
said in your opening testimony that we are fully committed to 
providing accessible care. You obviously did not have that in 
El Paso. If you had known all this, what would you have done 
differently?
    Dr. McCarthy. Congressman O'Rourke, I had the opportunity 
to visit El Paso. I had a visit there in June, the 16th and 
17th, and I know that at some point we are going to talk to you 
about that visit. What has happened in El Paso is tragic. There 
were five psychiatrists that left all at once. That left a huge 
hole in the ability for them to continue to provide mental 
health care.
    Mr.  O'Rourke. Here is what I am trying to ask, because I 
have limited time: What the VA was telling me and perhaps you 
and the veterans in El Paso was one thing which turned out to 
be untrue and was very different from what reality was, which 
was that there was terrible, terrible access to care for 
veterans who could get it and one-third could not get into 
mental health care at all. So if you had known that in 
September of 2013, what would you have done differently?
    Dr. McCarthy. I would have assisted you with a huge 
infiltration of kind of resources, but also telemental health 
services. I continue to provide care, even while I work at VA's 
central office, by telemedicine, and that is the kind of thing 
that we can help for places that are having a hard time 
recruiting. So deploying a system of being able to help----
    Mr. O'Rourke. You would have expanded capacity. We would 
have had greater access.
    Dr. McCarthy. Yes.
    Mr. O'Rourke. People like Nick would have been able to get 
in to see somebody.
    So given the fact that we were not told what the real 
conditions were and certainly the VA in El Paso and the VA in 
Washington, D.C., director of VHA reported different numbers to 
me to the veterans in our community, who is accountable for 
that and what are the consequences? Who is responsible?
    Dr. McCarthy. I am not prepared to answer that question. I 
am sorry. I would be happy to take that one for the record.
    Mr. O'Rourke. That is my case in point. You can't tell me 
who is accountable. There are no consequences for veterans 
dying. Nothing is going to change as long as we still have the 
same mentality and culture at the VA, which you exemplify today 
in your testimony. The fact that you cannot tell me who is 
accountable for this, that there are no consequences, that you 
agree that if you had known the truth, you would have done 
something different and arguably people would have survived who 
are now dead, and yet there are no consequences.
    I appreciate the surge in resources, the additional 
providers, your flight to El Paso in mid-June, but unless we 
change the culture at VA, this is going to be a temporary fix 
that will not last.
    And, Mr. Chairman, I yield back.
    The Chairman. Thank you very much.
    Mr. Jolly, you are recognized for five minutes.
    Mr. Jolly. Thank you, Mr. Chairman, and General Steele, 
thank you for being here today.
    Why are you pessimistic about the VA embracing art as a----
    Lieutenant General Steele. That is a great question.
    Mr. Jolly. It was your statement, not mine, by the way.
    Lieutenant General Steele. That was a great question that 
you asked me.
    I just think from the experiences, sir, that we have had in 
regards to trying to bring it in as an alternative therapy, 
along with these other issues that we are talking about, 
alternative therapies, I believe, because I am an eternal 
optimist, that the pessimism that I have about the VA, they 
will be pulled into it because of what is happening here and 
what we are being able to be successful with in the Department 
of Defense and the military right now because they are 
clamoring for art therapy because it works, particularly in the 
early stages of the Special Operations Command, those warriors 
who are having multiple deployments that are going back, they 
have come, they have sought art therapy and it has been very 
successful, returns them to the fight for Admiral McRaven and 
the special operators, and I believe that whole mechanism 
within DoD will result and it eventually being main streamed 
into VA if we pull all of these together, alternative 
therapies. So that is the reasons for that.
    Mr. Jolly. Thank you.
    Dr. McCarthy, is there something that stands in the way--
you know, you have a major research university partner ready to 
collaborate with a peer-review alternative therapy, what stands 
in the way of the VA from embracing that generally? I mean is 
it bureaucracy? Is it procedure? Is it regulation? Is it 
funding? Is it institutional bias? Is it not admitted here?
    Dr. McCarthy. I am sorry, I don't have an exact answer to 
that. I would really be happy to review the program and 
understand it and then understand what the barriers might be in 
order to make those particular--make the implementation. I 
personally don't know.
    Mr. Jolly. Sure. And I guess I am just asking the general 
conceptual. We hear about all of these alternative therapies 
that are available, these non-pharmaceutical therapies that are 
available that work. In my previous profession, I tried to work 
with the VA research department on a regenerative proposal that 
was discovered at a non-VA center and I came up against a bias 
of extramural research not wanting to be, you know, be too tied 
to extramural research and therapies.
    I am just asking an assessment, not why not art, but is 
there an institutional bias against extramural research and 
solutions?
    Dr. McCarthy. I would not say that there is an 
institutional bias. What I can say is that VA funds in 
particular intramural research and some of our providers are 
certainly funded externally, but we don't tend to fund 
extramural research. The way to fund that is to partner with 
someone in the VA and then it would become intramural and that 
would be what would allow the funding.
    Mr. Jolly. On non-drug therapies, are there any pertinent 
regulations that control how a VA physician counsels a patient 
on pharmaceutical therapies versus non-pharmaceutical 
therapies? Are those dictated by other medical standards or are 
there VA regulations that address that.
    Mr. Carroll. Congressman, that is an important question. I 
think the standard within mental health care for VA treatment 
is to provide the care that makes sense for the veteran at the 
veteran's point in life. We offer a recovery model which would 
include a range of evidence-based psychotherapies, evidence-
based psychopharmacologies, certainly supported by 
complementary and alternative medicine approaches, but it is to 
be an integrated package of care that makes sense for the 
veteran at that particular point in their life. So it doesn't 
bias against anyone one of those or towards any one of those.
    Mr. Jolly. Then I have a capacity question, which is when 
it does come to some of the pharmaceuticals, the first 30 or 60 
days--again, I am not a doctor, but I know it is kind of 
critical when you begin a regiment or frankly the testimony we 
heard earlier when you switch medications because DoD to VA, is 
there more precise oversight or care provided to the patient or 
is there a different follow-up with patients in those first 30 
days or 60 days that they begin a pharmaceutical regiment?
    Dr. McCarthy. I can speak to this. It is clearly the 
expectation that people are monitored more carefully as you are 
making changes, either initiating a therapy or making increases 
in doses, yes.
    Mr. Jolly. Okay, thank you.
    One last question: Dr. Steele, quickly, you have a 
distinguished DoD career and now working within VA, are there 
areas where DoD/VA, the transition, all of this together, given 
your career of experience and now with the research university, 
one or two things, quickly, that you would say could be game 
changers?
    Lieutenant General Steele. The first is that accountability 
and acceptance of responsibility are the game changers, that 
the separation from active duty to the VA system is such that 
it needs to have all this cohesiveness to be able to ensure 
that everything is transferred over--all the HIPAA discussions 
we have had--it is all transferred over. If we could get 
legislation that does that and to ensure that there is 
transparency and openness, I think that we have got a great 
chance to be able to have a major game change in all of this.
    Mr. Jolly. All right. Thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Mr. Walz, you are recognized.
    Mr. Walz. Well, thank you, Chairman for holding the hearing 
and to each of you.
    And I was going to say, Dr. McCarthy I was thinking, and I 
was going to say that it is not personal, but then I got to 
thinking that that is not true; there is nothing more personal 
than this. We had Daniel and Brian and Clay and this is pretty 
personal stuff.
    And so I guess the thing I am most amazed about is that I 
am amazed at the lack of anticipating what is going to be asked 
of you when you come here, and it shows me that it is a lack of 
self-reflection on this. I could have anticipated the question 
that the chairman was going to ask where you didn't have an 
answer. I could have anticipated what Mr. O'Rourke was going to 
say. You probably could anticipate maybe what I am going to ask 
because I ask it to every one of you who sits here and yet it 
might be symptomatic of that why would we go to that trouble--
why would we look?
    And my answer to you is, is because we are reflecting what 
the public is telling us. We are a reflection--if this place is 
working correctly, we should be mirroring and channeling that, 
and so I guess that is most disillusioned.
    Again, General Steele, I am, along with you, the eternal 
optimist, because on the matter of now--what the point now is 
nothing matters but results. Nothing matters that we get this 
fixed, right? The American public is fully behind getting this 
right and we just have to figure out how to do that.
    Again, here is what I caution all of you is that people 
have sat there and offered up good suggestions. We even got so 
far as getting things into play, so Dr. Carroll You get to 
answer a few questions now. Here's what the law said that was 
required of you. In carrying out the comprehensive program, the 
secretary shall provide for research on best practices and 
prevention. Research shall be conducted under this subsection 
in consultation with the heads of the following entities: The 
Department of Health and Human Services--what have you done 
with them?
    Mr. Carroll. Sir, we are in partnership with Department of 
Health and Human Services and DoD regarding--and through The 
National Action Alliance on Suicide Prevention.
    Mr. Walz. What has come out of that in concrete results and 
implementation that went forward?
    Mr. Carroll. We have--education of the suicide prevention 
coordinators provide at every VA medical center. They provide 
at the veterans service organizations to veterans groups, to 
veteran providers, as well as all VA and VHA and VBA----
    Mr. Walz. How do you measure that, because I am going to go 
to this--you are responsible for doing this: In carrying out 
the plan, the secretary shall provide for outreach to and 
education of veterans and families for veterans with special 
emphasis on providing information to veterans of Operation 
Iraqi Freedom and Enduring Freedom of these veterans. Educate 
to promote mental health shall include the following: removing 
the stigma associated with, encouraging veterans to seek 
treatment, promote skills for coping with mental illness, help 
families with veterans understanding issues arising, 
identifying signs, and encouraging veterans.
    You just saw a family here that said they didn't hear a 
damn thing from you. Would that not be the measure?
    Mr. Carroll. We have failed these families, sir. There is 
no question about that. Our suicide prevention campaign last 
year was called Stand By Them. It was specifically aimed 
towards veterans and people aimed in the community to stand by 
veterans and to reach out and to support them to look for the 
signs of suicide and to encourage to get them into care.
    Our suicide prevention coordinators at every VA medical 
center do at least five outreach events to community 
organizations, veterans service organizations every month.
    Mr. Walz. What does the peer-support counseling program 
look like? How much training are you doing and how much 
encouraging--are you encouraging outside people to come in and 
peer support?
    Mr. Carroll. Absolutely. Peer support is one of the most 
transformative things that we have done in VA mental health 
care. We have hired 915 peer support providers over the last 
year. They are veterans. They are veterans who are in recovery 
from a situation in their own lives. We have them either 
trained or certified as peer-support providers or we will pay 
for that training. They are deployed across VA medical centers. 
We need more of them. We want them to be in primary care, as 
well as in mental health programs. They are a very 
transformative force in our organization, sir.
    Mr. Walz. So we have some things out there, and I bring 
these up because we are going to have to see how this 
implements moving forward as we start to do things. I fall into 
this camp, and I think it was Dr. Sherin who made the case, we 
certainly aren't going to do it all alone. There are 40,000 
non-profits out there to help veterans; they simply aren't very 
well coordinated.
    So, Dr. Sherin, I would ask you, what level of confidence 
do you have in this time we will get there? Because--just a 
quick anecdote from me is I am a provider in the community who 
was fee-based. He mostly treats Vietnam veterans. This guy is a 
local legend and beloved in that group there, and so in the 
midst of all of this, of course, with perfect--ear, he 
cancelled his contract in the middle of this after 30 years 
from the VA on this. And so now I have got 24 Vietnam veterans 
who are like, why the heck did you cancel this, this one was 
working? Now I got to go up to the VA and start again.
    So, Dr. Sherin, what do you think, is there a chance that 
this new model, in which you are advocating, which I think most 
of us intuitively know is the right way to go?
    Dr. Sherin. I think there is. I think there is. The VA has 
led the way in the effort, but the VA is doing this internally, 
so this is happening within the walls of the VA and the 
concepts that we are pushing are actually to go beyond the 
walls. If we want to promote recovery and reintegration, we 
need veterans working with each other in the community.
    Mr. Walz. So some of the things that I read out of the Josh 
Omvig Act that the VA is doing, those could be applied the same 
way and already are?
    Dr. Sherin. Absolutely. That is right.
    Mr. Walz. Well, I yield back. Thank you, Chairman.
    The Chairman. Thank you, Mr. Walz.
    Very quickly, and thank you Members for being here.
    Under threat of subpoena we finally got from VA the 2013 
mental health employee survey, and if I can, I want to read 
just a few excerpts and ask if you will comment.
    Leadership is disrespectful, autocratic and uncaring. They 
are clear that getting bonuses is the top priority if we want 
to keep our jobs. This is the worst leadership from Senator 
Richter on down that I have ever heard of.
    The next one, poor leadership and administrative skills 
causing more confusion and disorganization at times when my 
superior does not fully find out all aspects of the issues 
before issuing a decree.
    And the third one, no effective leadership in mental health 
for psych nurses, abusive management practices such as control, 
self-selecting, choosing staff, performance roles, no 
transparency.
    Comments? I mean it took a long time for this committee to 
get this information.
    Dr. McCarthy. And I apologize for that delay. I don't know 
what held it up.
    The Chairman. Oh, I do. Continue.
    Dr. McCarthy. I have had a chance to review some of the 
aggregated data from that particular----
    The Chairman. You have not had a chance to review it?
    Dr. McCarthy. I have, sorry.
    The Chairman. Okay.
    Dr. McCarthy. And that survey consisted of items that could 
be rated, as well as the free text comments, and what you 
shared were some of the free text comments, but the other side 
of it is there are some aggregated results that are significant 
from 2012 to 2013. As we hired more individuals to be part of 
the team, people did focus on a real sense of teamwork and be 
able to provide for the veterans.
    Could I also add that--I would just like to respond to Mr. 
O'Rourke that I would like to restate my answer to your 
question about accountability and who is responsible. I think 
we at VA are all responsible and that includes me, and I 
apologize for not saying that beforehand, but when you reframed 
that question to me, it became clear that I answered that wrong 
and I am sorry.
    The Chairman. And one other--Dr. Carroll, you made this 
comment just a second ago talking about peer support was one of 
the greatest things that you did. Did VA support that?
    Mr. Carroll. Support it financially, sir?
    The Chairman. No, the concept.
    Mr. Carroll. Yes.
    The Chairman. You did?
    Mr. Carroll. Yes, we had----
    The Chairman. You fought it every step of the way. You 
fought it every step of the way. This committee and other 
people said you need to bring these folks who have experienced 
this in their own lives forward and VA fought tooth and nail 
against it.
    Mr. Carroll. I regret that, sir. Since I have been part of 
the central office team since 2007, we have been looking for 
ways to move this forward.
    The Chairman. I don't believe--if you ask any member who 
has been sitting here for an extended period of time, they will 
tell you that VA has, in fact, fought bringing them in because 
they claim they didn't have the right credentials, they were 
not specific to the treatment, and, in fact, you just 
highlighted it as one of your best successes.
    Dr. McCarthy. So thank you for your partnership in that.
    The Chairman. With that, if there are no further comments 
or questions, we thank everybody. We thank the witnesses for 
being here today.
    I would ask unanimous consent that all members would have 
five legislative days with which to revise and extend and add 
extraneous material.
    Without objection, so ordered.
    Once again, thanks to the witnesses and thanks to the 
members. This hearing is adjourned.
    [Whereupon, at 1:38 p.m. the committee was adjourned.]
                                APPENDIX

              Prepared Statement of Jeff Miller, Chairman
    Welcome to today's Full Committee oversight hearing entitled, 
``Service should not lead to Suicide: Access to VA's Mental Health 
Care.''
    Following a Committee investigation which uncovered widespread data 
manipulation and accompanying patient harm at the Department of 
Veterans Affairs (VA) medical facilities nationwide, this Committee has 
held a series of Full Committee oversight hearings over the last 
several weeks to evaluate the systemic access and integrity failures 
that have consumed the VA health care system.
    Perhaps none of these hearings have presented the all-too-human 
face of VA's failures so much as today's hearing will--a hearing that I 
believe will show the horrible human cost of VA's dysfunction and, dare 
I say, corruption.
    At its heart, access to care is not about numbers; it's about 
people.
    Recently, the Committee heard from a veteran who had attempted to 
receive mental health care at a VA Community Based Outpatient Clinic in 
Pennsylvania.
    This veteran was told repeatedly by the VA employee he spoke with 
that he would be unable to get an appointment for six months.
    However, when that employee left, another VA employee leaned in to 
tell this veteran that if he just told her that he was thinking of 
killing himself, she would be able to get him an appointment much 
sooner--in just three months instead of six.
    Fortunately, that veteran was not considering suicide.
    But what about those veterans who are?
    How many of the tens of thousands of veterans that VA has now 
admitted have been left waiting weeks, months, and even years for care 
were seeking mental health care appointments?
    How many are suicidal or are edging towards suicide as a result of 
the inability to get the care they have earned?
    Despite significant increases in VA's mental health and suicide 
prevention budget, programs, and staffing in recent years, the suicide 
rate among veteran patients has remained more or less stable since 
1999, with approximately twenty-two veteran suicide deaths per day.
    However, the most recent VA data has shown that over the last three 
years, rates of suicide have increased by nearly forty percent among 
male veterans under thirty who use VA health care services and by more 
than seventy percent among male veterans between the ages of eighteen 
and twenty-four years of age who use VA health care services.
    This morning, we will hear testimony from three families--the 
Somers, the Selkes [SELL-KEYS], and the Portwines--who will tell us 
about their sons--Daniel, Clay, and Brian--three Operation Enduring 
Freedom/Operation Iraqi Freedom veterans who sought VA mental health 
care following combat.
    Each of these young men faced barrier after barrier in their 
struggle to get help.
    Each of these young men eventually succumbed to suicide.
    In a note he left behind, Daniel Somers wrote that he felt his 
government had ``abandoned'' him and referenced coming home to face a 
``system of dehumanization, neglect, and indifference.''
    VA owed Daniel--and Clay and Brian--so much more than that.

                                 

   Prepared Statement of Michael H. Michaud, Ranking Minority Member
    Good morning, and thank you Mr. Chairman for holding this hearing 
today.
    We have had many discussions and debates about how to deliver the 
best health care services to our Nation's veterans, and how to ensure 
accountability within the leadership ranks of the VA.
    Over the course of these recent hearings and discussions, we have 
touched on a number of important issues. But one that we haven't zeroed 
in on too much yet has been access to mental health care and suicide 
prevention services for our veterans. That's why this hearing today is 
so important.
    I'd like to thank all of our panelists for joining us today, but in 
particular I want to thank the family members joining us who have lost 
loved ones--Howard and Jean Somers, Susan Selke and Peggy Portwine.
    I know that speaking about the loss of a loved one--particularly a 
child--can be an incredibly difficult and exhausting experience. But, 
in this case, I believe we can and must honor the memories of the 
children of Howard and Jean, Susan, and Peggy.
    We can listen to their stories, identify what went wrong, and we 
can take action to ensure those failures aren't repeated. So thank you 
very, very much for joining us today and sharing your stories.
    Eighteen to 22 veterans commit suicide each day. In my opinion, 
that is 18 to 22 brave men and women each day who our system has let 
down in some capacity. It is a totally unacceptable figure.
    When a veteran is experiencing depression or other early warning 
signs that may indicate mental health issues or even suicide, that must 
be treated like an immediate medical crisis, because that is exactly 
what it is. Veterans in that position should never be forced to wait 
months on end for a medical consult because quite frankly, that is time 
they may not have.
    We have taken steps to help put in place programs and initiatives 
aimed at early detection, and we have significantly increased our 
funding. VA spending on mental health has doubled since 2007. But it's 
not working as well as we would hope, and we have to figure out why--
and how we can correct these problems.
    Our veterans are the ones paying the price for this dysfunction. A 
2012 IG report found that VHA's data on whether it was providing timely 
access to mental health services is totally unreliable.
    And a GAO report from that year not only confirmed that disturbing 
finding, but also said that inconsistent implementation of VHA's 
scheduling policies made it difficult--if not near impossible--to get 
patients the help they need when they need it. That is a problem we 
have seen repeatedly as we dig into the VA's dysfunctions, and enough 
is enough.
    Our veterans and their families deserve a VA that delivers 
timely mental health services that cover a spectrum of needs, from 
PTSD, to counseling for family members of veterans, to urgent, round-
the-clock responses to a veteran in need. A recent VA OIG report found 
that in one facility patients waited up to 432 days--well over a year--
for care.
    So once again, we are finding that our veterans deserve much better 
than the care they are receiving.
    And of all the areas we must address, I would argue that fixing 
mental health services is among the most urgent. I look forward to a 
productive discussion that we will only begin today, but certainly 
continue over the coming days, weeks and months.
    Thank you Mr. Chairman, I yield back.

                                 

                Prepared Statement of Hon. Corrine Brown

    Thank you, Mr. Chairman and Ranking Member, for calling 
this hearing today.
    A veteran's mental health has been called many names 
through too many wars. From ``soldier's heart'' in the Civil 
War, to ``shell shock'' in World War I and ``combat'' or 
``battle fatigue'' in World War II and now Post Traumatic 
Stress Disorder.
    Other terms used to describe military-related mood 
disturbances include ``nostalgia'', ``not yet diagnosed 
nervous'', ``irritable heart'', ``effort syndrome'', ``war 
neurosis'', and ``operational exhaustion.''
    Yet the name is not important for the disease, but how 
those affected are treated.
    The men and women in our military are risking their lives 
to defend the freedom of this country and for them to be 
discarded after their operational usefulness has ended is 
inhuman and un-American.
    I cannot think of anything more important to the returning 
members of the wars in Iraq and Afghanistan than knowing their 
health, and especially their mental health, is uppermost in our 
minds. It has been said that TBI is the signature injury of 
these wars. It is our responsibility to make sure they are 
treated properly when they get back.
    Suicide is epidemic among our active duty servicemembers 
and the veterans who have served this country in the past.
    More reservists and national guardsmen are serving in 
active duty now than in any other war. These men and women 
don't necessarily live near a military base to get the proper 
and timely treatment they need.
    I do not think that VA and veterans mental health should be 
contracted out to the lowest bidder in an effort to rush any 
kind of care to our veterans. The VA has shown time and time 
again that they are the worldwide experts in treating PTSD and 
other mental illnesses, and that other mental health 
professionals, no matter how knowledgeable, cannot know the 
full range of PTSD symptoms unless they work regularly with 
veterans.
    I am reminded of the words of the first President of the 
United States, George Washington, whose words are worth 
repeating at this time:
    ``The willingness with which our young people are likely to 
serve in any war, no matter how justified, shall be directly 
proportional as to how they perceive the veterans of earlier 
wars were treated and appreciated by their country.''
    I look forward to hearing the testimony of those panelists 
here today and learn how to best help those who have bravely 
served our nation in war.

                                 

                Prepared Statement of Hon. Scott Peters

    I want to thank Chairman Miller, Ranking Member Michaud, 
and the Committee for tackling an issue that touches entirely 
too many veterans and their families in my district, and 
districts throughout the country.
    Improving access to mental health services in the VA is 
something I have a deep and committed interest in and while I 
am not a member of this Committee there is no place I'd rather 
be this morning.
    I also want to thank the panelists for agreeing to be here 
today to share their experiences and expertise--it takes a lot 
of courage to do what you're doing and I want to thank you for 
that.
    Beyond the power of your stories, you are providing us an 
invaluable education. These are insights that only you have and 
I know we are all thankful to have the opportunity to learn 
from you, and to use the knowledge we gain to work toward 
eliminating the barriers our veterans face in receiving the 
care they need.
    I especially want to thank you, Howard and Jean Somers--not 
only for your participation today, but for your continued 
leadership and advocacy on behalf of Daniel, the education 
you've given me, and for fighting for our nation's veterans and 
their families. Your work in the face of such a tragedy is an 
inspiration to all of us. As the father of a 20-year-old son, I 
can't even imagine such as loss.
    Sadly, the report you have shared with us today highlights 
the struggles faced by not only your son, but the struggle 
faced by veterans and their families throughout the country. 
The number of veterans who found themselves in a position 
similar to Daniel's is unacceptably high.
    Like many, Daniel returned from his service with invisible 
wounds including Post-Traumatic Stress and Traumatic Brain 
Injury. He was also afflicted with Gulf War Syndrome.
    Like many, he suffered in silence because his attempts to 
reach out for help through the Department of Veterans Affairs 
were met with roadblocks and inefficiencies that left him with 
the feeling that no one cared.
    Like many, Daniel tragically took his life rather than 
continue to struggle with his wounds, his constant pain, and 
the burdens of his service.
    The truth is Daniel wasn't and isn't alone. Every day, 22 
veterans find themselves with the same horrible choices and 
make the same decision he did.
    As a country, we have failed these men and women who 
sacrificed so much to serve. The Somers' experience is evidence 
that there were steps that should have been taken and 
highlights systemic problems with the way the VA delivers care.
    The House and the Senate have taken the initial steps 
toward fixing these problems. We will continue to work toward 
achieving much-needed reforms. However, these reforms will take 
time, and our veterans who are suffering from the very real 
pain of post-war mental anguish, shouldn't have to wait.
    While Congress acts, and the VA implements reforms, our 
veterans and their families should take advantage of the many 
community resources available to them.
    There are an estimated 44,000 volunteer organizations 
dedicated to helping servicemembers and their families: 
providing resources, information, and outlets for those who 
have kept us safe.
    Too often, servicemembers and their families are not aware 
of the services available to them. That is why the Somers 
initiated Operation Engage America. With greater visibility, 
the programs offered by extraordinary Americans can reach 
veterans and their families in time to make a difference.
    I had the opportunity to attend the inaugural event at 
American Legion Post 731 in June of this year.
    I have never met a family more dedicated to sharing their 
story, raising awareness for the invisible wounds our 
servicemembers suffer, and committed to making a major impact 
on the way we care for our veterans.
    Your determination and resolve in the face of sacrifice and 
severe adversity is truly inspiring. I thank you, Howard and 
Jean, for everything you have done, and everything you will 
continue to do to ensure that we in Congress remain committed 
to fixing the flaws in the way we treat our veterans.
    From time to time in Congress, you see testimony that you 
know is going to right away make a difference and that is 
certainly what's happened today. You can feel very confident 
that our nation's heroes will be helped by the time and effort 
you've put in today.
    I look forward to continuing to work with you to resolve 
these issues and to make things right with the veterans the VA 
treats.

              Prepared Statement of Howard and Jean Somers

    Thank you Chairman Miller, Ranking Member Michaud, and 
Committee members.
    We are grateful for the opportunity to testify today, and 
it is especially good to see Representative Kirkpatrick, who 
has been a great ally to us in our effort to advance reforms of 
the VA based on the experience of our son, Daniel Somers.
    As many of you know, our journey started on June 10, 2013, 
when Daniel took his own life following his return from a 
second deployment in Iraq. At that time, he suffered from Post-
Traumatic Stress Disorder, Traumatic Brain Injury and Gulf War 
Syndrome. Daniel spent nearly six futile and tragic years 
trying to access the VA health and benefit systems before 
finally collapsing under the weight of his own despair. We have 
attached ``The Story of Daniel Somers'' to our testimony, which 
provides the details of his efforts, and we hope you will read 
it if you have not already done so.
    Today, it is our hope that we can begin the process which 
will ultimately provide hope and care to the 22 veterans a day 
who are presently ending their lives.
    Four days after Daniel's death, we sat with Daniel's wife, 
who has a Bachelor of Science in Nursing, and his mother-in-
law, who is a psychiatrist, and prepared a 19 page report that 
we titled Systemic Issues at the VA. We have shared that 
document with several of you over the last year, and it is also 
attached to our testimony.
    The purpose of this report remains the same as when we 
wrote it: to improve access to first-rate health care at the 
VA, to make the VA accountable to veterans it was created to 
serve and to make every VA employee an advocate for each 
veteran. (VHA)
    A1.  At the start, Daniel was turned away from the VA due 
to his National Guard Inactive Ready Reserve status.
    A2.  Upon initially accessing the VA system, he was, 
essentially, denied therapy.
    A3.  He had innumerable problems with VA staff being 
uncaring, insensitive and adversarial. Literally no one at the 
facility advocated for him.
    A4.  Administrators frequently cited HIPAA as the reason 
for not involving family members and for not being able to use 
modern technology.
    B1.  The VA's appointment system known as VISTA is at best 
inadequate. It impedes access and lacks basic documentation.
    B2.  The VA information technology infrastructure is 
antiquated and prevents related agencies from sharing critical 
information. There is a desperate need for compatibility 
between computer systems within the Veterans Health 
Administration, the Veterans Benefits Administration, and the 
DoD.
    B3.  Continuity of care was not a priority. There was no 
succession planning, no procedures in place for ``warm 
handoffs''; no contracts in place for locum tenems; and a 
fierce refusal to outsource anyone or anything.
    B4.  At the time Daniel was at the Phoenix VA, there was no 
pain management clinic to help him with his chronic and acute 
fibromyalgia pain.
    B5.  There were few coordinated inter-Agency goals, 
policies and procedures. The fact that the formularies of the 
DoD and VA are separate and different makes no sense since many 
DoD patients who are stabilized on a particular medication 
regimen must re-justify their needs when they transfer to the 
VA.
    B6.  There were inadequate facilities and an inefficient 
charting process. (VBA)
    There was no way for Daniel to ascertain the status of his 
benefits claim.
    There was no VHA/VBA appointment system interfacing, nor 
prioritized, proactive procedures.
    There was no communication between Disability Determination 
and Vocational Rehabilitation.
    This report is offered in the spirit of a call to action 
and reflects the experiences of Daniel with VA program services 
beginning in the fall of 2007 until his death last June as seen 
through our eyes.
    Our concern then was that the impediments and deficiencies 
which Daniel encountered were symptomatic of deeper and broader 
issues in the VA--potentially affecting the experiences of a 
much broader population of servicemembers and veterans. 
Unfortunately, this has been proven true as dramatically 
evidenced by recent revelations.
    Many of the reforms outlined in our report will require 
additional funding for the VA. But with that new funding should 
come greater scrutiny and a demand for better, measurable 
results.
    There is, however, an alternative to attempting to repair 
the existing, broken system. We believe Congress should 
seriously consider fundamentally revamping the mission of the 
VA health system. In the new model we envision, the VA would 
transition into a Center of Excellence specifically for war-
related injuries, while the more routine care provided by the 
rest of the VA health care system would be opened to private-
sector service providers--much like Tricare. That approach 
would compel the current model to self-improve and compete for 
veterans' business. This would ultimately allow all veterans to 
seek the best care available, while allowing the VA to focus 
its resources and expertise on the treatment of complex 
injuries suffered in modern warfare.
    We thank you for your time, and would be happy to further 
discuss our recommendations and suggestions. We sincerely hope 
that the systemic issues raised here will provide a platform to 
bring the new VA Administration together with lawmakers, 
veterans and private sector medical professionals and 
administrators for a comprehensive review and reform of the 
entire VA system. And if the VA, Committee or Congress as a 
whole make the decision to involve other stakeholders in a more 
formal reform process, we would be honored to be among those 
chosen to represent the views of affected families.

                   Prepared Statement of Susan Selke

    Chairman Miller, Ranking Member Michaud, and Distinguished 
Members of the Committee.
    Thank you for the opportunity to speak with you today about 
this critically important topic of mental health care access at 
the VA, suicide among veterans, and especially about the story 
and experience of our son, Clay.
    My name is Susan Selke and I'm accompanied here by my 
husband, Richard. I'm here today as the mother of Clay Hunt, a 
Marine Corps combat veteran who died by suicide in March 2011 
at the age of 28.
    Clay enlisted in the Marine Corps in May 2005 and served in 
the infantry. In January of 2007, Clay deployed to Iraq's Anbar 
Province, close to Fallujah. Shortly after arriving in Iraq, 
Clay was shot through the wrist by a sniper's bullet that 
barely missed his head. After he returned to Twenty Nine Palms 
in California to recuperate, Clay began experiencing many 
symptoms of post-traumatic stress, including panic attacks, and 
was diagnosed with PTS later that year.
    Following the recuperation from his gunshot wound, Clay 
attended and graduated from the Marine Corps Scout Sniper 
School in March of 2008. A few weeks after graduation, Clay 
deployed again, this time to southern Afghanistan. Much like 
his experience during his deployment to Iraq, Clay witnessed 
and experienced the loss of several fellow Marines during his 
second deployment.
    Clay returned home from Afghanistan in October of 2008, and 
was then honorably discharged from the Marine Corps in April of 
2009. He earned numerous awards during his service in the 
Marine Corps, including the Purple Heart for the injuries he 
sustained in Iraq.
    Clay received a 30 percent disability rating from the VA 
for his PTS along with two smaller ratings for other health 
issues after separating from the military. After discovering 
his that PTS prevented him from maintaining a steady job, Clay 
appealed the 30 percent rating only to be met with significant 
bureaucratic barriers, including the VA losing his files.
    The lapse in time during this appeals process left Clay 
worried about his professional and financial future. Eighteen 
months later, and five weeks after his death, Clay's appeal 
finally went through and the VA rated Clay's PTS 100 percent. 
The stresses and delays Clay experienced with his claim and 
appeal processes were also mirrored in his experience accessing 
and using VA medical care and educational benefits.
    Clay exclusively used the VA for his medical care after 
separating from the Marine Corps. Immediately after his 
separation Clay lived in the Los Angeles area and received care 
at the VA medical center there in LA. Clay constantly voiced 
concerns about the care he was receiving, both in terms of the 
challenges he faced with scheduling appointments as well as the 
treatment he received for his PTSD, which consisted solely of 
medication. He received counseling only as far as a brief 
discussion regarding whether the medication he was prescribed 
was working or not. If it was not, he would be given a new 
medication. Clay used to say, ``I'm a guinea pig for drugs. 
They'll put me on one thing, I'll have side effects, and then 
they put me on something else.''
    At the same time, Clay also expressed frustration with 
delayed GI Bill benefit payments. This only aggravated his PTS 
symptoms and inhibited his ability to heal and move on with his 
life.
    In late 2010, Clay moved briefly to Grand Junction, 
Colorado, where he also used the VA there, and then finally 
home to Houston to be closer to our family. The Houston VA 
would not refill prescriptions Clay had received from the Grand 
Junction VA because they said that prescriptions were not 
transferable and a new assessment would have to be done before 
his medications could be re-prescribed.
    Clay only had two appointments in January and February of 
2011, and neither was with a psychiatrist. It wasn't until 
March 15th that Clay was finally able to see a psychiatrist at 
the Houston VA medical center. But after the appointment, Clay 
called me on his way home and said, ``Mom, I can't go back 
there. The VA is way too stressful and not a place I can go. 
I'll have to find a Vet Center or something.''
    After Clay's death, I personally went to the Houston VA 
medical center to retrieve his medical records, and I 
encountered an environment that was highly stressful. There 
were large crowds, no one was at the information desk and I had 
to flag down a nurse to ask directions to the medical records 
area. I cannot imagine how anyone dealing with mental health 
injuries like PTS could successfully access care in such a 
stressful setting without exacerbating their symptoms.
    Just two weeks after his appointment with a psychiatrist at 
the Houston VA medical center, Clay took his own life. The date 
was March 31, 2011. The cause of death--a self-inflicted 
gunshot wound to his head.
    Clay was consistently open about having PTS and survivor's 
guilt, and he tried to help others coping with similar issues. 
He worked hard to move forward and found healing by helping 
people, including participating in humanitarian work in Haiti 
and Chile after devastating earthquakes.
    He also starred in a public service advertising campaign 
aimed at easing the transition for his fellow veterans, and he 
helped wounded warriors in long distance road biking events. 
Clay fought for veterans in the halls of Congress and 
participated in Iraq and Afghanistan Veterans of America's 
annual Storm the Hill campaign to advocate for legislation to 
improve the lives of veterans and their families.
    Clay's story details the urgency needed in addressing this 
issue. Despite his proactive and open approach to seeking care 
to address his injuries, the VA system did not adequately 
address his needs. Even today, we continue to hear about both 
individual and systemic failures by the VA to provide adequate 
care and address the needs of veterans.
    Not one more veteran should have to go through what Clay 
went through with the VA after returning home from war. Not one 
more parent should have to testify before a congressional 
committee to compel the VA to fulfill its responsibilities to 
those who served and sacrificed.
    You all, especially here in the House of Representatives, 
have been aggressive, courageous, and vigilant in holding the 
VA accountable and trying to equip it with the resources it 
needs to care for veterans. But given the magnitude and extent 
of the problems at the VA, more is needed.
    Mr. Chairman, I understand that today you are introducing 
the Suicide Prevention for America's Veterans Act. The reforms, 
evaluations, and programs directed by this legislation will be 
critical to helping the VA better serve and treat veterans 
suffering from mental injuries from war. Had the VA been doing 
these things all along, it very well may have saved Clay's 
life.
    Mr. Chairman, Richard and I again appreciate the 
opportunity to share Clay's story and our recommendations for 
how we can help ensure the VA will uphold its responsibility to 
properly care for America's veterans.
    Thank you.

                                 

                   Prepared Statement of Peg Portwine

    I am here before you to tell the testimony of my son Spc. 
Brian Portwine. Brian was an infantryman and serve in Operation 
Iraqi Freedom in 2006-2008 and in Operation Enduring Freedom in 
2010.
    During his first tour he was deployed to Baghdad and his 
job was to patrol Haifa street, which was a very dangerous 
area. This was before the surge of troops. During this tour, 
Brian lost 8 brothers.
    While in Iraq in 2006 Brian was in a Bradley tank that was 
struck by a RPG. The tank was immediately engulfed in flames 
and the driver was knocked unconscious. Due to the driver being 
able to hydraulically let down the ramp the 5 soldiers had to 
scramble thru the fire to manually lower the ramp and 
miraculously they were able to get out, all with injuries. 
Brian suffered a blast concussion and had lacerations to his 
face and legs from shrapnel. This was Brian's first episode of 
Traumatic Brain Injury.
    During another mission Brian and his 1st Sgt were on patrol 
in a Humvee and had switched seats so Brian was now in the 
passenger seat. Twenty minutes later an IED hit the Humvee and 
his 1st Sgt was killed and Brian was thrown from the Humvee and 
injured his back. Besides these 2 incidents Brian was involved 
in 5 other IEDs during his 15 month deployment.
    After coming home after his 1st deployment Brian had 
trouble with short term memory. When his friends were going 
somewhere he would often say ``where are we going again, you 
know I have scrambled brains'' To help cope with this he would 
post everything he had to do on his calendar or computer.
    In 2010 Brian was recalled to the Army and deploying from 
Fort Shelby, Miss. During this deployment Brian did not email 
or call home or to his friends. Little did we know how he was 
struggling with PTSD and TBI. He had panic attacks being on the 
same roads he had traveled on the 1st tour where IEDs went off 
often. He had nightmares 3 x a week and would wake up his unit 
and someone would have to wake him up. He suffered with 
anxiety, depression, insomnia, poor concentration, and 
hypervigilance. But he was never sent home.
    After returning from his 2nd deployment in Dec. 2010 to 
Daytona Beach he did not want to return to school. We did not 
know he had applied for disability due to his PTSD/TBI. He knew 
the stigma of saying you had PTSD so he kept it to himself.
    During out processing from Fort Shelby in 2010 Brain was 
diagnosed with PTSD, TBI, depression, and anxiety. During one 
assessment the counselor stated ``Pt cannot remember questions 
asked''. He had guilt, anxiety, hypervigilance, poor 
concentration, rage and anger but the VA/DoD told him to 
follow-up with the local VA outpatient.
    I am horrified by this. All his symptoms are classic 
symptoms of PTSD and TBI. He should have been sent to the 
National Intrepid Center for excellence at Fort Hood, TX where 
they have a 3-4 week program for those with TBI and PTSD.
    Brian deteriorated quickly from Dec, 2010 to May 2011. He 
could not stand how he acted but had no coping methods or 
treatment. It took a toll on his relationships with friends.
    If the DoD and VA assessed Brian at high risk for suicide 
it is their duty to treat him. But he got nothing.
    Brian's unit has lost 3 others to suicide, one just June 
21st, 2014. It is a very slippery slope from PTSD and TBI and 
the VA should realize this.
    Our soldiers never hesitated in their missions to protect, 
serve, and sacrifice for our country.
    Now it is time for the VA to prove their commitment to our 
solders.
    I never knew of Brian's PTSD and TBI or high suicide risk. 
I would think a life threatening event like this should be told 
to the emergency contact person.
    The VA needs to work the service organizations and include 
the families in the plan of care.
    I beg this Committee to pass act 2182, the Suicide 
Prevention for Americans Act
    As a mother I have lost my only miracle child to suicide. 
It is devastating!
    I would like to close by saying a quote from Rose Kennedy. 
It says, ``time heals all wounds.''
    I disagree. The wounds remain. In time the mind to protect 
its sanity covers them with scar tissue and the pain lessen. 
But it is never gone. Thank you.

                                 

                  Prepared Statement of Josh Renschler

    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee:
    I am honored to have the opportunity to speak to you today 
regarding VA mental health care.
    I proudly served as a United States Army Infantryman for 
5\1/2\ years, and was medically retired due to severe injuries 
from a mortar blast in Iraq. Working now with a non-profit in 
Washington state, I assist servicemembers, veterans and their 
families who are struggling due to deployment-related trauma. I 
have a great deal of experience with VA medical facilities and 
VA mental health care--not just as a patient, but as an 
advocate for many other warriors I've mentored, and through 
dialogue with veteran leaders from across the country. Recently 
VA leadership invited me to participate in an online learning 
session through VA's eHealth University to share my perspective 
as a veteran accessing VA care, so VA clinicians and staff 
could have the opportunity to learn from my experience.
    That experience with the VA health care system began in 
2008. As I explained in testifying before the Subcommittee on 
Health last year, that experience began badly. At the time I 
was being treated for anxiety, sleep problems, migraines, pain, 
and seizures, and it had taken Army doctors 3 years to 
determine the right medications and dosages to treat those 
conditions. Because several of those 8 different medications 
were not on the VA formulary, my primary care provider at the 
American Lake VA Medical Center substituted different 
medications, despite the urging of my wife due to the failure 
of these medications in the past. The side effects caused me so 
much difficulty that I began to backslide in my recovery. I was 
soon on 13 medications (some to simply counter the effects of 
others); and soon all my conditions worsened and I had a severe 
panic attack at work.
    Since then, with my multiple medical and surgical issues 
and my work with other warriors, I've had extensive experience 
with VA care. As to VA mental health care in particular, I've 
benefitted from excellent care at a VA medical center that for 
a period of time made that care a priority and staffed it 
accordingly. The facility provided easy one-stop access to OEF/
OIF/OND veterans through a ``Deployment Health Team'' that 
brought together in one spot medical, mental health, pharmacy 
and social work providers. Unfortunately, medical center 
leadership concluded that providing this excellent, well-
staffed interdisciplinary care was too costly. With budget 
considerations trumping patient-centered care considerations, 
the team's providers were reassigned. (While the facility still 
has a unit called the ``deployment health team'' it now 
provides only primary care and social work services. Having 
only a skeleton staff, the team manages a huge caseload and, as 
a result, has long wait times and shorter appointments.) 
Instead of seeing an interdisciplinary team, GWOT veterans now 
go through an impersonal intake/assessment process. From there 
they are channeled into a conventional system where providers 
do not work as a team, and where veterans have to navigate 
their way to the different services scattered across the 
sprawling, complex campus to get the care they need. For many 
of the warriors with whom I've worked, just navigating around 
the many buildings housing different treatment services in this 
complex facility is anxiety-provoking.

Interdisciplinary, Team-Based Care: Key to Mental Health Care 
and Suicide Prevention

    I cite my and other veterans' very positive experience with 
this interdisciplinary, team-based-care approach (and the 
effective demise of that program) because it highlights some 
very important points. First, veterans with mental health 
issues are seldom going to open up to a clinician they've never 
met and begin discussing painful, private issues. They're more 
likely to skirt those deeper issues and simply report that 
they're experiencing difficulty sleeping, having headaches, or 
some more general problem, with the hope that there's 
medication to provide relief. It takes time to build trust to 
open up to deeper problems or even to recognize them. And not 
every clinician is necessarily skilled at eliciting that trust 
or insightful enough to gauge from a veteran's demeanor that 
there are deeper issues, and to ask the probing questions that 
might begin to identify them. Working with a team increases the 
likelihood that one or more will see things that others missed.
    Interdisciplinary care has profound implications for 
suicide-prevention. Veterans will rarely volunteer to 
clinicians that they're contemplating suicide, and there aren't 
obvious signs by which a mental health provider can reliably 
identify a veteran as a suicide risk. And we certainly won't 
prevent suicides by having physicians go down a mandatory 
checklist and mechanically asking a veteran-patient a series of 
questions like ``have you thought recently about harming 
yourself?'' While people who commit suicide often have a mental 
health condition, that alone is seldom an explanation for a 
suicidal act. Life events and problems are often important 
catalysts.\1\  But in a treatment system, where, for example, 
I'm sent to Building 3 to see the neurologist for severe back 
pain, to Building 61 to see a psychiatrist for medication to 
help with sleep problems, and to Building 81 to see my social 
worker for serious relationship problems, no one is getting a 
full picture and no one can see and put together the red-flag 
signs that may point to the fact that my life is spinning out 
of control. This isn't just a problem in VA. But as an 
integrated health care provider, VA can provide the kind of 
care I got from the interdisciplinary deployment health team in 
the past. There, the team members shared observations, and 
could see potential problems as they had begun to develop and 
question veterans about issues before they became explosive. In 
my view, therefore, it is much less fruitful to press VA to 
establish or re-design ``suicide prevention programs'' than to 
improve VA health and mental health care delivery.
---------------------------------------------------------------------------
    \1\ Keith Hawton, ``Suicide prevention: a complex global 
challenge,'' 1(1) The Lancet (June 2014), 2.

---------------------------------------------------------------------------
``Access'' Is Only Half the Equation

    When we discuss mental health care, it's not enough to talk 
about ``access.'' One has to get to the question, ``access to 
what?'' Access to a system in which I go to three different 
buildings to see three different providers for health issues 
which are all related to my mental health--pain, lack of sleep, 
and relationship issues--is a real problem when those providers 
aren't working as a team, and aren't even given the needed time 
to coordinate their observations and treatment approaches with 
one another. In other words, access to mental health care isn't 
enough unless that mental health care is also effective.
    This is particularly important as it relates to combat 
veterans; having been trained to tough it out and soldier 
through pain, they often come into treatment hesitantly and 
even distrustfully. A provider needs to understand that warrior 
mentality, and often must work hard to win that veteran's 
trust. A clinician who doesn't understand that warrior culture 
or isn't permitted the time needed to develop that relationship 
of trust is unlikely to have success in helping that warrior 
overcome his or her demons. In my experience, veterans have a 
greater likelihood in the VA of working with a clinician who 
has some understanding of that warrior experience and of 
working with combat-related mental health problems than they 
would ``outside.'' But a veteran who has to work with a 
provider who lacks cultural awareness or whose patient care 
load doesn't allow time will inevitably become frustrated 
(whether in the VA or outside) and often drop out of treatment. 
Similarly, many veterans who aren't ready for an often very 
traumatic exposure-based therapy have dropped out of these 
intense multi-week treatment programs, even though they are 
hailed as an ``evidence-based therapy.'' I question the wisdom 
of evaluating facilities, as VA does, based on the percentage 
of veterans with PTSD who complete these evidence-based 
therapies. While the underlying intent has merit, there are 
many reasons that veterans don't complete those programs: for 
some, they're just too intense, for others, it's too difficult 
to come in for treatment that often. The bottom line is that 
this performance requirement, like others, can not only be 
``gamed,'' it fails to take the patient's preferences into 
account. VA has often cited the importance of a veteran-
centered approach to mental health care. But if care is to be 
veteran-centered, as it must be, it's critical to recognize 
each veteran's unique situation, and their individual treatment 
preferences, and build systems to meet their needs and 
preferences, not the other way around. That seems to me, to be 
essential to providing effective care, whether in the VA or 
elsewhere.
    The warriors I'm describing--and I've worked with many of 
them--very often don't come into treatment for PTSD or anxiety 
or depression when the textbooks say they should, at an early 
stage when the problems can be most easily dealt with. They 
finally come into treatment when things have gotten really bad. 
Sometimes that's when their spouse is threatening to leave. In 
some cases, it's when they've gotten into trouble with law 
enforcement, often involving substance abuse. Or it might be 
when the veteran has experienced a panic attack or overwhelming 
thoughts of self-harm, to cite some common examples. Timeliness 
is obviously critical in those kinds of instances, and they're 
not at all isolated occurrences among OEF/OIF veterans. Clearly 
a veteran in distress who finally asks for help for a combat-
incurred mental health condition needs to get into treatment. 
VA policy did establish the expectation that veterans were to 
be afforded initial appointments for mental health care within 
14 days. But--just as with the challenges many VA facilities 
faced in meeting that requirement for primary care 
appointments, limitations in mental health staffing at many 
facilities have made provision of timely mental health care 
either very challenging or impossible to meet. What I saw 
facilities do was to reconfigure their staffing to meet the 
technical requirement of the 14-day rule. At these facilities, 
warriors with mental health issues were assessed within the 14-
day window; in that way they were ``seen,'' even though 
facility staffing wouldn't permit an initial treatment 
appointment itself until many weeks later. Understandably, 
warriors who are at the end of their rope and finally seek help 
at a VA medical facility often experience deep frustration and 
even despair if they are told to wait six weeks or longer to 
begin therapy. Deferred treatment can set the stage for 
potentially tragic outcomes.
    I do believe that there are VA facilities that are 
providing veterans timely access to effective, patient-centered 
mental health care. But that's certainly not the case 
systemwide. Unfortunately there are no measures in place to 
assess patient outcomes. (In that regard, I would suggest that 
the Committee look into the rates at which OEF/OIF veterans 
drop out of PTSD treatment programs, surely one relevant 
indicator). But with what appear to be widespread disparities 
in the timeliness of VA care (but not necessarily the same 
focus on care-effectiveness), I understand that some have 
called for expanding veterans' access to care from non-VA 
providers.

Purchased Care: No Silver Bullet

    It seems doubtful that that step by itself can be the 
``silver bullet'' solution for veterans' mental health care. 
For one thing, it assumes first that the private sector holds a 
key to meeting VA's mental health workforce ``supply'' problem. 
But a 2013 report to Congress warns of ``an already thinly 
stretched [behavioral health] workforce.'' \2\  The report 
points to longstanding concerns about a national shortage of 
behavioral health workers, cited in previous publications, 
including the following:
---------------------------------------------------------------------------
    \2\  Hyde, P., ``Report to Congress on the Nation's Substance Abuse 
and Mental Health Workforce Issues,'' Substance Abuse and Mental Health 
Services Administration (Jan. 24, 2013), 5. Accessed at http://
store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf

         A 2009 Study that found that 77 percent of 
        counties had a severe shortage of mental health 
        workers, both prescribers and non-prescribers and 96 
        percent of counties had some unmet need for mental 
        health prescribers;
         A 2012 Government report that found there were 
        3669 areas of the country with shortages of mental 
        health professionals;
         A 2007 Report that 55% of U.S. counties, all 
        rural, had no practicing psychiatrists, psychologists 
        or social workers; and
         A 2010 Government report finding that more 
        than two-thirds of primary care physicians who tried to 
        obtain outpatient mental health services for their 
        patients reported they were unsuccessful due in part to 
        shortages in mental health care providers.\3\

    \3\  Id., 10.
---------------------------------------------------------------------------
    Not only is there a real issue in terms of a national 
mental health workforce shortage, but there are real quality of 
care issues to contend with. According to the 2003 report of a 
presidential commission on mental health care in this country, 
``not only is there a shortage of [mental health providers, but 
those providers who are available are not trained in evidence-
based and other innovative practices. This lack of education, 
training, or supervision leads to a workforce that is ill-
equipped to use the latest breakthroughs in modern medicine.'' 
\4\ The Commission found that ``too few benefit from available 
treatment'' because ``state-of-the-art treatments vital for 
quality care and recovery . . . are not being used.'' \5\ A 
later report by the Institute of Medicine that focused on 
improving the quality of behavioral health care cited 
``numerous studies [that] document the discrepancy between the 
[mental health and substance use] care that is known to be 
effective and the care that is actually delivered.'' \6\
---------------------------------------------------------------------------
    \4\ ``Achieving the Promise: Transforming Mental Health Care in 
America,'' The President's New Freedom Commission on Mental Health 
(July 2003), 70. Accessed at http://store.samhsa.gov/shin/content//
SMA03-3831/SMA03-3831.pdf.
    \5\ Id., 68.
    \6\ Institute of Medicine, ``Improving the Quality of Health Care 
for Mental Health and Substance-Use Conditions,'' National Academies 
Press, 2006, 35.

---------------------------------------------------------------------------
A Better Purchased-Care Model

    Years ago, Washington State's Department of Veterans 
Affairs, recognized the unique needs of Wartime Veterans and 
their families and established a PTSD Counseling Program to 
provide access to best practices of care for those who 
otherwise couldn't get that care through VA because of service-
unavailability or distance. Under the Department's program, 30 
licensed practitioners across the state provide counseling 
services at State expense; importantly each has a minimum of 24 
years of experience and all providers are veterans or are 
trained to be military and veteran culturally competent. 
Veterans need only contact the program director who will 
determine the best practitioner for the individual situation 
and connect the Veteran with that office. Given the counselor's 
experience and backgrounds, the veterans I've referred to the 
program have found it very helpful. (For the same reasons, 
veterans with whom I've worked and whom I've met around the 
country have similarly positive experiences with VA's Vet 
Centers.) But in the most recent instance, the veteran I 
referred to the Washington State program was informed that all 
the providers in his area had full case loads and were not 
taking new clients.
    I don't want to suggest that VA could not benefit from 
greater use of purchasing care, where that care is available 
and where it offers promise of being effective. But it would 
not be particularly helpful simply for veterans to be ``seen'' 
outside the VA by a provider who is not equipped to provide 
effective care--for lack of training in treating combat- or 
MST-related PTSD, for lack of ``cultural competence,'' or any 
other shortcomings. In short, it is pretty clear that providing 
an avenue to mental health care, even if there is a source, 
does not assure that veterans will get effective care.

Improving VA Mental Health Care

    So what's the answer? It's important to appreciate that the 
VA health care facilities do have caring, dedicated providers. 
I know, for example, that some of my own health care providers 
are coming in on weekends and staying late at night to keep up 
with their work. I don't believe the answer to improving VA 
mental health care is to demand more of those clinicians.
    But I think we have to demand that VA mental health care--
especially for veterans with service-incurred mental health 
conditions--become a top priority. VA leaders have, of course, 
repeatedly stated that it is. But if that were so, why would my 
VA medical center in Washington State have effectively 
eliminated--for reasons of cost--the one program through which 
OEF/OIF veterans got excellent mental health care? Why, given 
strong policies on PTSD care would there be variability on PTSD 
management from facility to facility, and why would it be 
``unclear whether VA leaders adhere to [VA PTSD] policies,'' as 
a recent Institute of Medicine study reported.\7\ And why would 
veterans in facilities across the country be having problems 
getting timely and effective VA mental health care?
---------------------------------------------------------------------------
    \7\ Institute of Medicine, ``PTSD in Military and Veteran 
Populations,'' National Academies Press, 2014, 6.
---------------------------------------------------------------------------
    From this veteran's perspective--with staggering numbers 
who have come back from war with psychic wounds and PTSD--the 
starting point for improving VA mental health care lies with VA 
leadership at all levels embracing the principle that providing 
timely, effective mental health care for those with service-
incurred mental health conditions--whether due to combat, 
military sexual trauma, or otherwise--MUST be a top priority! 
These are not just words. We've seen with the example of VA's 
efforts to combat veteran homelessness, that this Department 
can have a real impact when the direction and priority are 
clear, when artificial performance requirements don't create 
distortions, and when clinicians have latitude to provide good 
care. Improving mental health care may be as or more complex a 
challenge, but it surely requires a comprehensive approach. I 
don't think legislation is necessarily the path through which 
to meet the challenge, although there are important steps 
Congress can take. These might include:

         Providing incentives to help increase the 
        mental health workforce;
         Funding training programs for non-VA mental 
        health providers on treating service-incurred PTSD and 
        on military culture to improve clinicians' expertise 
        and cultural competence in working with military and 
        veteran populations; and
         Increasing VA funding for research to find 
        better treatments for PTSD.

    But I believe that there is much that VA should, and with 
the right leadership, can do itself. First, I would reiterate 
the point I made above about instituting interdisciplinary, 
team-based treatment. While VA's PACT program employs that 
approach in the primary care arena, it shouldn't end there. 
There is also much to be learned from the Vet Center program, 
and why veterans--who have to feel safe and trust their 
provider if they are to engage in mental health care--are 
comfortable in that setting. Vet Center counsellors are 
typically veterans, and often combat veterans. Having a 
connection with peers is critical. And Vet Centers engage 
family members as well. I believe VA medical centers and 
clinics would have far greater success in treating veterans for 
PTSD and other mental health conditions--and keeping them in 
treatment--if they routinely engaged the family at the same 
time.
    Many of the problems with which this Committee has wrestled 
in overseeing VA seem to relate to management practices. 
Perhaps it's time for VA to change course and rely more on the 
dedicated clinicians in this health care system, and less on 
arbitrary performance requirements and metrics. As the ones who 
are closest to the patients, the clinicians are probably best 
able to develop veteran-centered programs--like the Deployment 
Health Team I described earlier.
    Finally I would draw on my own experience working with 
other warriors as a peer-mentor. As a former infantryman who 
was badly injured and experienced psychic wounds too, I can say 
things to other warriors that a clinician can't and I can 
assure those warriors from my own experience that mental health 
treatment can work. To its credit, VA has hired and provided 
for the training of more than 800 peer-specialists, to work as 
members of VA mental health treatment teams. That is a great 
concept, but with the numbers of veterans coming to VA for 
mental health care, I would recommend that that number be 
greatly expanded.
    I hope my experiences, observations, and recommendations 
are of some help, and would be pleased to answer your 
questions.

                                 

                 Prepared Statement of Maureen McCarthy

    Good morning, Chairman Miller, Ranking Member Michaud and 
Members of the Committee. Thank you for the opportunity to 
discuss the provision of mental health care to Veterans, 
particularly those who are at risk for suicide. I am 
accompanied today by Dr. David Carroll, National Mental Health 
Program Director for Program Integration, Dr. Harold Kudler, 
Acting Chief Consultant for Mental Health Services and Mr. 
Michael Fisher, Operation Enduring Freedom/Operation Iraqi 
Freedom Specialist. My written statement will provide a brief 
overview of VA's mental health care system and programs for 
suicide prevention.

Mental Health Care Overview

    Since September 11, 2001, more than two million 
Servicemembers have deployed to Iraq or Afghanistan. Long 
deployments and intense combat conditions require optimal 
support for the emotional and mental health of Veterans and 
their families. Accordingly, VA continues to develop and expand 
its mental health system. The number of Veterans receiving 
specialized mental health treatment from VA has risen each 
year, from 927,052 in Fiscal Year (FY) 2006 to more than 1.4 
million in FY 2013. We anticipate that VA's requirements for 
providing mental health care will continue to grow for a decade 
or more after current operational missions have come to an end. 
VA believes this increase is partly attributable to proactive 
screening to identify Veterans who may have symptoms of 
depression, posttraumatic stress disorder (PTSD), substance use 
disorder, or those who have experienced military sexual trauma 
(MST). In addition, VA has partnered with the Department of 
Defense (DoD) to develop the VA/DoD Integrated Mental Health 
Strategy to advance a coordinated public-health model to 
improve access, quality, effectiveness, and efficiency of 
mental health services for Servicemembers, National Guard and 
Reserve, Veterans, and their families.
    VA has many entry points for VHA mental health care, 
through 150 medical centers, 820 Community-Based Outpatient 
Clinics (CBOCs), 300 Vet Centers that provide readjustment 
counseling, the Veterans Crisis Line, VA staff on college and 
university campuses, and other outreach efforts. To serve the 
growing number of Veterans seeking mental health care, VA has 
deployed significant resources and increases in staff toward 
mental health services. Since March 2012, VA has added 2,444 
mental health full-time equivalent employees and hired 915 peer 
specialists and apprentices. As of January 2014, VHA has 21,128 
Mental Health full-time equivalent employees providing direct 
inpatient and outpatient mental health care. VA has expanded 
access to mental health services with longer clinic hours, 
telemental heath capability to deliver services, and standards 
that mandate immediate access to mental health services to 
Veterans in crisis. Starting in FY 2012, site visits have been 
conducted to the mental health programs in each VA facility. 
All facilities were visited in the initial round, and 
subsequently one third are being visited each year by a survey 
team from VHA's Office of Mental Health Operations. The site 
visits are informed by ratings on performance measures; 
findings from the visits are used to develop action plans; and 
improvements are evaluated by following performance measures as 
well as the milestones and deliverables included in the plans. 
In an effort to increase access to mental health care and 
reduce any stigma associated with seeking such care, VA has 
integrated mental health into primary care settings. From the 
beginning of FY 2008 to March 2014, VA has provided more than 
3.6 million Primary Care-Mental Health Integration (PC-MHI) 
clinic visits to more than 942,000 unique Veterans. This 
improves access by bringing care closer to where the Veteran 
can most easily receive these services, and quality of care by 
increasing the coordination of all aspects of care, both 
physical and mental. Among primary-care patients with positive 
screens for depression, those who receive same-day PC-MHI 
services are more than twice as likely to receive depression 
treatment as those who did not.
    VA has made deployment of evidence-based therapies a 
critical element of its approach to mental health care and 
offers a continuum of recovery-oriented, patient-centered 
services across outpatient, residential, and inpatient 
settings. State-of-the-art treatment, including both 
psychotherapies and biomedical treatments, are available for 
the full range of mental health problems, such as PTSD, 
substance use disorders, and suicidality. While VA is primarily 
focused on evidence-based treatments, we are also assessing 
complementary and alternative treatment methodologies that need 
further research, such as meditation and acupuncture in the 
care of PTSD. VA has trained over 5,900 VA mental health 
professionals to provide two of the most effective evidence-
based psychotherapies for PTSD, Cognitive Processing Therapy 
and Prolonged Exposure Therapy, as indicated in the VA/DoD 
Clinical Practice Guideline for PTSD \1\ VA operates the 
National Center for PTSD, which guides a national PTSD 
mentoring program, working with every specialty PTSD program 
across the VA health care system. The Center has begun a PTSD 
consultation program for any VA practitioners (including 
primary care practitioners and Homeless Program coordinators) 
who request consultation regarding a Veteran in treatment with 
PTSD. So far, over 500 VA practitioners have utilized this 
service.
---------------------------------------------------------------------------
    \1\ http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg-PTSD-
FULL-201011612.pdf.
---------------------------------------------------------------------------
    We know that there have been Veterans with complaints about 
access. We take those concerns seriously and continue to work 
to address them. Receiving direct feedback from Veterans 
concerning their care is vitally important. During the fourth 
quarter of FY 2013, a survey of 26 questions was mailed to over 
40,000 Veterans who were receiving mental health care. This 
survey shows VHA's effort to seek direct input from Veterans in 
understanding their perceptions regarding access to care. We 
recognize that this is data only from those who chose to 
respond. We will bear those responses in mind as we strive to 
improve the timeliness of appointments; reminders for 
appointments; accessibility, engagement, and responsiveness of 
clinicians; availability and agreement with clinician on 
desired treatment frequency; helpfulness of mental health 
treatment; and treatment with respect and dignity.

Programs and Resources for Suicide Prevention

    Overall, Veterans are at higher risk for suicide than the 
general U.S. population, notably Veterans with PTSD, pain, 
sleep disorders, depression, and substance use disorders. VA 
recognizes that even one Veteran suicide is too many. We are 
committed to ensuring the safety of our Veterans, especially 
when they are in crisis. Our suicide prevention program is 
based on enhancing Veterans' access to high quality mental 
health care and programs specifically designed to help prevent 
Veteran suicide.
    In partnership with the Substance Abuse and Mental Health 
Services Administration's National Suicide Prevention Lifeline, 
the Veterans Crisis Line/Military Crisis Line (VCL/MCL) 
connects Veterans and Servicemembers in crisis and their 
families and friends with qualified, caring VA responders 
through a confidential toll-free hotline that offers 24/7 
emergency assistance. August will mark seven years since the 
establishment of the initial program, which was later rebranded 
to show its direct support for Servicemembers. It has expanded 
to include a chat service and texting option. As of March 2014, 
the VCL/MCL has rescued 37,000 actively suicidal Veterans. As 
of March 2014, VCL/MCL has received over 1,150,000 calls, over 
160,000 chat connections, and over 21,000 texts; it has also 
made over 200,000 referrals to Suicide Prevention Coordinators 
(SPCs). In accordance with the President's August 31, 2012, 
Executive Order titled, ``Improving Access to Mental Health 
Services for Veterans, Servicemembers and Military Families,'' 
VA completed hiring and training of additional staff to 
increase the capacity of the VCL/MCL by 50 percent.
    VA has a network of over 300 SPCs located at every VA 
medical center and the largest CBOCs throughout the country. 
Overall, SPCs facilitate implementation of suicide prevention 
strategies within their respective medical centers to help 
ensure that all appropriate measures are being taken to prevent 
suicide in the Veteran population, particularly Veterans 
identified to be at high risk for suicidal behavior. SPCs 
receive follow-up consults from the VCL/MCL call responders 
after immediate needs are addressed and any needed rescue 
actions are made. SPCs are required to follow up on consults 
received from the VCL/MCL within one business day to ensure 
timely access to care for Veterans callers who need additional 
support, treatment, or other services, including enrollment 
into VA's health care system. SPCs also plan, develop, 
implement, and evaluate their facility's Suicide Prevention 
Program to ensure continual quality improvement and excellence 
in customer service. SPCs are responsible for implementing VA's 
Operation S.A.V.E (Signs of suicidal thinking, Ask the 
questions, Verify the experience with the Veteran, and Expedite 
or Escort to Help). This is a one-to-two hour in-person 
training program provided by VA SPCs to Veterans and those who 
serve Veterans to help prevent suicide. Suicide prevention 
training is provided for every new VHA employee during Employee 
Orientation.
    SPCs participate in outreach activities, which remain 
critically important to VA's goals of reducing stigma for 
mental health issues and improving access to service for all 
Veterans. Examples include community suicide prevention 
training and other educational programs, exhibits, and material 
distribution; meetings with state and local suicide prevention 
groups; and suicide prevention work with Active Duty/National 
Guard and Reserve units as well as college campuses. To date, 
each SPC is required to complete five or more outreach 
activities in their local community each month.
    Veterans may be at high risk for suicide for various 
reasons. Determination of suicide risk is always a clinical 
judgment made after an evaluation of risk factors (e.g., 
history of past suicide attempts, recent discharge from an 
inpatient mental health unit), protective factors, and the 
presence or absence of warning signs. VHA Handbook 1160.01, 
``Uniform Mental Health Services in VA Medical Centers and 
Clinics,'' requires inpatient care be available to all Veterans 
with acute mental health needs (including imminent danger of 
self harm), either in a VA medical center or at a nearby 
facility through a contract, sharing agreement.
    To ensure that high-risk Veterans are being monitored 
appropriately, SPCs manage a Category I Patient Record Flag 
(PRF) with a corresponding High-Risk List. The primary purpose 
of the High Risk for Suicide PRF is to communicate to VA staff 
that a Veteran is at high risk for suicide, and the presence of 
a flag should be considered when making treatment decisions. 
Once a Veteran is identified as high-risk, the SPC ensures that 
weekly contact is made with the Veteran for at least the first 
month, and that continued follow-up is made, as clinically 
appropriate. The SPC works with the treatment team to ensure 
that patients identified as being at high risk for suicide 
receive follow up for any missed mental health and substance 
abuse appointments at VA. Clinicians are required to initiate 
at least three attempts to contact Veterans on the High-Risk 
List who fail to appear for mental health appointments and 
ensure appropriate documentation. If attempts to contact the 
Veteran are unsuccessful, the SPC collaborates with the 
Veteran's treatment team to decide what further action is 
appropriate involving a range of options from continued 
outreach efforts to the Veteran and/or family members up to 
requesting local law enforcement perform a welfare check in-
person.
    SPCs ensure that all Veterans identified as high risk for 
suicide have completed a safety plan that is documented in 
their medical record, and that the Veteran is provided a copy 
of his or her safety plan.
    National suicide prevention outreach efforts continue to 
expand and include targeted efforts for Veterans, 
Servicemembers, families, and friends. VA has sponsored public 
service announcements, rebranded and optimized the VCL/MCL Web 
site for mobile access and viewing, and developed social and 
traditional media advertisements designed to inform Veterans 
and their families of VA's VCL/MCL resources including phone, 
online chat, and text services.
    In addition, VA has established an online Community 
Provider Toolkit \2\ for individuals outside of VA who provide 
care to Veterans. This Web site features key tools to support 
the mental health services provided to Veterans including 
information on connecting with VA, understanding military 
culture and experience, and working with patients with a 
variety of mental health conditions. There is also a 
comprehensive Suicide Prevention Mini-Clinic which provides 
clinicians with easy access to useful Veteran-focused treatment 
tools, including assessment, training, and educational 
handouts.\3\
---------------------------------------------------------------------------
    \2\ http://www.mentalhealth.va.gov/communityproviders.
    \3\ http://www.mentalhealth.va.gov/communityproviders/clinic-
suicideprevention.asp.
---------------------------------------------------------------------------
    In 2010, DoD and VA approved plans for a Joint Suicide Data 
Repository (SDR) as a shared resource for improving our 
understanding of patterns and characteristics of suicide among 
Veterans and Servicemembers. The combined DoD and VA search of 
data available in the National Death Index represents the 
single largest mortality search of a population with a history 
of military service on record. The DoD/VA Joint SDR is overseen 
by the Defense Suicide Prevention Office and VA's Suicide 
Prevention Program.
    On February 1, 2013, VA released a report on Veteran 
suicides, a result of the most comprehensive review of Veteran 
suicide rates ever undertaken by VA. With assistance from state 
partners providing real-time data, VA is now better able to 
assess the effectiveness of its suicide prevention programs and 
identify specific populations that need targeted interventions. 
This new information will assist VA in identifying where at-
risk Veterans may be located and improving the Department's 
ability to target specific suicide interventions and outreach 
activities in order to reach Veterans early and proactively. 
These data will also help VA continue to examine the 
effectiveness of suicide prevention programs being implemented 
in specific geographic locations (e.g., rural areas), as well 
as care settings, such as primary care, in order to replicate 
effective programs in other areas. VA continues to receive 
state data which is being included in the SDR. VA plans to 
update the suicide data report later this year.
    In 2011, the most recent year for which national data are 
available, the age-adjusted rate of suicide in the U.S. general 
population was 12.32 per 100,000 persons per year. At just over 
12 for every 100,000 U.S. residents, the 2011 rate of suicide 
has increased by approximately 15 percent since 2001. Rates of 
suicide in the United States are higher among males, middle-age 
adults, residents in rural areas, and those with mental health 
conditions.
    The most recent available data shows that suicide rates are 
generally lower among Veterans who use VHA services than among 
Veterans who do not use VHA services. In 2011, the rate of 
suicide among those who use VHA services was 35.5 per 100,000 
persons per year; a decrease of approximately 6 percent since 
2001. Rates of suicide among those who use VHA services have 
remained relatively stable; ranging from 36.5 to 37.5 per 
100,000 persons per year over the past 4 years. Despite 
evidence of increased risk among middle-aged adults (35-64 
years) in the U.S. general population, rates of suicide among 
middle-aged adults who use VHA services have decreased by more 
than 16 percent between the years 1999-2010. For males without 
a history of using VHA services, the rate increased by more 
than 60 percent, whereas for males with a history of using VHA 
services, the rate decreased by more than 30 percent. Decreases 
in suicide rates and improvements in outcomes were also 
observed for some other high-risk groups. Between 2001 and 
2010, rates of suicide decreased by more than 28 percent among 
VHA users with a mental health or substance abuse diagnosis, 
and the proportion of VHA users who die from suicide within 12 
months of a survived suicide attempt has decreased by 
approximately 45 percent during the same time period.\4\
---------------------------------------------------------------------------
    \4\ www.mentalhealth.va.gov/docs/Suicide-Data-Report-Update-
2014.pdf.
---------------------------------------------------------------------------
    Comparisons of rates of suicide among those with use of VHA 
services and the U.S. general population are ongoing. However, 
in 2010, rates of suicide were 31 percent higher among males 
who used VHA services when compared to rates of suicide among 
males in the U.S. general population. During that same year, 
women who used VHA services were more than twice as likely to 
die from suicide when compared to women in the U.S. adult 
population. Increases in rates of suicide have also been 
identified for younger males who use VHA services. Over the 
last three years, rates of suicide have increased by nearly 44 
percent among males under 30 years of age who use VHA services 
and by more than 70 percent among males who use VHA services 
between 18 and 24 years of age.
    In response to these findings, VA has been focusing on 
public health and community programming. This includes 
increased and targeted outreach efforts throughout the country 
to Veterans and their family members with significant emphasis 
on safety. We encourage Veterans and their families to learn 
more about mental illness and to take precautions particularly 
during times of stress (e.g., properly storing weapons and 
medications). Being alert to items in the environment that 
offer potential means of suicidal behavior can make a life-
saving difference during a crisis. Messaging and interventions 
are geared toward those who are most at risk for suicide, 
including our younger male Veterans, women Veterans, Veterans 
with mental health conditions, and established patients who are 
known to be at high risk for suicide. Strategies include 
specialized training for VHA staff to enhance their recognition 
and treatment of those at risk, and offering Veterans skills-
building and other preventive strategies to address major 
stressors in their lives. Furthermore, VA is engaged in ongoing 
research to determine the most effective mental health 
treatments and suicide prevention strategies. Finally, VA has 
established the Mental Health Innovations Task Force, which is 
working to identify and implement early intervention strategies 
for specific high-risk groups including Veterans with PTSD, 
pain, sleep disorders; depression, and substance use disorders. 
Through early intervention, VA hopes to reduce the risk of 
suicide for Veterans in these high-risk groups.

Readjustment Counseling Service (RCS)

    VA's RCS provides a wide range of readjustment counseling 
services to eligible Veterans and active duty Servicemembers 
who have served in combat zones and their families. RCS also 
provides comprehensive readjustment counseling for those who 
experienced military sexual trauma, as well as offering 
bereavement counseling to immediate family members of 
Servicemembers who died while on active duty. These services 
are provided in a safe and confidential environment through a 
national network of 300 community-based Vet Centers located in 
all 50 states (as well as the District of Columbia, American 
Samoa, Guam, and Puerto Rico), 70 Mobile Vet Centers, and the 
Vet Center Combat Call Center (877-WAR-VETS or 877-927-8387). 
In FY 2013, Vet Centers provided over 1.5 million visits to 
Veterans, active duty Servicemembers, and their families. The 
Vet Center program has provided services to over 30 percent of 
OEF/OIF/Operation New Dawn Veterans who have left active duty.

Closing Statement

    Mr. Chairman, VA is committed to providing timely, high 
quality of care that our Veterans have earned and deserve, and 
we continue to take every available action and create new 
opportunities to improve suicide prevention services. We 
appreciate the opportunity to appear before you today, and my 
colleagues and I are prepared to respond to any questions you 
may have.
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                 Prepared Statement of Jonathan Sherin

Greeting

    Thank you Mr. Chairman, ranking member and committee for 
convening today's hearing on the critical issues of mental 
health access and suicide prevention challenges in the Veteran 
community. I am deeply honored to testify on these topics. 
Aside from being core drivers of my mission in life they 
represent national imperatives of the highest order.

Preface

    Let me preface my testimony by stating that to manage 
serious mental health issues and to prevent suicide in any 
population requires not only identifying those who are 
suffering and dismantling any barriers that may be interfering 
with their access to treatment, but also creating enriched and 
cohesive communities in which all comers belong, in which 
opportunities to live purposefully are cultivated, in which 
wellbeing is nourished broadly and in which human flourishing 
is an articulated, promoted and attainable goal; in other 
words, we need proactive systems set up to disrupt suicidal 
thinking on the front end.

My Expedience, Current Role and Perspective

    After completing my graduate work in medicine and 
neurobiology I was fortunate to be selected by UCLA as a 
psychiatry trainee. On the first day of residency orientation I 
drove myself to the majestic and hallowed grounds of the WLA VA 
campus, a primary clinical venue affiliated with UCLA's 
training program, and parked myself at the golf course where I 
watched Veterans come and go for hours. This experience changed 
me as it became clear in this one afternoon that my life's work 
would revolve around caring for our nation's Veterans. Four 
years later, the VA hired me straight out of training and my 
dream became a reality. Over the course of the next decade I 
served as a clinician, teacher, researcher and administrative 
leader at VA with my last stop as Chief of Mental Health for 
the Miami VAHS.
    Since leaving the VA 2 = years ago to join Volunteers of 
America (VOA) as Executive Vice President for Military 
Communities and Chief Medical Officer, this mission has 
continued. VOA is a large direct human service provider whose 
legacy of work with Veterans dates back to the post-Civil War 
era. We currently employ over 16,000 staff working in over 400 
communities around the country and provide a broad array of 
programs to the Veteran community including services to well 
over 10,000 homeless Veterans through VA grants and contracts 
alone. It is VOA's national priority to do anything and 
everything we can for the Veterans of our Nation which we do 
not only through programs funded specifically for Veterans, but 
through any resources we can bring to bear for the mission. One 
of these programs, the Battle-Buddy-Bridge (B3), which 
leverages Veterans as peers in service to one another, is 
particularly relevant to solving access problems that are under 
review today (see B3 Concept Proposal, attached).
    My experience working on this mission from inside the VA 
and now outside the VA gives me a great deal of perspective as 
to the nature of the problems facing Veterans and some possible 
solutions. It is my contention that a great deal can be done to 
improve access to the resources that will help improve mental 
health outcomes and decrease suicides by aligning VA and 
community in a manner that mutually leverages existing 
infrastructure and expertise to increase the depth, breadth and 
efficacy of our efforts.

The Access Problem

    One of the primary challenges facing VA as well as the 
health and human service sector in general, is dealing with 
broken systems of access to services. Access barriers are 
present in essentially every community today and affect 
vulnerable individuals as a rule, but they are particularly 
problematic for Veterans in need who can be hard to reach for 
any number of reasons: some are unaware of available services 
and opportunities; many are reluctant to seek help as a 
consequence of military culture and/or mistrust of the system; 
others are too sick to advocate for themselves or have been 
rebuffed or delayed in seeking assistance; and too many have 
fallen through the cracks as a consequence of poorly 
coordinated and overly complex bureaucratic systems. Though not 
unique to the Veteran community, a massive amount of 
unnecessary suffering is endured, lives are broken, and in some 
cases lives are taken as a result of suboptimal access. Access 
problems simply cannot continue to plague our Veteran 
population.

A Holistic Approach

    The ultimate goal of our work with Veterans facing 
emotional challenges involves accessing not only mental health 
treatment but also interventions targeting other factors that 
mitigate mental distress and thereby protect against mental 
illness and suicide. For example, it is possible to improve 
mental status by providing access to resources such as peer 
navigation, case management, housing, education, training, 
employment, legal services, benefits assistance and family 
support when indicated.
    Given the vulnerabilities conferred on any number of these 
factors by the military experience, Veterans in particular must 
receive care in a holistic manner that extends well beyond 
mental health treatment. Along these lines, the familial 
relations found in peer-peer programs, the community experience 
provided by a respectable job and the spiritual benefits 
obtained by engaging in mission-oriented endeavors are salves 
for disruptions in life that can occur during enlistment, 
service and separation.

    The Need

    As the offerings needed in the Veteran community are 
myriad, the resources limited, and the processes for accessing 
them frustrating to navigate, urgent problems sometimes go 
unaddressed, worsening mental states evolve and devastating 
life circumstances such as homelessness or life-threatening 
emergencies such as suicidal behavior emerge. Keeping in mind 
the principles of overcoming access barriers and broadly 
targeting needs to mitigate mental distress as well as suicide, 
Veterans with urgent problems (such as worsening family 
dynamics, spiraling substance-abuse, housing instability, 
health crises, progressing financial problems, acute legal 
challenges or loss of employment) need real time access to 
resources that can keep them on a road toward community 
reintegration.
    For these reasons, a caring advocate such as a fellow 
Veteran functioning as a battle buddy in the community who is 
trained, equipped, deployed and supported to provide expert 
hands-on engagement and local resource navigation can make all 
of the difference. We must immediately scale this type of 
solution as part of a full frontal assault on the barriers to 
access that face our nation's Veterans.

The Current Situation

    Access to mental health services is suboptimal. In light of 
recent findings from investigations of scheduling practices at 
VA as well as a plethora of testimonials regarding wait times 
and inadequate service availability, there is clearly a need to 
develop strategies for improving real-time responsiveness to 
Veterans reaching out for help.
    Suicide rates are unacceptably high, especially in the 
younger and older Veteran populations. Though discrepancies 
exist regarding the rates of suicide in different 
subpopulations, rates have climbed in the Veteran community and 
require the highest level of attention that our nation can 
muster to improve access.
    The VA reaches less than half of the Veteran population. 
While it is clear that receiving care at VA benefits Veterans 
and mitigates suicidal behavior, many Veterans at risk never 
connect with these programs. Though many Veterans never connect 
with these programs because of outreach limitations, many 
others refuse to use the VA system.
    Receiving care at the VA can be difficult due to time and 
distance constraints. Many of those who are reached by the VA 
find travel and wait times problematic which deters their 
interest in ongoing treatment, especially in the face of 
rapidly developing crises.
    Community providers are woefully under leveraged as 
resources to support mental health and mitigate suicide risk. 
Due in part to the VA's noble tradition of trying to serve all 
the needs of all Veteran and in part to the constraints that 
complicate public-private-partnership, communities have not 
been fully engaged to assist in getting services to Veterans.

Recommendations for VA

    The VA alone cannot provide all services to all Veterans in 
all geographies and must partner vigorously with appropriate 
providers to improve access to services as has been done to 
house homelessness Veterans by partnering with and embracing 
the community.
    1. Promote pubic-private partnerships (PPP) across all 
sectors to increase agency reach and expand access 
opportunities for Veterans.
    2. Use grant mechanisms straight out of VACO (such as 
NCHAV's SSVF) to avoid layers of bureaucracy and improve 
overall efficiency.
    3. Identify partnerships to push out services as below that 
strategically supplement, complement and create synergy with VA 
operations to increase access through outreach, engagement and 
resource navigation according to a B3-like program model.
    a. Place Veteran Peer Specialists (VPS) in the community to 
function as ``battle buddies''.
    b. Connect Veterans in need to VPS thru suicide prevention 
coordinators, crisis line, 211.
    c. Retrofit VA campuses with, and transform service centers 
into, reintegration centers that host VPS, a modicum of 
services and a map of all available community resources.
    d. Leverage technology to amplify access to VPS (for 
example, PosRep).

Requests of Congress

    Assistance from Congressional leadership in moving forward 
is critical.
    1. Visit the trenches of your local VA and community 
providers to better understand the opportunities available 
through partnership between VA and other organizations.
    2. Review the structure of VA and its strategy for 
facilitating Veteran reintegration in partnership with the 
community with special focus on considering the SSVF grant 
mechanism as a gold standard for how to manage organizational 
relationships.
    3. Lobby for and support demonstration projects that employ 
Veterans to work as peer specialists who can expand outreach, 
facilitate engagement and lead navigation efforts for Veterans 
with acute needs.
    4. Push reform where possible and develop new legislation 
where necessary to facilitate partnerships with the community.

Closing

    Time is a conspiring enemy in what is becoming a domestic 
war. The resolve and urgency that our country mounts to win 
foreign wars must be employed to achieve victory at home. With 
the help of Congressional leaders, bureaucratic barriers must 
be torn down aggressively so that solutions can be erected. 
Most importantly, facile mechanisms that foster relationships 
across all sectors of the American collective must be developed 
with unprecedented efficiency to implement a shared process for 
promoting the wellbeing of our noble military community.

                        Statement For The Record
                        
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      Report by Citizens Commission on Human Rights International

                        Questions For The Record

                 LETTER AND QUESTION FROM: HVAC, TO: VA

    July 17, 2014

    The Honorable Sloan Gibson
    Acting Secretary
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420
    Dear Mr. Secretary:
    Committee practice permits the hearing record to remain 
open to permit Members to submit additional questions to the 
witnesses. In reference to our Full Committee hearing entitled, 
``Service Should Not Lead to Suicide: Access to VA's Mental 
Health Care'' that took place on July 10, 2014, I would 
appreciate if you could answer the enclosed hearing questions 
by the close of business on August 29, 2014.
    In preparing your responses to these questions, please 
provide your answers consecutively and single-spaced and 
include the full text of the question you are addressing in 
bold font. To facilitate the printing of the hearing record, 
please email your response in a Word document, to Carol Murray 
at [email protected] by the close of business on 
August 29, 2014. If you have any questions please contact her 
at 202-225-9756.
    Sincerely,
    MICHAEL H. MICHAUD
    Ranking Member

    Questions Submitted by Ranking Member Michaud:
    Ranking Member Michaud
    1. How is a call from a veteran in crisis handled by the 
phone system or personnel of VA facilities during working 
hours?
    2. Is a veteran in crisis currently able to be transferred 
directly to the VA crisis hotline by automated system during 
off hours when he or she calls any VA facility, that is, 
without having to hang up and dial another number?
    3. Has the VA analyzed what resources would be needed to 
provide an automated system that would allow a veteran in 
crisis to be directly transferred to the crisis hotline if he 
or she calls any VA facility?
    4. Has the VA analyzed what resources would be needed to 
provide a ``warm handoff'' to the crisis hotline to a veteran 
in crisis calling a VA facility during non-working hours?
    Rep. Brown
    1. There are 22 veterans who commit suicide every day. The 
treatment most accessible to veterans is psychiatric drugs and 
the most commonly prescribed are the SSRI anti-depressants. The 
FDA placed a black box warning on these drugs noting the 
particularly high risk of suicide in those 24 years old and 
younger taking them. Are the veterans who are prescribed SSRI 
anti-depressants told the drug may greatly increase their risk 
of suicide? What is the VA doing to ensure veterans are 
receiving full informed consent (which includes all information 
about risks and alternative treatments)?
    A study in the Journal of Clinical Psychiatry titled, 
``Pharmacotherapy of PTSD in the U.S. Department of Veterans 
Affairs: diagnostic- and symptom-guided drug selection,'' found 
that 80% of veterans diagnosed with PTSD received psychotropic 
medication, with 89% prescribed anti-depressants, 61% 
anxiolytics/sedative-hypnotics, and 34% antipsychotics.
    According to Department of Defense Instruction, Number 
6000.14, September 26, 2011, entitled, ``DoD Patient Bill of 
Rights and Responsibilities in the Military Health System 
(MHS),'' military personnel are entitled to informed consent 
for any treatment and to refuse to receive treatment. That 
regulation states, in part, under the section, ``PATIENT 
RIGHTS'':
    ``f. Informed Consent
    ``Patients have the right to any and all necessary 
information in non-clinical terms to make knowledgeable 
decisions on consent or refusal for treatments, or 
participation in clinical trials or other research 
investigations as applicable. Such information is to include 
any and all complications, risks, benefits, ethical issues, and 
alternative treatments as may be available.''
    2. A UCSF professor once explained: ``The mechanism of 
action of SSRI anti-depressants is to block the normal re-
absorption of Serotonin, which leaves it firing at the receptor 
site over and over, artificially creating the effect of 
elevated Serotonin in the brain. It is possible to have an 
initial positive response to the drug, but shortly thereafter 
the brain recognizes the unnatural excess firing of Serotonin 
at the receptor sites. As a result, the brain adapts and tries 
to regain its equilibrium by shutting down production of 
Serotonin. If the SSRI anti-depressant continues to be taken, 
the brain will then move to shut down some of the receptor 
sites in a bid to regain normal. This mechanism of action is 
why the drugs stop working and why people have a hard time 
coming off them and why people get depressed when they come off 
the drug. The SSRI altered the normal brain chemistry and 
created a chemical imbalance. This is evidence-based. The use 
of SSRIs leads to chronic depression.''
    a. This is creating more need for treatment and 
overburdening the system. Has the VA done any outcome studies? 
What percentage of patients treated with SSRIs recover and are 
able to successfully discontinue the drug? Where is the 
evidence of SSRI effectiveness?
    3. The VA is relying heavily on psychotropic drug 
treatments. Adverse reactions of psychotropic drugs include a 
long list of medical symptoms and conditions including weight 
gain, diabetes, metabolic syndrome, liver damage. Has the VA 
done any studies on iatrogenic illnesses caused by psychotropic 
drugs?

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